The aim of this study was to present our experience in the management of the recalcitrant upper lip and describe the surgical technique. We took a retrospective chart review of all patients who underwent reconstruction of the recalcitrant upper lip after maxillectomy and radiation therapy. Three female patients were identified. All patients had a history of malignant maxillary tumors, mucoepidermoid carcinoma (n = 1), verrucous carcinoma (n = 1), squamous cell carcinoma (n = 1). Tumor extirpation was carried out through total maxillectomy (n = 2), and bilateral subtotal maxillectomy (n = 1). Primary reconstruction was accomplished with scapula free flap (n = 1), fibula free flap (n = 1), and nonvascularized iliac crest bone graft (n = 1). Two patients underwent adjuvant radiotherapy. All patients developed recalcitrant upper lip. All patients had secondary reconstruction to correct of the recalcitrant upper lip using radial forearm free flap. All patients had successful dental rehabilitation. The mean follow-up was 5 years (range 3-7 years). Subjective functional and aesthetic outcome was assessed in all patients at the last follow up visit. All patients reported subjective improvement in speech, mastication and aesthetics. Free tissue transfer provides an ideal method to reconstruct the recalcitrant upper lip. Favorable functional and aesthetic outcomes can be successfully achieved using the technique described in this series.
Aim: This paper focus is to describe and evaluate the authors' personal technique for a simplified transpalpebral eyebrow lift.
Methods: We performed surgery in 179 patients (95% females and 5% males) between years of 2008 and 2009. Initially, a thorough assessment of brow stability and symmetry was performed. To achieve desirable aesthetic we agreed upon the consensus that the eyebrow lateral third should be 0.3 to 1 cm above the supraorbital rim in women and just above or at supraorbital rim in men. Hence the surgery consisted of the removal of excess skin, treatment for bags if they were present and a transpalpebral lateral eyebrow lift.
Results: There were only 5 cases in which patients reported episodes of pain on the temporal undermined area related with the suture with the evidence of pain subsiding over time and disappearing all together within 3 months. No patients required revision surgery and no patients presented laghophtalmos or any eyelid closure difficulties.
Conclusion: This paper presents a simplified version of an eyebrow lift technique that is easy to reproduce and effective.
While amputation was traditionally the only option available for patients with sarcomas of the extremities, chemotherapy, radiation, and advances in microsurgical technique have allowed many patients to undergo limb-salvaging procedures. Given the low incidence and heterogeneity of these tumors, there is currently no standard treatment algorithm for limb reconstruction after large sarcoma resection. Thus, we systematically reviewed the various types of free tissue transfer used for the reconstruction of lower limbs after sarcoma resection. Techniques were described based on anatomic location. This literature review supports free tissue transfer as a safe and acceptable modality for reconstruction after sarcoma resection of the lower limb. It allows for the application of healthy vascularized tissue to the defect while also providing freedom of flap positioning. Flap choice is dependent on tumor and defect size, tissue type and function, as well as donor site availability.
Aim: Peri-commisural defect reconstruction using the Abbe or Estlander flaps tend to pilfer tissue from the lower lip, contributing to microstomia, with its attendant problems. In this study, we aim to design a flap for more superficial defects, in which the underlying orbicularis oris muscle can be preserved when resecting peri-commisural skin malignancies whilst also ensuring completeness of excision.
Methods: In a retrospective case review of 7 cases at our institution over a 12-month period (2016-2017), we conceptually designed a perforator-plus fascio-cutaneous flap from within the labio-mandibular fold with a 6-month follow-up in terms of oncological clearance and aesthetic outcome. The cohort was composed of patients with skin cancers e.g. basal and squamous cell carcinomas, presenting to a tertiary care facial plastic surgery centre. The technique involved raising a flap from within the peri-oral area, with a scar disguised along the labio-mandibular and naso-labial folds which allows for both an aesthetic reconstruction and the preservation of the oral sphincter mechanism, by avoiding microstomia. The outcomes measured were (1) to ascertain whether this procedure is oncologically safe, (2) there were instances of microstomia and (3) aesthetic appearance.
Results: All oncological lesions were completely excised in all cases and at up to six months’ follow-up, there were no instances of recurrence. Functionally, oral sphincter function was preserved in all instances as was aesthetic appearance.
Conclusion: The labio-mandibular flap is an oncologically safe procedure for skin cancers whilst preserving oral sphincter function and maintaining aesthetics. It is hence, a superior alternative to Abbe and Estlander flaps, for more superficial defects, not requiring mucosal excision.
Aim: An atraumatic insertion of graft is key to successful outcomes in this procedure but there is a definite learning curve in available techniques. Many physicians do not continue hair restoration practice because of the repeated initial failures. The goal of any technique or instrument in follicular unit extraction (FUE) is to extract an individual follicular unit without transaction and implanting it in recipient area without producing physical trauma to the follicular unit. This article describes a novel technique in which an innovative instrument, the KD spreader, that addresses all the problems faced by novice physicians during FUE hair transplantation. More importantly unique design of the instrument also solves the problem of fatigue of the operator’s hands while performing the hair transplantation procedure.
