This study reviews information about the most novel ideas and modalities being incorporated into facial and neck cosmetic care. We seek to identify trends and developments within these areas as well as perceptions of plastic surgeons regarding their probable significance, and discussion on how these modalities may impact future practice patterns. It is hypothesized that nano and regenerative technologies are considered the most “hopeful”. Emerging invasive and non-invasive modalities utilizing nano and regenerative concepts were reviewed. We intentionally sought to investigate approaches to beautification, including maintenance and reversal of signs of aging, utilizing methods lacking an established level of evidence. This included promising modalities which are currently at the investigational stage. Twelve board-certified plastic surgeons were surveyed regarding the clinical importance of twelve concepts and their expected impact on facial and neck rejuvenation. Scientific and technological creativity in aesthetics is rapidly changing, and the efficacy of innovations and safety margins are improving. Nano and regenerative medicine-based technologies and procedures were ranked most promising for the future of cosmetics. Their potential applications and research were reviewed in the context of surgical and non-surgical modalities in clinical practice. There has been an advent of new approaches to facial and neck aesthetic surgery and tissue care, which is well-beyond just skin care. With this new level of knowledge regarding variability in care responses and indications for procedures on an almost “molecular level”, personalized and precise aesthetic surgery and medicine are quickly becoming a reality.

Modern face transplant techniques have advanced to allow for the transfer of vascularized skeletal components in addition to overlying soft tissue. This represents significant opportunity for individuals with mandibular defects that are not amenable to traditional reconstruction. Care must be taken when planning and executing transplants with these complex grafts, as satisfactory functional and aesthetic outcomes rely on achieving proper spatial relationships between the mandible, skull base, and midface. Which donor skeletal elements are included in the allograft and how they are harvested are important considerations in this planning and are associated with controversy. To optimize outcomes in the reconstruction of single-jaw defects, some advocate for transplantation of only the affected jaw while others support bimaxillary transplantation. Clinical evidence in this debate is not conclusive at this time. In current practice, including donor dentoalveolar anatomy by utilizing a bilateral sagittal split osteotomy of the mandible is favored to optimize outcomes such as dental occlusion. It has been suggested that harvesting the mandible at the level of the condyle or even the temporal bone may also be possible and may improve temporomandibular joint-related outcomes. Despite encouraging preclinical evidence, these strategies remain controversial. After allograft design, successful mandibular reconstruction with face transplantation relies on surgical precision in the donor and recipient procedures. Computerized surgical planning, computer-aided design and manufacturing, and intraoperative navigation are technologies currently in use to mitigate operative complexity. Results in both cadaveric and clinical face transplantations suggest these technologies are reliable and beneficial, although some room for improvement remains.

Congenital aneurysms of the palm are uncommon in the pediatric population compared to aneurysms in adults. A seven-month-old boy presented with a true aneurysm of the ulnar artery with reconstruction with surgical excision and end-to-end microvasculer anastomosis using a superficial vein of the dorsal foot. To our knowledge, there have been only 15 reports of congenital aneurysms of the palm.

Osseointegration (OI), targeted muscle reinnervation (TMR), and vascularized composite allotransplantation (VCA) are just a few ways by which our reconstructive ladder is evolving. It is important to recognize that amputation does not necessarily denote failure, but surgeons should strive to find ways to provide these patients with means for obtaining better satisfaction and quality of life postoperatively. TMR and OI have added options for mutilating lower extremity injuries that necessitate amputation. More recently, the senior author (Levin LS) described the “penthouse” floor of the reconstructive ladder being VCA. Despite the advances in VCA over the last 20 years, there are many challenges that face this discipline including indications for patient selection, minimizing immunosuppressive regimens, standardizing outcome measures, establishing reliable protocols for monitoring, and diagnosing and managing rejection. Herein, the authors review TMR, OI, and VCA as additional higher rungs of the reconstructive ladder.

Abdominal wall reconstruction is a relevant and important topic not only in plastic and reconstructive surgery, but in the practice of general surgeons. The ideal anatomic location for mesh placement during the repair of ventral hernias has been debated; however, the most common anatomic locations include onlay, inlay, sublay-retromuscular, sublay-preperitoneal, and sublay-intraperitoneal techniques, as defined by the European Hernia Society. Additionally, the availability of numerous synthetic and biologic meshes on the market provides for several options for the practicing surgeon. In this review, we provide a summary of the available literature of both the ideal mesh plane and the appropriate opportunities to use both synthetic and biologic meshes.

Aim: The rationale of using liposuction to treat lymphedema is that the chronic inflammatory process of lymphedema results in fat hypertrophy. The authors describe the technique of indocyanine green lymphangiography-guided liposuction, its rationale, and our patient selection criteria for better clinical outcomes.

Methods: Thirty-two patients underwent liposuction for breast cancer-related lymphedema. Indocyanine green lymphangiography was performed prior to liposuction. For patients without linear and splash patterns in indocyanine green lymphangiography, circumferential liposuction was performed liberally. For patients who had linear or splash patterns, liposuction was not performed at regions with remaining functional lymphatic vessels. Outcomes were assessed using circumferential reduction rate.

Results: At a mean follow-up of 24.5 ± 6.5 months, all (100%) patients had a reduction in limb circumferences after liposuction. The mean circumference reduction rate was 67.6% ± 27.9%.

Conclusion: Liposuction is a valuable treatment for breast cancer-related lymphedema. We believe patients with fat predominant lymphedema are the best candidates for liposuction.

Prehabilitation for abdominal wall procedures provides an opportunity to further modify patient risk factors for surgical complications. It includes interventions that optimize nutrition, glycemic control, functional status, and utilization of the patient’s microbiome pre-, intra-, and postoperatively. Through a multidisciplinary and anticipatory approach to patients’ existing co-morbidities, the physiological stress of surgery may be attenuated to ultimately minimize perioperative morbidity in the elective setting. With increasing data to support the efficacy of prehabilitation in optimizing surgical outcomes and decreasing hospital length of stay, it is incumbent on the surgeon to employ these practices in elective abdominal wall reconstruction. Further research on the effects of prehabilitation interventions will help to shape and inform protocols that may be implemented beyond abdominal wall procedures in an effort to continually improve best practices in surgical care.

Aim: Unpredictable retention outcomes remain a significant issue in autologous fat grafting procedures. Liposuction cannula variation leads to variability in fat particle size. Recent data suggest that the size of fat particles is closely related to graft healing outcomes; however, this remains a point of contention due to potential confounding variables such as tissue trauma with harvest. The aim of this study was to compare autologous fat grafting outcomes with variable fat particle sizes in an animal model which isolated fat particle size as the primary experimental variable. The overall goal of this work was to determine if reducing fat particle size is an effective method for enhancing graft retention in autologous fat grafting.

Methods: The range of fat particle diameter harvested by four common liposuction cannulas was quantified to define relevant small and large particle target diameters. To determine if particle size impacted nutrient and oxygen permeability, small and large particles were incubated in vitro in a spinner flask with an abundance of culture media and vascular endothelial growth factor secretion was measured with enzyme-linked immunosorbent assay. Finally, small and large fat grafts were prepared from subcutaneous mouse fat pads and grafted in syngeneic Balb/CJ mice. Weight and volume retention were evaluated at 1, 4, 8, and 12 weeks. Histological analysis with Masson’s trichrome and perilipin immunofluorescent staining was performed. Real-time quantitative polymerase chain reaction was performed for adipogenic, inflammatory and apoptotic genes.

Results: The range of fat particle diameters harvested with four commonly used cannulas was 2-7 mm. In vitro studies showed that 5-7-mm particles had significantly increased VEGF secretion normalized to weight, indicating increased tissue hypoxia in these particles compared to 2-4-mm particles. Surprisingly, in vivo comparison in two unique studies showed 2-4-mm and 5-7-mm fat particles had comparable graft retention (P = 0.5329). Masson’s trichrome staining revealed increased extracellular matrix and fibrosis in the 5-7-mm particle group (P = 0.0115). Adipocyte survival with perilipin demonstrated comparable viability. Gene expression showed large particles experienced increased inflammation and apoptosis at one week after grafting, but overall there were no significant differences between groups.

Conclusion: The ideal fat particle size should be large enough to contain adequate mesenchyme while not so thick as to preclude imbibition. This study suggests that, despite changes in hypoxia and VEGF levels, differing fat particles (2-4-mm and 5-7-mm) can achieve similar graft retention.

As people live longer and stay healthier, many want to look as youthful as they feel. The general population continues to explore nonsurgical options to augment and possibly delay traditional rhytidectomy. Herein, we present a unique nonsurgical option to enhance our current modalities of neuromodulators and fillers commonly used on the face and neck. In addition, we discuss the ideal application of this technology including treatment times and intervals between treatments.

Lipedema is a frequently unrecognized and misdiagnosed disorder of the fatty tissue of extremities and hips, which affects almost purely women. The beginning of the disease usually occurs with hormonal changes, such as puberty, pregnancy, or menopause. Women suffer from pain, easy bruising, and disfigurement, which may lead to early immobility and social stress. Accurate diagnosis and treatment are essential. The differentiation between obesity and lipedema is difficult, as these two different entities often occur together. Other differential diagnoses are lymphedema, benign lipohypertrophy, and Dercum’s disease. A therapy targeting the underlying cause of lipedema is not available because the exact etiology of the disorder is not clarified yet. Decongestive physical therapy is the basic conservative treatment, which is usually necessary lifelong. However, liposuction has led to a paradigm shift in the treatment of lipedema. The purposes of this article are to describe the symptoms and treatment options of the still fairly unknown disease Lipedema and to show the distinctions to its differential diagnoses.

Aim: With the normal aging process, the malar fat pad descends vertically, causing a number of characteristic changes to the face. Various techniques have been used to correct ptosis of the malar fat pad.

Methods: The authors describe a technique that is minimally invasive and can be used to correct malar fat pad ptosis. This technique uses a suspension suture to elevate the malar fat pad to a more youthful position. The technique has been successfully used in 71 patients.

Results: All of the cases were performed in the office setting under local anesthesia. There were no complications, and, by patient self-report and physician exam, results have been lasting and satisfactory.

Conclusion: The minimally invasive midface suspension is a safe and successful approach to midface rejuvenation in properly selected patients.

Aim: Eyelid contour is a key component to satisfactory lid position and appearance following ptosis repair, the components of which have been highly debated and remain difficult to objectively measure. We sought to minimize the number of intraoperative adjustments required and reduce reoperation rates by addressing only the central 6 mm of tarsus when reapproximating levator to the anterior surface of tarsus, thereby eliminating contour as an adjustable variable.

Methods: All patients who underwent external levator resection with blepharoplasty for correction of involutional ptosis between 2012 and 2019 by a single surgeon at one center were retrospectively reviewed. Patients who underwent concomitant brow lifting surgery were excluded. The same technique was used for each eyelid with uniform suture placement. One 6-0 silk horizontal mattress suture was placed partial thickness through the superior third of tarsus 3 mm lateral to the center of tarsus; another was passed 3 mm medial to the center of tarsus. No sutures were placed outside of this central 6-mm zone. Patient fixation was used to determine lid height and symmetry. Once satisfactory, the sutures were tied down in a permanent fashion and the eyelid position again verified. In total, 153 eyelids in 85 patients were evaluated. Data obtained included preoperative and postoperative margin-to-reflex distance (MRD1), intraoperative and postoperative complications, reoperation rates, and patient satisfaction with appearance of lid contour and symmetry.

Results: The mean follow up time was 3.41 months. The mean preoperative MRD1 was 1.05 mm. The mean post-operative was 3.18 mm. All patients had recovery of an anatomically normal temporal peak height. Two of 153 eyelids (1.31%) required reoperation due to residual ptosis or overcorrection. No patients had postoperative lagophthalmos. Ninety-one percent of patients who underwent bilateral surgery had satisfactory symmetry defined as less than or equal to 1-mm difference between right and left MRD1. Eighty-two of the 85 patients were satisfied with their postoperative appearance.

Conclusion: This simple and standardized technique for suture placement gives reliable and effective results for external elevator advancement for ptosis repair by eliminating contour as an adjustable variable. Addressing the central 6 mm of tarsus is not only paramount but also in and of itself satisfactory in achieving optimal contour during external levator resection, without regard to more medial or lateral lid anatomy.

Aim: To review the choices of soft tissue coverage in distraction osteogenesis of the extremity.