Methods: In this technique, the KD spreader, comprised of a shaft and a hook connected to the shaft are configured to allow the user to work efficiently. Two finger grip of the device provides efficient gripping for fatigue free operation. While performing FUE, the KD spreader provides sufficient traction at the time of scoring. During implantation of the grafts in premade coronal slits, this device provides adequate dilation and maximum visualization of the slit. Attachment of the graft holding plate reduces the chances of dehydration of the graft.
Results: In this study, we have observed use of KD spreader definitely showed advantages over the conventional technique forceps. The KD spreader provides efficient gripping, maximum visualization of slit and better stretching force for the dilatation of the slit to adjust even bigger size follicular unit grafts.
Conclusion: The KD spreader may improve ability of the beginners to perform FUE extraction and implantation smoothly.
Aim: An ideal injectable material would be biocompatible with long-lasting effects. The relative polymerization and chain length of the compound determines its viscosity, as measured by centistokes (cp). It is available in 350, 1000 and 5000 cp - the higher the number, the more viscous the oil. Most of the reports used 1000-cp silicone oil for filling purposes and due to high viscosity, only microdroplet injection technique is recommended to avoid complications. This is the first report of patient series using liquid silicone with a 350-cp viscosity The objective of this study was to explore the reliability and efficacy of low viscosity liquid silicone for lower face contour correction.
Methods: Lower facial region of 43 patients including chin, nasolabial and melolabial regions were treated by low viscosity (350 cp) liquid silicone. Instead of microdroplet tehniqe, retrograde linear threading technique was used. Total injection volume was 6.0 ± 3.9 mL. At least two sessions were required for complete correction which are spaced one month apart. Overcorrection was avoided. The treated areas had a soft and natural feeling with no lumpiness and stiffness.
Results: Mean follow-up period was 16.8 ± 14.3 months. The mean aesthetic satisfaction score was 4.51. No migration of the material was seen which is revealed by palpation and no major complication was encountered. None of the patients had any complaints regarding late facial deformity due to silicone migration.
Conclusion: Low viscosity liquid silicone is effective, well-tolerated and easy to use. It can be used as an alternative to higher viscosity silicones to avoid technical errors and complications.
Surgical resection of soft tissue sarcoma of the trunk can result in large defects requiring complex reconstruction for coverage of vital neurovascular structures and tissue defect. Large defects of the back could be reconstructed with multiple random pattern or local pedicled flaps. We present the case of a 48-year-old patient with a locally advanced dermatofibrosarcoma protuberans of the back. Wide local excision of the lesion was performed. The soft tissue defect measured 22 cm × 20 cm × 4 cm and was reconstructed with bilateral reverse latissimus dorsi myocutaneous (RLDM) flap. Each RLDM flap measured 24 cm × 10 cm. The donor site on the back was closed directly on both sides. The patient recovered well and the two flaps healed uneventfully. Twelve months after surgery the patient is disease-free. The use of a RLDM flap in mid-back reconstructions provided wide well-vascularized soft tissue, minimized risk of infection, and maximized back coverage. This flap is an excellent choice for reconstruction of large defects of the mid-back.
Aim: Numerous non-surgical methods and surgical options are available for the solution of baldness in the practice. Technology provides mighty weapons in this field. Thus, individualized solutions are best carried out with well-trained and qualified practitioners. Here, a modification of follicular unit extraction, direct hair implantation is introduced with previously licensed unique pens.
Methods: Follicular unit extraction and direct hair implantation methods were carried out in 207 hair transplantations between January and December of 2014. The nests for the grafts were created via pieces of hand-cut razor blade in follicular unit extraction. In addition, a new modification of follicular unit extraction, direct hair implantation, is done via pens that are produced for this purpose.
Results: Thirty-eight direct hair implantations were performed in addition with 169 follicular unit extractions. An average number of 2973 grafts were transplanted. Mean operation time was calculated as 385 min.
Conclusion: Hair transplantation is still the best solution for hair loss. In conjunction with the surgery, the addition of non-surgical interventions may give a better result to the patient. On the other hand, the promising results in the field of regenerative medicine with cell-based solutions may alter hair transplantation and change the options solely into this field.
The development of vascularized composite allotransplantation (VCA) and its clinical need has led to the need for more animal models to study and perform the research required to further this specialty in terms of functional recovery and immunomodulatory improvements. Much of the animal models are reported in individual series in the literature but there has not been a review as such of these models. Here we present a compilation of the animal models reported in the literature thus far in VCA. A comprehensive review of the literature was performed for any studies which involved the use of animal models in various aspects of VCA research. The models were organized according to the type of VCA transplant, whether they were orthotopic or heterotopic, immunosuppressive regimen each study used and investigation purpose. Twenty-one facial transplant models were reported, 3 abdominal wall transplants, 4 penile transplantations, 21 uterus transplantations, 12 hindlimb transplantations and 4 myocutaneous flap transplantation animal models were reported. Primates, swine, rats, mice, rabbits, sheep and dog animal models in VCA were also reported. The most used immunosuppressive drugs are calcineurin inhibitor such as cyclosporin A and tacrolimus in these VCA animal models. They can significantly suppress lymphocyte function by blocking the phosphatase activity of calcineurin of lymphocytes. They are sometimes used combined with mycophenolate mofetil or steroids or antilymphocyte serum. The review of existing animal models will allow further research to be focused in other areas of VCA where there is a current paucity of literature. The immunosuppressive regimens used in each animal model can also be reviewed to determine which regimen works in which type of animal model which will save time and resources for future research.