Methods: A PubMed literature search yielded 14 articles included for systematic review. Data were extracted from each article if available (sample size, patient age, surgical indications, type of flap, use of additional modalities, method of bone osteogenesis, postoperative events, follow-up, satisfaction, weight-bearing status, and success rate). Unpaired t-tests were performed to compare complication rates. A retrospective review of three cases was also conducted.

Results: Fourteen articles discussed 145 patients with a mean age of 33.4 years and 146 extremity injuries followed over 3.3 years on average. Indications included chronic osteomyelitis or nonunion (58.2%) and acute trauma (41.8%). Average time from injury was 1.1 years. Ilizarov frame was used in 12 articles. Free flaps (88.0%) or rotational flaps (12.0%) were used, with muscle flaps (96.7%) being most common. Most extremities received free latissimus dorsi or rectus abdominis flaps. Bone grafts and antibiotic beads were often used in conjunction. Although complications and reoperations were not uncommon (up to 30%), 98.8% of patients on average were ultimately weight bearing and all articles reported > 91% success rate. Additionally, the rates of any complication were not statistically different between “fix and flap” protocol and flap or frame first. Lastly, a three-patient case series is presented.

Conclusion: Bone transport with soft tissue reconstruction remains an excellent choice for patients with large bony defects or who are unable to undergo autologous bone grafting. Not one surgical approach to limb salvage is superior, and decision should be made on a case by case basis between the surgeon and the patient.

The extracellular matrix (ECM) occupies the space between cell and cell, and serves as a sort of intranet which connects the whole organism. Current research is focused on the ECM and, it is now possible to develop increasingly effective strategies for the prevention and treatment of degenerative diseases and even, cutaneous ageing. In fact, the most advanced anti-aging treatments are those that regenerate the ECM, which is now regarded as the main player in the physical support of, and exchange with and between cells of nutrients, cellular mediators and growth factors.

Breast cancer-related lymphedema (BCRL) can affect breast cancer patients, especially after axillary surgery and radiation treatment, for life. First line treatment is conservative and involves physical therapy and compression. It requires absolute, life-long compliance with treatment by the patient and, in some cases, it is ineffective. In recent years, surgery has emerged as a possible alternative or even, complementary therapy for BCRL. The most commonly reported techniques are reconstructive or debulking procedures. Reconstructive procedures are aimed at restoring the lymphatic pathways and can be effective early in the disease process, when increased arm volumes are mostly due to the accumulation of protein-rich fluid in the interstitial space. In more advanced stages, where fibrotic and hypertrophic adipose tissues are dominant, debulking techniques such as liposuction can be recommended. A standard of care for the treatment of BCRL has not been established. Currently, different techniques can be combined to optimize clinical outcomes, and the surgical approach must be individualized for each patient, based on sound clinical and imaging assessment. BCRL surgical treatment remains a challenging topic that requires further study before it can be standardized.

Fascial closure is crucial for abdominal wall reconstruction (AWR) but can be especially difficult in patients with massive ventral hernias or loss domain. Recently, botulinum toxin A (BTA) has been increasingly utilized as an adjunct in AWR to aid in fascial closure. This review aims to evaluate the current literature on the use of BTA in AWR to assess current treatment regimens, side effects, outcomes and complications. A literature search was performed, yielding 10 studies that met the inclusion criteria. There was a significant amount of heterogeneity in treatment regimens, with studies differing in BTA injection timing, dosage, concentration, and location. The majority of studies showed that injection of BTA preoperatively was able to augment abdominal wall musculature, with many showing a decrease in mean transverse defect size and high rates of successful fascial closure. No major complications were reported from BTA administration, with only mild side effects reported by some studies. The most common side effects include a weak cough or sneeze, bloating, and back pain, which generally all resolved prior to surgery. While BTA appears to be a promising adjunct for AWR, further investigation is needed to determine optimal patient selection and treatment regimens.

Aim: The aim of this study was to evaluate the usefulness of suction-assisted cartilage shaver (SACS) system closed curettage by comparing it with open excision regarding safety and efficacy.

Methods: A retrospective chart review was conducted for patients with axillary osmidrosis (AO) who underwent either open excision or SACS closed curettage between 2006 and 2018. We investigated the demographic data of patients and compared the postoperative complications and outcomes of the patients undergoing the two procedures.

Results: A total of 91 patients underwent SACS closed curettage and 188 patients underwent open excision. The complication rate in the SACS group (10.4%) was significantly lower than that in the open excision group (20.7%). Each procedure led to unsuccessful outcomes for two patients.

Conclusion: SACS closed curettage was safer than open excision for AO. Both procedures were extremely effective. Although decision-making for surgical treatment options for AO is affected by such other factors as discomfort in dressing, recovery time, scar formation, and cost, our results should be helpful for both surgeons and patients.

Large abdominal cutaneous defects may occur in association with complex ventral hernias, trauma, tumor resection, necrotizing infections or septic evisceration. Soft tissue reconstruction of the abdominal wall is performed when there is insufficient adipocutaneous tissue to permit standard, primary closure. A number of reconstructive techniques are available, the choice of which is based on a number of factors, including the size and location of the defect, etiology, and timing of closure. In general, local fasciocutaneous advancement flaps and adjacent tissue rearrangement are the workhorse techniques, followed by regional myocutaneous flaps and free tissue transfers for the most complex and extensive of defects. Herein, we describe our approach to abdominal soft tissue reconstruction, indications, technical nuances, and management of complications.

Lymphoedema is a chronic debilitating disease of the lymphatic system that occurs due to either abnormal development or damage of the lymphatics resulting from cancer or infection. The optimal treatment of lymphoedema is still elusive. Management is tailored according to clinical features, investigations and expectations of each patient. Lymphoedema patients should undergo a trial of conservative management with compression therapy, manual lymphatic drainage and external sequential compression devices. Early lymphoedema is treated by lymphovascular anastomosis, where the lymph vessels are connected to the subdermal veins by supermicrosurgery. In late cases when the limb is fibrotic, vascularised lymph node transfers are done, where lymph nodes are transferred from a healthy area to the affected area. In advanced cases, when the limb is fibrotic with cutaneous folds and skin changes, surgical debulking is done. In lymphoedema, along with accumulation of lymphatic tissue, there is also fat deposition, which can be removed by liposuction. One should be conversant with all treatment modalities to provide the lymphoedema patient with optimal care.