The adipose body of cheek is the tissue located in the buccal space. In the past, the partial removal of this tissue, called jugal lipectomy, was indicated to fill defects resulting from buccosinusal communications and/or maxillary resections. Recently, such technique became popular in facial aesthetics as it gives patients the feel of a more delicate face, in which the zygomatic bone appears to be more prominent due to the reduction in the volume of the cheeks. However, many professionals are unaware of how to establish the correct diagnosis of facial volume alterations, as well as in performing and treating the complications that may arise from jugal lipectomy. The aim of this paper is to present three clinical cases with different applications of jugal lipectomy, discussing some relevant aspects of surgical planning that involve the request for imaging exams and a previous study of this tissue’s anatomical features.
Aim: The ideal flexor tendon repair should be reliable, simple and strong enough without impairing the tendon healing. Based on these requirements, we have imagined the use of a single barbed intra-tendinous suture for stumps connection. The aim of our research is to quantify the stress that the suture and barbs should withstand in order to ensure perfect stumps connections.
Methods: Seven different cross-section sutures were selected for the research study. One circular and 6 different elliptical shapes were defined according to the ratio of their minor and major axes (ρ = b/a). Barbs were designed with 3 different depths and 3 different cut angles. Thus, 9 different situations were considered for each suture geometry. Finally, 2 loading conditions were applied on each barb and tested in ANSYS Workbench using a finite element analysis technique.
Results: Studies showed that a barbed suture with 0.18-mm depth, 150˚ cut angle and ρ = 3 produced the lowest stresses within the barb itself, while a barbed suture with 0.18-mm depth, 160˚ cut angle and ρ = 4 demonstrated lowest stress within the entire suture.
Conclusion: The stress values in these two configurations are observed to be very close and both can fit a single barbed suture for tendon insertion and repair.
Aim: There is no previous description on the anatomy of the inferior belly of the omohyoid muscle. This muscle has specific morphological characteristic that make it appealing when solving specialized reconstructive problems. Our objective is to describe the microsurgical anatomy of the inferior belly from the omohyoid muscle.
Methods: Supraclavicular bilateral dissection in 5 anatomic models (fresh human cadavers). Measurements were taken with a millimetric caliper. Statistical analysis was performed with measures of central tendency.
Results: Eight muscles were dissected in 5 anatomic models. Average dimensions were: 93 mm long, 12 mm wide, and 7.5 mm thickness. The vascular pedicles showed great anatomical variability. In 2 flaps (1 model) irrigation came exclusively from transverse cervical vessels, in the remaining models the pedicles came directly from the subclavian vessels; 2 flaps had an accessory minor pedicle from the transverse cervical vessels. The diameter of all vascular pedicles was less than 0.8 mm, with an average length of 22.3 mm. The nerve pedicle came from ansa cervicalis in all flaps, with an average length of 27.8 mm.
Conclusion: Based on the findings we conclude that omohyoid muscle could be a reconstructive option when small functional flaps are required, such as facial reanimation surgery, sphincters, ptosis and vocal cord reconstruction, and blink restoration surgery although more anatomical studies are required to determine the microsurgical feasibility, excursion and strength of the muscle, and axonal load in this new myofunctional flap.
Aim: To evaluate available evidence for the effective management of venous leg ulcers with fibrin matrix with or without growth factors.
Methods: A systematic review of the literature was performed to evaluate the use of fibrin matrices with or without growth factors for the management of chronic venous ulcers in lower limbs. Article searches were performed in MEDLINE, EMBASE, COCHRANE, LILACS and ongoing clinical trials at ClinicalTrial.gov.
Results: The search in MEDLINE and EMBASE identified three articles; one was a pilot study evaluating the use of fibrin matrix and autologous growth factors that included patients with chronic ulcers of different etiology. The second article was a description of the product used in the previous study, and the third consisted of a series case reports of patient treated with cultured keratinocytes in a fibrin matrix. A COCHRANE searched resulted in one study assessing the cost effectiveness of using different fibrin matrices. The search in ClinicalTrial.gov and LILACS did not result in any findings.
Conclusion: The study did not provide a conclusive evidence for the use of fibrin matrices in patients with venous leg ulcers.
Aim: Many classifications have been described in the literature for ptotic breasts, focusing on the nipple areola complex position compared to the inframammary fold. These use centimeters and lateral views to illustrate their various grades in a manner always insufficient to propose a clear treatment plan aimed at achieving natural results. We discuss a new dynamic approach to breast ptosis with a complete treatment algorithm.
Methods: Patients were examined in a standing position first with hands down then with hands up. We observed the elevation of the inter-nipple line called the “BK-line” and its relationship to a sternal benchmark that we call the "BK-Point". The "hands-up test" was positive when the line crossed the landmark. The algorithm defines the indication according to this clinical examination and to the patient's wishes. An angle between the nipple, the “BK-point” and the body meridian (called the “BK angle”) was appreciated before and after surgery. This angle should become 90° or more after ptosis treatment.