Periorbital rejuvenation is a common aesthetic goal sought by patients presenting to the plastic or oculoplastic surgeon. For this reason, it is critical that the surgeon understand the functional considerations, such as preexisting blepharoptosis, which will contribute to the ultimate aesthetic outcome. This article will review the anatomy of the normal and ptotic lid and will discuss the approach to diagnosing and characterizing the type and degree of lid ptosis. High-yield surgical techniques for ptosis correction will then be described, including the indications for and steps of each procedure. Finally, the diagnosis and management of common complications that follow ptosis surgery will be discussed. Our main objective is to arm the surgeon with the preoperative and operative planning tools to successfully manage comorbid ptosis and thereby improve blepharoplasty outcomes.

Building a tertiary referral center of excellence for complex abdominal wall reconstruction is a multi-step process that requires many elements to garner and promote success. Ultimately the creation of such a center is important for continual improvement of abdominal wall reconstruction outcomes by decreasing complications, recurrences, length of hospital stay, hospital readmissions, and overall costs. Establishing a center of excellence incorporates several key components including the surgeon’s desires and expertise, institutional participation, multidisciplinary collaboration, outcomes research and innovation, and financial stability. This article outlines the principal elements of building a sustainable, functional, and successful center of excellence for complex abdominal wall reconstruction.

Aim: The objective of this follow-up study was to explore the barriers and facilitators to use of daytime compression among women with breast cancer related lymphedema who previously took part in a trial examining the efficacy of night compression.

Methods: We used a multi-methods approach involving a survey and subsequent focus group sessions. The survey questions were developed based on clinical experience and findings from the literature. Questions were framed to align with the Theoretical Domains Framework. For the focus group data, we applied an interpretive description qualitative methodology to understand participants’ experiences and views on use of daytime compression. Qualitative findings were mapped to the Theoretical Domains Framework.

Results: Questionnaires were completed by 48 of 52 participants. Only 15 participants (31%) reported adhering to wearing the garment for greater than 12 h each day. Better adherence was positively associated with perceived control of lymphedema (r = 0.304; 95%CI: 0.051-0.564 ; P = 0.021). Survey findings suggest that participants have good knowledge about the rationale for, and the benefits of, wearing the compression sleeve. Twenty-three survey respondents took part in one of the five subsequent focus group sessions. Five key themes were identified representing the primary barriers to regular use of daytime compression: discomfort, negative emotions, interference with function, social situations and visibility, and use of alternative management strategies.

Conclusion: The findings suggest less than optimal adherence to daytime compression sleeve use. Further research is needed to explore the relative benefit of daytime compression, optimal wear times, and implementable strategies to improve adherence.

Reconstruction of dorsal hand soft tissue defects after severe injury is challenging for surgeons. Depending on the degree of defect, extensor tendon reconstruction may also be necessary. Various reconstruction methods are commonly performed to cover dorsal hand defects, such as skin grafting and distant, free, or local flaps. Among them, free vascularized flap transplantation is an ideal procedure because the major vessels that feed the local flap may have been damaged, and the affected limb can be reconstructed using a flow-through method. Although free flap surgery has advanced, few surgeons can choose this option due to its technical difficulty and uncertainty. On the other hand, distant flaps have been commonly used for the reconstruction of dorsal hand defects, and local flaps, such as reverse forearm flaps and retrograde posterior interosseous flaps, do not require microvascular anastomosis. However, they have some problems; distant flaps require at least two surgeries, reverse forearm flaps sacrifice major vessels and leave a scar at the donor site, and retrograde posterior interosseous flaps require meticulous dissection of the vascular pedicle. The radial artery perforator-based adipofascial flap is a versatile flap that is safe and easy to elevate without sacrificing the radial artery. In addition, elevating it as an adipofascial flap enables surgeons to avoid an unacceptable donor scar. We present two cases, demonstrating the usefulness of this pedicled perforator flap.

Aim: Traditional facelift techniques rely on pulling. They approach the superficial or intermediate layers where the facial nerves and muscles are located, increasing the risk of facial nerve injury. They approach the central oval from the periphery and produce unnatural vectors of pull and aesthetic results. Alternative techniques that work on the subperiosteal plane using endoscopic techniques are described. Modern concepts of volume augmentation, beautification and rejuvenation of the facial expression are an inherent part of such techniques, or can be easily integrated.

Methods: The central oval is approached via four small scalp incisions and additional intraoral, upper gingivo-buccal incisions. The interconnected frontal subperiosteal, temporal subfascial and midface subperiosteal areas are lifted, imbricated and suspended sequentially. The brow/forehead is suspended to the skull using cortical screws. The midface and lower periorbita are suspended to the fascia of the temporal muscle. The buccal fat pad is used to enhance the ogee line of the midface. Other three-dimensional volumetric maneuvers can easily be applied. In this setting, upper and lower lid blepharoplasties become more straightforward, skin only procedures. Actinic or nicotine damaged skin can be treated with lasers, peels or fluidified fat grafting in the same setting. The excess skin on the lower face and neck can be redrapped with standard cervicofacial techniques. Deep subplatysmal cervicoplasty can be done concomitantly, or at another time to complete comprehensive rejuvenation.

Results: The procedures described herein has been performed in 824 patients with excellent aesthetic results and low complication rate. The average rate of rejuvenation was 18 years.

Conclusion: These combination techniques are called Biplanar Endoscopic Assisted Mask and Triplanar Endoscopic Assisted Mask facial rejuvenation. They are advanced techniques of facial rejuvenation that provide comprehensive, natural, long lasting results.

Aim: Cryopreservation of fat is an effective method for repeat fat grafting, but there are few reports about the clinical use of cryopreserved fat. The aim of this study was to determine the effectiveness and safety of cryopreserved fat for clinical use.

Methods: Between Aug 2015 and Dec 2018, we investigated 590 patients who underwent fat harvesting at our clinic. The harvested fat was cryopreserved at a temperature of -196 °C at a cell processing center and injections were performed in our clinic.

Results: Of the 590 patients studied, 216 (312 cases) have undergone fat injections so far. Volume augmentations using harvested fat, such as facial and breast augmentations, were performed on 180 patients. For 84 patients, harvested fat was utilized only for revitalization/fertilization purposes, such as to improve skin condition. There were no severe complications in any patients. However, volume maintenance was rarely observed. Skin rejuvenation effects were comparable to that in cases using fresh fat.

Conclusion: The clinical use of cryopreserved fat is thought to be safe and effective.

With refinement and better understanding of Plastic Surgery, there is increasing expectation of aesthetic outcomes after resurfacing of wounds. The major problems in resurfacing procedures are tissue bulk, donor site issues, excessive scarring and distal edema due to damaged lymphatics and veins after flap harvest from adjacent areas in the extremities. Ultra-conservative debridement simplifies reconstruction by reducing the need for flaps and improves the chances of skin graft take through limited access dressing, which can improve the final aesthetic result following reconstruction. In this paper, we describe three representative cases treated under limited access dressing.

Stem cells and tissue engineering have made great strides in plastic surgery. This review of the literature evaluates some current background information and recent advances in our laboratory to bring these areas more into the clinical setting.

Secondary damage in trauma may increase morbidity, mortality and the cost of treatment considerably. This article reviews the literature of 46 relevant articles on this topic. We hope to provide a better understanding of the various mechanisms that can lead to secondary damage following major trauma and aim to improve the management of such in trauma patients. We also explore the utility of limited access dressing and its ability to minimize and treat secondary musculoskeletal trauma. Four interdependent cellular mechanisms have been described that contribute and perpetuate secondary tissue damage - lysosomal, protein/enzyme denaturation, membrane permeability and mitochondrial. Systemic changes are mainly due to systemic hypoxia and the systemic inflammatory response syndrome. Limited access dressing appears to be an efficient and cost-effective method for the management of secondary damage, as evidenced by the reduced number of debridements, shorter wound coverage time, and reduction in total length of hospital stay while lowering treatment costs and improving quality of care.

Aim: To describe findings when comparing lympho-SPECT-CT images before and after lymphovenous anastomosis (LVA) surgeries and to correlate these results with pre- and post-operative volume changes in the limbs of patients.

Methods: An observational, prospective, longitudinal study was designed. 20 consecutive patients were treated for lymphedema by means of LVA between 2015 and 2018. All were affected by secondary lymphedema (ISG II-III) following lymphadenectomy, radiation or both. All patients received preoperative rehabilitation as well as radiotherapy after oncological surgery. Limb volume was measured before surgery and at one year later. LVA was performed under general anesthesia with ICG guidance. ICG was also used to evaluate postoperative outcomes. Lympho-SPECT-CT was performed in all subjects at their first consultation and at one year after every surgical intervention. Description of findings included an absence of lymph nodes, new lymph node activity in anatomical areas and new lymphatic activity in extra-anatomical areas.

Results: Limb volume decreased in 19 patients after LVA. Six patients showed preoperative linear ICG patterns, combined with areas presenting with another type of pattern. After LVA, the linear pattern was observed in 11 patients. SPECT-CT/lymphoscintigraphy before surgery showed a total absence of lymph nodes, except in two cases, in whom small nodes in anatomical locations were described. After LVA, we observed new landmarks in 16 patients corresponding to lymphatic circulation that was not present in preoperative studies. In six cases, new lymphatic activity compatible with lymph nodes was detectable after LVA. The Spearman correlation coefficient was negative when circumferences and lympho-SPECT-CT were tested (P = 0.02).

Conclusion: Results showed a postoperative decrease in volume that correlated inversely with lympho-SPECT/CT findings. Lympho-SPECT/CT provided additional information related to accurate identification and the anatomical location of lymphatic structures that were not observed before reconstructive surgery. It can be a complementary test to conventional lymphoscintigraphy.

The life quality of patients with craniofacial malformations is severely affected by the physical disabilities caused by the malformation itself, but also by being subjected to bullying, which leads to a series of relevant psychological and societal effects that have an economic impact on the health sector. Orofacial clefts, notably cleft lip (CL), cleft palate, and microtia, are the most common craniofacial birth defects in humans and represent a substantial burden, both personal and societal. On the other hand, osteoarthritis is a widespread degenerative disease that is becoming more common due to the extension of the human lifespan and to an increase in injuries in young people as a result of their lifestyle. Advances in tissue engineering as a part of regenerative medicine offer new hope to patients that can benefit from new tissue engineering therapies based on the supportive action of tailored 3D biomaterials and the synergic action of stem cells that can be driven to the process of bone and cartilage regeneration. This review provides an update on recent considerations for stem cells and studies on the use of advanced biomaterials and cell therapies for the regeneration of craniofacial congenital malformations and articular degenerative diseases.

Nerve transfers were used, originally, to restore shoulder and elbow function in brachial plexus lesions. This concept has been developed over the years and applied to distal nerve injuries in which lower functionality was expected because of the gap between the injury site and the target muscle. The aim of this review is to describe nerve transfers in the distal forearm and hand for isolated lesions of the median, ulnar and radial nerves. The different advantages achieved by transposition of a functional nerve stump near the effector muscle have opened up new options for the management of nerve lesions. Some of these alternatives have only been recently reported and a few are exclusively case reports.

An increasing number of transgender and gender non-conforming patients are seeking genital gender affirming surgeries in order to better align their physical characteristics with their innate gender identity and treat gender dysphoria. Phalloplasty is the most complex of these surgeries, and this complexity creates a wide range of potential complications. Some of the most common complications and therefore, targets for improvement in outcomes, concern neourethral fistula/stricture, efficacy of reinnervation of the phalloplasty flap, postoperative flap monitoring, and donor site morbidity. In the setting of no established “gold standard”, this review seeks to describe the components and staging of phalloplasty, with an emphasis on established and experimental solutions to the most common and vexing problems.