Results: Three hundred patients were treated for ptotic breasts, including breast reductions, from January 2010 to September 2017. The definitions of “normal” non-ptotic and ptotic breast and the “ideal” breast were reconsidered. The surgical indications were adjusted to the clinical situation and to the patient's wishes, refining the final version of the algorithm.
Conclusion: This new classification is easy, reproducible and efficient. We propose an appropriate algorithm to treat every situation that takes care to consider patient’s wishes and expectations.
Aim: Over the last 15 years, hyaluronic acid (HA) fillers have become the most popular injectable biomaterial for soft tissue correction. With the increasing number of available HA fillers and the multiplication of facial treatments all over the world, there has been a need from physicians to better understand the HA fillers science. There is especially a growing interest in the science-based evaluation of rheological characteristics which represents an essential tool to guide physicians in the selection of the most appropriate HA fillers, administration techniques and depths of injection for their clinical applications.
Methods: Four key rheological parameters (viscosity η, elasticity G’, normal force FN and elasticity E’) are measured and discussed on five HA fillers.
Results: These four key rheological parameters are demonstrated to play a pivotal role, in combination with the cohesivity, for better predicting the clinical behavior of HA fillers at different stages of their lifetime.
Conclusion: This article discusses the importance of four key rheological parameters during the main steps of the clinical HA fillers’ lifetime, from the product injection to the loss of clinical effects. A better knowledge of these HA fillers’ rheological parameters can help the physicians to optimize their aesthetic outcomes, safety and patient satisfaction.
Aim: Brachioplasty in patients who are normal weight, with moderate skin excess and who are not accepting long scars, remains a challenge for plastic surgeons.
Methods: We present our experience in 47 patients with short scar brachioplasty in combination with posterolateral liposuction, fascia anchoring and fat grafting in the inferomedial arm in order to improve skin quality and correct minor irregularities. Patients’ satisfaction rates were evaluated after 3 and 6 months following the procedure.
Results: Patients (groups IIa, IIb and IIIa according to Rohrich classification) showed high satisfaction rates with the result both after 3 and 6 months after the procedure. The results were maintained. There were 2 cases (4.2%) of isolated wound dehiscence occurred, which were all resolved conservatively with dressings and antibiotics.
Conclusion: The technique presented in this paper has shown to be an easy and effective solution for a diverse selection of patients suffering brachial lipodystrophy. Limited scar brachioplasty only has specific applications, and should not be considered a replacement for traditional brachioplasty.
Aim: Hyaluronic acid (HA) is considered as the gold standard biomaterial for facial soft tissue correction. Over the last 8 years, there has been a strong demand from physicians for HA products with high projection capacity to restore facial volume loss at the level of the cheeks, cheekbones, chin, temples and jawlines. The projection capacity is thus an essential property for HA fillers especially for the products dedicated to the restoration of the volume of the face.
Methods: In this publication, a new skin model assay for evaluating the projection capacity of HA fillers is presented, applied and discussed.
Results: This skin model assay enables to efficiently assess the projection capacity of a HA filler product. The comparative evaluation of a product benefiting from the novel OXIFREE technology and Juvéderm Voluma shows a higher projection capacity for the OXIFREE product than for Juvéderm Voluma.
Conclusion: This assay is demonstrated to be a key tool to guide physicians in the selection of products with high ability of tissue projection to optimize their aesthetic outcomes when they need to create facial volume.
Fournier’s gangrene or necrotizing fasciitis of the perineum scrotum and penis is a highly debilitating condition with a high mortality rate of 20% to 88% reported in the literature. Management is multimodal, and the importance of aggressive debridement, broad-spectrum antibiotics and intensive supportive care cannot be emphasised. The addition of newer modalities of ulcer/wound management like low level laser therapy, hydrojet debridement and platelet rich plasma can be used to augment the existing principles of management and reduce the morbidity and mortality associated with the condition. This article is the authors’ experience with the condition and the above stated newer modalities in the management while staying true to the principles of management.
Aim: Use of barbed sutures for flexor tendon repair is a promising technique. These sutures lie within the substance of the tendon, avoiding the need of external knots and so improving tendon gliding. The load is dispersed equally along the length of the barbed suture, decreasing the possibility of rupture. The purpose of this article is to propose enhanced suture geometry by comparing different cross-sectional configurations, barb cut angles and cut depths using the finite element method.
Methods: Inspired by the geometry of flexor tendons, an elliptical cross-sectional wire was investigated. Mechanical behavior of five different aspect ratios (ρ = 1/3, 1/2, 1, 2, 3), three different cut angles (150°, 154°, 160°) and three cut depths (0.07-mm, 0.12-mm, 0.18-mm) were studied via extended finite element analysis using ABAQUS, for two different loading conditions: one to assess the strength of the suture and the second to evaluate the strength of a single barb. An extended finite element method has been implemented on ABAQUS to predict crack growth in viscoelastic material.
Results: Based on these results, an elliptical suture having an aspect ratio of 1/2, 160° of cut angle, and 0.12-mm of cut depth is recommended.
Conclusion: Barbed sutures are a good option for tendon repair. Our experiments assessed the mechanical performance of barbed sutures and suggested an optimized suture geometry for a single-stranded repair technique.
Aim: This paper describes the author’s personal experience with using the minimally-invasive Earfold™ implant.
Methods: The author inserted the Earfold™ implant into 19 patients (5 men, 14 women) between November 2016 and June 2018. Bilateral implantation was performed in 14 patients. In 5 cases, implantation was limited to one ear. The author’s main indication for treatment was a helical-mastoid distance of more than 20 mm. Additional antihelixplasty of the upper ear was performed in 4 patients (2 primarily and 2 after explantation). One patient underwent simultaneous treatment of protruding ear lobes.
Results: The overall satisfaction rate was high, with 16 patients (84%) being satisfied or very satisfied. The procedure proved to be rapid with little down-time in the recovery phase. The demand for, and acceptance of the procedure was high. Although surgical otoplasty was always discussed as an alternative, no patient who presented for consultation chose standard otoplasty surgery. Complications occurred in 6 patients and implants were removed in 5 patients, 1 of them completely.
Conclusion: The EarfoldTM procedure is an interesting, minimally-invasive alternative to surgical otoplasty which produces results which patients are pleased with. However, in this early series, the complication rate was high. A hybrid technique might reduce the complications observed.
The ageing process starts in the centre of the face in the periocular region and around the mouth, with a combination of volume loss and tissue descent. It is a logical approach to assess all these problems at once. The combination of minimal incisions vertical endoscopic lifting combined with superficial enhanced fluid fat injection can be an integral approach to facial rejuvenation.
Stevens Johnson syndrome (SJS) is a rare and often fatal hypersensitivity reaction commonly triggered by drugs which results in the uncontrolled destruction of keratinocytes with both cutaneous and mucosal involvement. Fusion of the oral commissures, although reported in burn victims, is a very uncommon complication of SJS. The successful reconstruction of oral commissures fusion using a modified commissuroplasty technique in a 19-year-old Hispanic female with severe microstomia secondary to SJS is presented here. Re-establishment of normal speech, oral intake, as well as aesthetic appearance were achieved.
Facial aging is the combination of multiple effects such as sun exposure, tobacco, environmental stress and smog, reflecting the cumulative and dynamic effects of time on the skin, soft tissues and the deep structural components of the face that show an important change structural features of the skin and loss of facial volume. There are many different techniques currently used to perform face lifting, the ultimate goal is to get good results with respect for patient safety. This article describes a new approach to facial rejuvenation combining superficial musculoaponeurotic system (SMAS) plication elements on four vectors, with a blepharoplasty to achieve a lasting improvement in facial aging. The plication of the SMAS on the suture provides three vectors of elevation under the skin in the middle rhytidectomy, linked to the Lorè fascia and to the third platys elevation vector behind the ear. The blepharoplasty technique is often unavoidable in the execution of the global facial rejuvenation. This allows obtaining excellent results both in terms of aesthetic and of a good patient empowerment. This new surgical technique, called “KORU technique”, was used on 31 patients between October 2010 and October 2012, producing lasting results, reducing injuries and respecting anatomical planes. This approach can be safely and easily performed under local anesthesia as an isolated midface procedure, respecting and safeguarding the facial nerve. This type of chiropractic technique can be used by young surgeons.
Aim: Soft tissue defects with or without exposed bones in the lower extremity, ankle and the foot-with or without bone defects or exposed hardware-often require coverage with vascularized flaps. Free flaps, which add healthy tissue especially to the lower extremity instead of further injuring a limb, are the first choice in high volume microsurgical centres. Nevertheless, in some instances pedicled flaps may have indications when free flaps are not suitable.
Methods: The distally based peroneus brevis flap is harvested from the lateral compartment of the leg based on the distal perforating arterial supply and covered with split skin.
Results: We performed a total of 69 peroneus flaps between 2003 and 2017. Minor flap necroses at the distal tip were noted in 8% of the peroneus brevis reconstructions. Total flap loss occurred in 1 peroneus flap. Defect etiology and patient age were not associated with surgical outcome.
Conclusion: While nowadays the first choice of lower extremity reconstruction is an appropriate free flap solution, the peroneus brevis muscle flap can also be seen as a valuable tool to reconstruct small to medium sized defects at the ankle, distal tibia, and the heel with an acceptable donor site morbidity. Despite the easily available variety of free flaps to achieve this purpose, still proper indications remain where a local flap can be a viable option in the hand of experienced plastic surgeons. However, caution is advisable in patients with peripheral arterial occlusive disease or venous insufficiency.
Cherubism is a rare disease characterized by significant loss of medullary bone which is replaced by excessive amounts of fibrous tissue growth within the mandible and maxilla. We present a case of a 4-year-old boy with a rapidly enlarging mandible and maxilla, causing significant change in the facial contour, malocclusion and phonation difficulties. He was treated with aggressive tumor curettage, lateral mandibular cortex osteotomies with medial repositioning. This allowed obliteration of the enlarged medullary space and restoration of the normal mandibular anatomy. At 12 months postoperatively, the patient had significant improvement in facial contour, normal outward appearance, and stable dentition.