Keloid is a fibroproliferative disorder resulting from the abnormal wound healing process, and it causes both cosmetic concerns and functional disabilities. Genetic predisposition, wound trauma, foreign body reaction, mechanical stretch, and immune dysfunction are common risk factors, but there remain mechanisms unclarified, leaving challenges in addressing the clinical concerns of recurrence and resistance. However, similar patterns of growth and metabolism between keloids and cancers provide a unique insight into the future exploration of keloid pathogenesis. Psychological stress has been demonstrated to be involved in the development and drug resistance of multiple cancers, but this aspect remains less-explored in keloids. Clinical observations and published investigations have noticed that persistent stress is common among keloid patients and their symptoms tend to deteriorate under stressful conditions. Following a thorough review of the published literature, we have identified three signaling pathways that might imply how stress hormones are likely to influence the keloid pathogenesis via activating adrenergic receptors and dysregulating the immune system. Thus, we hypothesized that psychological stress would be a key risk factor for keloid development via stimulating fibrosis, aggravating local hypoxia, and inflammation.

This review examines the issue of equality of care amongst those with cleft lip and/or palate in the European Union (EU) and beyond. Issues of equality both between and within national populations are considered, and it is argued that those from countries with smaller healthcare expenditure and who are from marginalised groups are at the greatest risk of, and affected most severely by, healthcare inequalities. The socioeconomic impact of inequality is also discussed. Having reviewed these topics, the goals and activities of the European Cleft and Craniofacial Initiative for Equality in Care Action, formed pursuant to an award from the EU’s European Cooperation in Science and Technology, are introduced. Constituted of an open network of clinicians and researchers committed to exploring and reducing such inequalities, the ongoing Action is formed of multiple working groups examining these issues within the EU and has organised training schools, conferences and short-term scientific missions concerned with these issues. These activities are discussed along with the future directions of the Action, the impact it has had to date and the benefits of the European Cooperation in Science and Technology award.

Hyaluronic acid (HA) is the most common component of aesthetic fillers. Many formulations exist, each exhibiting properties that are manifestations of individual molecular modifications. The enzyme hyaluronidase degrades hyaluronic acid and can therefore be injected into soft tissue to reduce suboptimally placed HA fillers or to reverse local ischemic complications. The clinically available varieties of hyaluronidase may be derived from crude animal extracts or genetically engineered from recombinant human DNA. Different HA fillers are not uniformly dissolved by a single source hyaluronidase, and hyaluronidase from different sources may have varying efficacy in the degradation of HA. Previous studies of subsets of HA fillers and hyaluronidases have provided limited and often conflicting data regarding these differences, and a more comprehensive scientific study is needed. In this review, the authors describe commonly available formulations of HA and hyaluronidase and review all studies of HA-hyaluronidase interaction available via a PubMed and Google Scholar search from 2005 to present, exploring trends in the data. Factors determined to confer increased resistance to degradation included higher concentration of HA, higher crosslinking density, and status as monophasic versus biphasic. Fillers of the Juvéderm family were generally found to be more resistant to degradation than members of the Restylane family. Results are less consistent for Belotero Balance. No variety of hyaluronidase was consistently superior at dissolving any variety of HA filler. More research is needed to clarify these clinically relevant relationships.

Aim: To determine the association between dental anomalies and type of facial cleft, gender, ethnicity and timing of hard palate repair surgery.

Methods: This observational study comprised a total of 85 non-syndromic cleft children (mean age 9.7 ± 3.2 years) of different ethnicity (68 Caucasians, 7 Asians, 4 Africans, 5 Hispanics and 1 Indian). Sixty-four patients were affected by lip palate cleft, 11 by lip alveolus cleft and 10 by palate cleft. Sixty-one children underwent delayed palate repair at 4.3 years of age, while 21 underwent early palate periosteoplasty at 7.2 months of age. Patients were examined clinically and radiologically to assess dental anomalies. Dental cavities were registered using dmft/DMFT indexes in primary and permanent dentition, while enamel defects were evaluated only in permanent teeth using Aine index.

Results: Tooth rotation and agenesis were the most common tooth anomalies affecting 59% and 42.2% of cleft patients, respectively. While a late closure of the cleft palate was associated with a higher number of rotations (P = 0.03), an early surgical correction was associated to a higher frequency of tooth agenesis (P = 0.02), number of carious lesions in primary dentition (P = 0.002) and more severe enamel defects in permanent teeth (P < 0.01). A late palate repair increased 3.5 times the likelihood of having at least one rotated tooth (P = 0.034), while decreased the odds of having agenesis by 70% (P = 0.029) compared to an early surgical repair.

Conclusion: Early surgical approaches seem to have more detrimental effects on dental development in both primary and permanent dentition than late surgical protocols. Dental abnormalities in cleft patients have complex etiology combining genetic and external factors and their prevalence can also depend on timing of hard palate surgery.

Aim: Although not very popular, the olecranon bone graft is a useful option for this type of operation due to the minimal donor morbidity and its ease of use in small bone defect reconstruction and non-union therapy. To our best knowledge, few studies have evaluated the use of the olecranon bone graft as a treatment for non-union after distal finger replantation. Our aim in this report was to present our experience of using olecranon grafts in our nonunion patients undergoing distal replantations.

Methods: Between 2013 and 2019, a total of 14 patients who developed nonunion or had segmental bone defects due to the injury were included in the study. Retrospectively the results were analyzed in terms of complication and union rates.

Results: The mean follow-up period was 37 months (range 8-72 months). No major complications were seen in the donor region or recipient regions. One patient developed necrosis in the nail bed and one patient had a hematoma in the donor site. The minor complications were solved without any problem.

Conclusion: In conclusion, we found the olecranon bone grafting for the treatment of nonunion after distal finger replantation is a safe and convenient method. It can be preferred as the first choice for nonunions of distal finger replantations.

About 5%-11% of all abdominal surgery results in incisional hernia. This rate can be even higher among high-risk populations such as transplant patients. Lifetime incidence of incisional hernia following liver transplant is as high as 43% in recent studies. The transplant population is at higher risk for incisional hernia precisely because of their immunosuppressive therapy. Thus, it is imperative to understand the risk factors for incisional hernia in this unique patient population. This article focuses on understanding preoperative, intraoperative, and postoperative risk factors for failure of hernia repair in the transplant population in addition to discussing risk stratification for incisional hernia in this population. Furthermore, we discuss the utility of panniculectomy in abdominal organ transplantation. Additionally, we discuss the value of mesh placement in abdominal wall closure. Finally, we review the concept of vascularized composite allograft as a method for achieving abdominal wall closure for patients who have failed more traditional repairs and who are left with inadequate tissue for successful repair.