Due to the continuous development in the field of bariatric surgery, there is an increasing need for postbariatric body contouring surgery. The morbidity of postbariatric patients predisposes them to develop wound healing complications. In this article we describe the preoperative, intraoperative and surgical factors influencing the wound healing and therefore the final outcome. The most common postbariatric body contouring procedures, including brachioplasty, breast contouring surgery, abdominoplasty/circumferential body lift and medial thigh lift are being discussed in terms of wound healing characteristics and subsequent complications. The preoperative preparing as well as special operative techniques are described in order to achieve a low rate of wound healing complications.
Growing interest in regenerative medicine and advances in adipose tissue research have led to the identification of mesenchymal stem cells in adipose tissue, so called adipose tissue-derived stem cells (ASCs). Due to the simple and safe harvest technique as well as high regenerative capacity, ASCs are regarded as a potential source for various indications including cutaneous wound repair. This review provides a short overview over mechanisms of ASC action in cutaneous wound repair and data regarding its clinical application. Mostly experimental data provide accruing evidence for the supportive effect of ASCs in cutaneous wound healing by secretion of soluble factors, differentiation into keratinocyte and fibroblasts, neovascularization and interaction with myofibroblasts. A number of in vivo experiments also support a positive effect of ASCs in different wound healing models. Furthermore, first clinical data evaluated the feasibility of ASCs in the treatment of different wound healing pathologies, e.g., chronic ulcers and burn wounds. Although the majority of currently available data indicate a beneficial role of ASCs in cutaneous wound repair, additional detailed experimental studies and larger, high-quality clinical trials are required to provide a reliable statement on the true value of ASCs in this context.
Aim: Sternoclavicular joint infection associated with liver cirrhosis is an uncommon condition and the optimal surgical treatment is undefined.
Methods: Patients and methods: we retrospectively analysed data from six patients with sternoclavicular joint infections and liver cirrhosis underwent between February 2008 and May 2018 a staged therapy using negative pressure therapy followed by secondary "en bloc" joint resection and a pectoralis muscle flap (PMF) obliteration of the thoracic wall defect.
Results: Four patients successfully underwent a transfer of the PMF. The surgical revision was required for relevant bleeding in one and a tracheostomy was performed due to the prolonged intubation in another case. One patient died on the fifth day after surgery due to a cerebral septic embolic ischemia and aortic endocarditis.
Conclusion: The presence of liver insufficiency and coagulopathy was associated with an extensive blood product demand and required a well-balanced interdisciplinary management. During the follow-up only a minimal restriction in the shoulder mobility was observed.
Surgical treatment of deep partial thickness to full thickness burn wounds by knife has been the undisputed standard of care and was one key point in surgical burn medicine for decades. Recently, it gets more and more challenged by Bromelain-based enzymatic burn wound debridement (ED) as technique for non-surgical, selective eschar removal. Although the literature on ED is increasing constantly it cannot comprise the rapid progress that is made in clinical application of ED. To outline the current state of art in ED, recent literature as well as clinical experience is summarized and the main steps in clinical application including indications, wound preparation, application of the enzyme, wound bed assessment and further treatment after ED are discussed. Initial indications and limitations in application of ED could be gradually extended to increase versatility of ED as tool in burn surgery. Several randomized controlled trials compared ED to standard of care (SOC). They could show significant shorter time to complete burn wound debridement and wound closure, reduced need for surgery, reduced blood loss, reduced area of burns that needed surgical excision and need for autograft as well as an improved scar quality. Further research is necessary to justify an extensive use of ED as tool for burn eschar removal. Especially a robust comparison to surgical burn wound excision by knife as SOC is required to facilitate evidence-based burn surgery.
Aim: Common pitfalls with existing breast reduction techniques include poor aesthetic outcome, such as development of a “boxy” breast shape, and pseudoptosis. Presented here are a series of modifications to the technique of central mound breast reduction, based on previous work, aimed at ensuring consistent aesthetic results which are maintained in the long-term.
Methods: All patients undergoing bilateral breast reduction by the senior author over a 7-year period were included, with outcome data collected prospectively. A detailed description of the technique is offered.
Results: One hundred and sixteen patients underwent bilateral breast reduction over the study period. Mean follow-up was 20.6 months. There were no cases of nipple necrosis or infection requiring antibiotics. There was one post-operative haematoma which required surgical evacuation. Three patients developed a degree of fat necrosis which was managed conservatively in two, but required surgical debridement for liquefactive necrosis in one. Results of these breast reductions at the second post-operative year and beyond are presented.
Conclusion: The technique described offers benefits of improved predictability, consistency and longevity of aesthetic results over existing techniques. Development of pseudoptosis in particular is effectively delayed. The modifications described have not been shown to increase the rates of surgical complications.
Aim: The aim of the study was to describe the applicability of a single-layer acellular dermal matrix, in combination with split-thickness skin graft (STSG) in one-stage surgical procedure in patients with deep neck second - and third - degree burns.
Methods: A descriptive longitudinal study was conducted at the Burn Unit of the Health Services Unit of Simón Bolívar North Subnetwork E.S.E. of the Secretariat of Health in Bogotá, Colombia, from January 1 2016 to December 31 2017 in which we describe the applicability of a single-layer acellular dermal matrix in combination with STSG in one-stage surgical procedure in patients with deep neck second and third degree burns.