Langer’s lines are still the recommendation and matrix for surgical incisions in most surgical textbooks, even if they were never meant to be by their first describer in 1861. To achieve minimal scarring, surgeons should attempt to make incisions parallel to skin tension lines, i.e., in skin folds or skin creases. On the basis of visible stretch marks (striae distensae) in the skin, which always appear in the same direction against skin tension in men and women, the direction of skin tension lines can be manifested also in the skin of children and young patients. These invisible or virtual tension lines are the same as the main folding lines (MFL) in adults and run perpendicular to the stretch marks. While well-established on the face and abdomen, these folding lines may not be obvious on other parts of the body. On chest, back and extremities, optimal direction of surgical skin incisions should take into account the patterns of striae distensae, which develop perpendicular to skin tension lines. MFL should be used in elective incisions in children, adolescents, and young women as a guide for the prevention of later visible hyper- or hypotrophic scars.

The ultimate goal of periodontal regeneration is to restore the damaged alveolar bone proper, root cementum, and periodontal ligament with collagen fibers inserted into the root surface. The search for new regenerative strategies is a challenging field of periodontal research, and tissue engineering, using stem cells, has recently been shown as a promising approach. This paper aims at reviewing the current available literature on the use of stem cells for the treatment of periodontitis. Up to now, different mesenchymal stem cells (MSCs) have shown potential for periodontal regeneration in animal studies. The most investigated MSCs for periodontal regeneration are bone marrow MSCs (BMMSCs), periodontal ligament stem cells (PDLSCs), and dental pulp stem cells (DPSCs), which have shown very promising results in animal models. Few studies on humans are available but BMMSCs, PDLSCs, and DPSCs have been proven safe and effective. Clinical trials are sparse, but tend to support the efficacy of MSCs for periodontal regeneration. In the future, more human studies will be required to support the use of MSCs in daily clinical practice, especially in order to identify the best protocol to harvest, process, and graft MSCs. Future perspectives include trans-differentiation of somatic cells to generate induced pluripotent stem cells, homing procedures, the use of exogenous stem cells, and 3D-printed scaffolds.

Replantation of major segments of the extremities can be a formidable task. Adequate debridement of crushed tissues is a prerequisite for successful major limb replantation. This article serves to elucidate the important situational and patient factors a surgeon must consider when choosing between replantation or revision amputation for upper limb salvage.

Gender dysphoria is a condition where there is a discrepancy between the gender assigned at birth and the desired gender, leading the patient to pursue surgical intervention. Reconstruction of the neophallus for transmen is still challenging, even though there are many surgical techniques with satisfying results. The aim of neophallic reconstruction in gender affirmation surgery (GAS) for transmen is to provide stand-up voiding, erotic sensation, orgasm and penetration ability, and acceptable donor site morbidity with minimal scarring and complications. Metoidioplasty as a variant of phalloplasty for transmen is a one-stage procedure that results in male-like external genitals, with minimal scarring, ability of standing micturition, and full erogenous sensation with the ability to achieve orgasm during sexual intercourse. Metoidioplasty is a method of choice for those transmen who wish to have GAS in one procedure without multi-staged procedures to create the adult-male-sized neophallus.

Soft tissue fillers are a mainstay in contemporary, minimally invasive facial rejuvenation procedures owing to timely results and minimal recovery period. Although associated with a low complication rate, soft tissue fillers are not without risk. Complications range from mild superficial skin irregularities to granuloma formation to vascular occlusion leading to skin necrosis or even blindness. Fillers vary in composition, elasticity, hydrophilicity and duration of effect that is tailored to specific cosmetic indications. Selecting the right product for the desired effect can cut down on unwanted outcomes. Severe adverse events can be avoided with safe injection technique, early recognition of symptoms and a thorough knowledge of the local anatomy. This review outlines several complications all providers should recognize and discusses strategies for their prevention and management.

Aim: To investigate a novel method for penile shaft reconstruction.

Methods: Penile tissue loss is caused by injury, infections, obesity or cancer resection. Reconstructive techniques comprise skin grafts with the risk of scarring and tissue rigidity. To develop an alternative reconstructive procedure, the pertinent vascular anatomy was studied on fresh cadavers instilled with red latex, which permitted the design of the midline raphe scrotal artery flap (MiRA). After anatomical proof-of-feasibility, penile reconstruction was performed in adult patients with classic buried penis or after cancer resection.

Results: Anatomical studies revealed a novel finding of two scrotal septa, each with the terminal branch of the internal pudendal artery. Pedicled on both arteries, a neurovascular island flap could be harvested. In the presence of excess scrotal tissue, the entire circumference of the penile shaft could be covered by this flap. Patients with penile skin defects and excess scrotal tissue were eligible for flap harvest. The flap was raised either as an extended island flap pedicled on both septal arteries for complete penile shaft coverage, or as a VY-flap for partial reconstruction; the donor site was closed primarily. Post-operative complications included swelling or partial wound dehiscence. There were no flap losses or perfusion problems. Patients reported full sensitivity to the penile shaft skin and sufficient skin elasticity for erection.

Conclusion: The MiRA flap is a technically safe neurovascular flap suitable for the reconstruction of partial or full defects of the penile shaft, such as after type III buried penis surgery, and provides sufficiently elastic and sensitive skin for functional penile reconstruction.

Aim: The purpose of this study was to ascertain the effect of surgical procedures and their timing on maxillofacial growth in unilateral cleft lip and palate (UCLP) patients through a systematic literature review.

Methods: In December 2019, a search was conducted in PubMed and Web of Science on the basis of the keywords: “UCLP”, “maxillofacial growth” and “facial growth”, complemented by a hand search.

Results: Eleven articles were included. An important finding was the wide range of treatment protocols. Eight studies performed a multistage procedure, whereas three studies applied a simultaneous repair of cleft lip, palate, and alveolus in a single surgical session. The findings in these articles were based on cephalometric measures. Comparative tables were constructed regarding method of study and time and technique of closure.

Conclusion: The results of the articles were conflicting, and it was clear that more research on this subject is necessary. Overall, most studies agreed on the important factor of palatoplasty in maxillofacial growth. The most common finding was a retrusive maxillary growth in comparison to a noncleft control group. This was illustrated by a negative effect on A-point - nasion - B-point. A lot of discussion remains on the effect of lip closure. However, most studies seemed to agree that lip closure results in retro-inclined upper incisors. In conclusion, it is essential that an agreement be reached on the treatment for UCLP, since this is the most common congenital craniofacial condition.