Results: A total of 9 patients were treated. Exposed areas required definitive coverage using a single-layer dermal regeneration matrix and autografts in a one-stage procedure, following excision of keloid scars and scar retractions (n = 7), and in the case of acute-phase deep burn wounds, following complete necrotic tissue removal (n = 2). No patient presented infection during postoperative follow-up. At 2 months postoperatively, stability of treated area and adequate resistance of the skin substitute and autografts could be observed. They appeared normal in color, with no degree of contractures or functional limitations.
Conclusion: This is the first study demonstrating that the use of a single-layer acellular dermal matrix template for one stage reconstruction of post-burn full thickness neck defects is an effective, safe and excellent reconstructive option. The use of an artificial dermal matrix in one-step surgical approach, allows rapid healing and early mobilization of the neck, and in selective cases, it may reduce the need for local-regional or free flap coverage; moreover, it is associated with excellent skin formation, good functional and esthetic results and minimal donor site morbidity.
Aim: The use of negative pressure wound therapy (NPWT) is well established in the treatment of chronic wounds. NPWT with instillation (NPWTi) combines traditional NPWT with the application of a topical irrigation solution (in this case octenidine based octenilin® wound irrigation solution) within the wound bed. The purpose of the study was to investigate the impact of NPWTi on pressure ulcers (PUs).
Methods: In total 13 patients with PUs in different locations were treated with negative pressure therapy combined with ocitenidine based instillation fluid after first surgical debridement. After 6 days the dressing was removed and wound closure using different local flaps was performed.
Results: Normal wound healing without irritation was found 30 days post-debridement and after 90 days the wounds showed complete healing. No adverse incidents occurred and no toxic tissue reactions were documented. During the follow up period, there was no recurrence of the PU in any of the treated patients.
Conclusion: It is generally recognised that for chronic wounds to heal, optimum wound bed preparation is of paramount importance. This helps prepare for secondary healing, skin grafting or coverage with flaps. Tests were performed in vitro simulating real clinical conditions using PU vacuum exudates. These tests quantified the antiseptic efficacy of octenilin® wound irrigation solution in the eradication of microorganisms. Further research is needed to establish the role of NPWTi with octenilin® in the management of category 4 PUs, but these initial results on 13 patients lead in the direction of developing an enhanced protocol for the treatment of chronic wounds.
New developments in regenerative medicine are bound to revolutionize the way we approach loss of function and form in human organisms. Especially in the field of reconstructive plastic surgery new biotechnologies find their way from bench to bed. Biofabrication is an evolving field that aims to combine natural biologic processes with bioartificial constructs with the scope of reconstituting tissue without having to rely on autotransplantation. In this brief review we present the concepts of intrinsic vs. extrinsic neovascularization and we discuss the use of neovascularization in three dimensional matrices. In a clinical context matrix flaps for application in reconstructive surgery can be fabricated this way.
Necrotizing fasciitis (NF) is a severe soft tissue infection which has to be treated with a radical debridement as the key element. In the further course often large tissue defects occur, so that a long-term stable defect reconstruction plays a crucial role after any successful debridement. The reconstruction can include split skin grafting or local and free flaps. Here we present a case of a 41-year-old male patient with a NF in the trochanter major region after spondylodesis and spinal cord stimulation (SCS) device implantation. After multiple operations including local and free flaps we performed a defect reconstruction using an arteriovenous (AV) loop and subsequent free latissimus dorsi transplantation leading to no further operations. This complex reconstruction can be considered as the final stage of any reconstruction latter.
Ischemia as well as ischemia-reperfusion injury (IRI) can cause serious tissue damage and therefore is a feared complication in reconstructive surgery. This is the reason why researchers around the world invest their efforts to improve tissue viability after ischemic events. Tissue conditioning offers a broad scope of different techniques which can be applied pre-, peri- or postoperatively to adapt the affected tissue to the subsequent stress during and after ischemia to prevent or minimize IRI. The different ways of tissue conditioning in flap surgery include surgical delay, ischemic conditioning, remote ischemic conditioning as well as thermic preconditioning and other techniques, using growth factors, pharmaceutical agents, extracorporeal shock waves as well as stemm cells. Therefore, we want to shed some light on the effects of ischemia and ischemia-reperfusion injury and further illustrate the different strategies of tissue conditioning with special concern to flap surgery but also regarding wound healing in general.
Aim: The aim of this study is to determine whether the split-thickness grafts should be applied to the treatment of burn patients, parallel to the relaxed skin tension lines as described by Kraissl, which would help scarring and reduce the development of abnormal scars.
Methods: A descriptive longitudinal case series study was conducted at the Burn Unit of Health Services Simón Bolívar North Subnetwork E.S.E. of the Secretariat of Health in Bogotá, Colombia, from 1 Jan 2016 to 31 Dec 2017. A total of 138 burn patients exhibiting deep partial- or full-thickness burns involving different body regions, except for the face, were included. Burns required split-thickness skin grafts for definite wound coverage, and these were applied transversely following relaxed skin tension lines. Results were assessed according to the Vancouver Scar Scale (VSS) during a 12-month follow-up. Within this period, function was assessed by the rehabilitation unit, after which physical and functional activities were determined and splinting was implemented, as per rehabilitation protocols, to control and improve functional and physical outcomes.
Results: Based on the VSS, most patients (134) had a mean score of 5 (range: 3-7), resulting in clinically acceptable scars with no functional limitations.
Conclusion: Applying split-thickness skin grafts to cover deep partial- or full-thickness burns along relaxed skin tension lines, such as Kraissl’s lines, seems to reduce wound tension force, which constitutes one of the most predominant factors contributing to the development of abnormal scars and functional sequelae.
Aim: Second degree superficial burns are painful and heal over a period of two to three weeks time. Multimodality treatment approach is effective in reducing time of healing, pain, rate of complications and overall cost of treatment. Aim of this study is to observe effect of low level laser therapy (LLLT) as an adjunct to conventional therapy for second degree superficial burn.
Methods: This article presents a case series of twenty patients in which LLLT was used as an adjunct therapy for target burn areas.
Results: Average time taken for complete healing of areas with second degree superficial burns was 11.75 (SD 2.86) days. One patient was healed on day 6; ten patients were healed on day 10, six patients on day 13, and three on day 17.
Conclusion: We could not found significant evidence of positive effect of LLLT over rate of wound healing. However its effects are promising and further large multicentric trials are needed to establish its role and standardize its dose parameters.
The periocular area is one of the first regions of the body to show signs of aging, which include static and dynamic rhytids as well as subcutaneous volume loss. The complex anatomy and dynamic underlying muscles of facial expression make this region particularly difficult to treat. Botulinum toxins and fillers, especially when used in combination, offer an excellent approach to minimally invasive rejuvenation of this area. This article aims to present a basic overview and clinical primer for the use of these injectables along with advice on avoiding and managing common complications.
The omentum is a well-established pedicled flap for coverage of intra-abdominal and thoracic pathology, and as a free-flap for a multitude of applications. Its use as a pedicled flap for extra-abdominal applications other than those on the chest is less well described. Here we present a case where a pedicled omental flap was utilized to provide circumferential and buried coverage of an in-line ilio-femoral bypass graft well below the level of the inguinal ligament. The reach of the omentum was more than adequate, and the delicate nature of the flap provided excellent circumferential coverage of a cryo-vein bypass graft.
Aim: The single-stage procedure is a challenging procedure for Plastic Surgeons. The single-stage layered mastopexy with augmentation is a new technique that is aiming to add safety, preserving breast function and to restore normal parameters of breast.
Methods: A retrospective chart review of 50 consecutive cases of layered mastopexy with augmentation mammoplasties was performed. All patients had their implants placed in muscle splitting pocket. Incisions for mastopexy were selected on the basis of nipple areolar complex to inframammary crease. Mastopexy is performed using a medially based pedicle, leaving a sufficient tissue covering the implant. Patients were divided into three groups. Group “A” who had periareolar mastopexy, Group “B” had vertical scar mastopexy and Group “C” patients had mastopexy with Wise pattern markings.
Results: Group A comprised 11 patients. The mean age was 28.82 ± 7.01 years, mean preoperative and postoperative nipple areolar complex (NAC) to IMC measurement was recorded in 10 patients with the mean of 7.15 ± 1.98 cm and 8.35 ± 1.18 cm respectively. Mean size of the implant used was 379.55 ± 77.18 cm3. Group B comprised 29 patients. Mean age was 35.17 ± 12.37 years and the mean preoperative and postoperative NAC to IMC crease was 8.53 ± 1.48 cm and 9.72 ± 1.51 cm respectively. The mean implant size used was 289.48 ± 109 cm3. Group C had 10 patients. Mean age was 39.60 ± 12.15 years and the mean preoperative and postoperative NAC to IMC crease of 10.11 ± 1.24 cm and 8.75 ± 0.98 cm respectively. The mean implant size used was 287.00 ± 55.08 cm3.
Conclusion: The procedure allows better arterial supply, wider area for venous and lymphatic drainage, better sensory innervation to NAC and maximises lactation potential of the breast.
Cervical splints are used to maintain the neck position in burn patients with involvement of neck, which provides pain relief and prevent hypertrophic scarring and contracture. Due to the technical difficulty, cervical splinting often deferred in patients with tracheostomy. To overcome the difficulty the authors have described a simple modification of hard cervical collar, which provided adequate immobilization and adequate space for tracheostomy care. Innovative modification of hard cervical collar proposed in this case report can be a solution to overcome the difficulty posed by tracheostomy in patients sustained with neck burns.
Aim: To affirm that autologous platelet rich plasma is a useful adjunct to early tangential excision and skin grafting to enhance wound epithelization rates and improve scar quality.
Methods: The study was conducted in JIPMER Tertiary Burn Care Centerfrom November 2017 to February 2018. The study was purely descriptive in nature and no statistical analysis was performed. A total of 12 patients were included with burn wounds involving 10% to 25% total body surface area.
Results: There was 100% epithelization noted at the end of 2 weeks for all the 12 participants. Skin graft take was faster with mean 85.4% take for all the 12 patients within 5 days.
Conclusion: Since it is an autologous component, platelet rich plasma is extremely safe and free of antigenic components. It is relatively simple to prepare, less time taking, cost effective and highly efficacious in improving wound healing and improving the efficacy of the traditional techniques like tangential excision and skin grafting in burn patients.