Complex penile reconstruction continues to pose a significant challenge to surgeons and patients alike. The ideal phalloplasty is one that can be reproducibly performed in a single stage, creates a neourethra that allows for voiding while standing, produces a phallus with tactile and erogenous sensation, allows for penetrative sexual intercourse, and offers satisfactory aesthetic results. With recent advances in microsurgery and perforator flap dissection, several techniques and modifications thereof have been described that aim to achieve these reconstructive goals. All of these now conventional techniques, however, fall short in one way or another - often with regards to urinary transport, the ability to achieve an erection, and the need for multiple surgical stages and revision operations. These limitations of conventional reconstruction have led some surgeons to explore new avenues for complex penis reconstruction, giving birth to the novel field of penile transplantation. In this article, we discuss the complexities of male genitourinary reconstruction in the context of conventional methods for reconstruction as well as the burgeoning field of penile transplantation.

Aim: The aims were: (1) to examine the clinical application of a geometric morphometric method (GMM) that quantifies the three-dimensional (3D) configuration of the facial soft tissues in patients with a repaired unilateral cleft lip and palate (UCLP); and (2) to determine the morphological characteristics that distinguish between non-cleft participants and patients with UCLP.

Methods: 3D facial images at rest were recorded from Japanese patients with a repaired UCLP (Cleft group; n = 60) and healthy adults featuring a straight type facial profile with normal occlusion (Control group; n = 200) using 3D photogrammetric cameras. For each participant, wire mesh fitting was conducted based on the assignment of landmarks to each 3D facial image. This method generated landmark-based GMM models consisting of 6017 nodes on the fitted wire mesh. For each node, the mean and standard deviation were determined in the Control group and were used as the normative range of the faces. With this normative range, the Z-scores before and after surgery were evaluated for patients with UCLP who underwent orthognathic bimaxillary surgery. Further, the morphological characteristics of the Cleft group were evaluated using a principal component (PC) regression analysis that distinguished between two subject groups. In addition, K-means clustering analysis and MANOVA were used to examine the morphological variation of the Cleft group.

Results: A patient with UCLP was evaluated with the system. After surgery, the normal area increased by 8%-20% on all axes, which means that the surgery was effective for normalizing the patient’s face. However, even after surgery, the protrusion of the lower lip and asymmetry remained. Nine PCs were extracted, and seven PCs were selected for the regression model to discriminate two subject groups, e.g., midfacial retrusion, nasal bump, and chin protrusion. The MANOVA also revealed significant differences between both the Cleft and Control groups and the sex subgroups, and the effects of cleft on the facial morphology was found to be related to sex (all, P < 0.01).

Conclusion: The clinical application of GMM was confirmed to be effective. GMM detected variations of the Cleft group and morphological characteristics. GMM is considered to be a powerful tool to quantitatively evaluate faces in clinics.

Cartilage has the ability to transmit and distribute loads, providing lubrication in the diarthrodial joints. Risk factors including age, gender, genetics, nutrition and bone density may predispose to osteoarthritis (OA) and cartilage defect formation. Appropriate treatment include sufficient rest and medical therapy. Intra-articular injections such as steroids, platelet-rich plasma, visco-supplementation and mesenchymal stem cells (MSCs) injections present as alternative options for non-operative treatments. For cartilage defects, microfracture (MF), osteochondral autograft transplantation (OAT) and autologous chondrocyte implantation (ACI) are the most common treatment procedures. MSCs have been identified as an ideal cell source for OA therapy because they are easily expanded in culture, generally non-tumorigenic, and can be readily obtained from patients. It may be harvested from bone marrow (BMSCs), adipose tissue (ADSCs), synovium (SDSCs) or peripheral blood. BMSCs features the most common source of stem cells, and infrapatellar fat pad (IPFP) is another popular stem cell source. A phase 1 clinical study entitled “Treatment of Knee OA with Autologous Mesenchymal Stromal Cell Product (RegStem®)” was conducted in Taiwan and utilized 5 × 107 IPFP-MSCs in the study for OA therapy. Most of the existing clinical studies have shown that patients receiving MSCs treatment have improved clinical outcome, such as Visual Analogue Scale, International Knee Documentation Committee and Western Ontario and McMaster Universities Arthritis Index (WOMAC) score. Some studies have also found an improvement in cartilage volume by Magnetic Resonance Imaging evaluation. Furthermore, MSCs can also be used for cartilage defect treatment. Clinical outcomes such as IKDC, Lysholm, and Tegner scores showed significant improvement when the cartilage defects were repaired and regenerated by several millions of stem cells. A 10-year follow-up clinical research indicated that there was no apparent increased tumor formation risk when BMSCs were used for cartilage defect treatment. In addition, a BMSCs/collagen gel composite for cartilage repair clinical trial in Taiwan was conducted in 2008, and results suggested that there was an improvement in IKDC and MRI score at 9-years of follow-up. It appears that the use of MSCs for OA and cartilage defect treatment may be a promising method.

The first successful digit replantation was reported in 1965 and accepted enthusiastically by hand surgeons. The decade that immediately followed saw a surge of interest in this complex surgery, fueling significant improvements in success rates and the rise of hand and microsurgeons who were highly proficient in replantation. The decades that followed, however, showed a stable field lacking any significant changes or advancements. More recently, and especially in the United States, the frequency with which surgeons even attempt replantation and the rate of survival have plummeted. If this trend continues, successful replantation surgery will become all too rare of an event. It is critical that we evaluate the state of replantation surgery today, identify the primary causes, and work to not only revive the field but allow it to advance similar to other areas of medicine.

Wide variation in overall strategies and surgical specifics for masculinizing genital surgery has created a “phalloplasty chaos” that is confusing to both surgeons and patients seeking gender confirming surgery. The purpose of this article is to review masculinizing genital confirming surgery, or “phalloplasty”, focusing on specific goals and categorizing each component of the surgical process. Experienced surgeons from several high-volume centers review and categorize the commonly employed strategies and techniques for gender confirming phalloplasty, including the permutations of approaches to cutaneous flap for phallic construction, the sequence and staging of procedures, and strategies for urethral construction. There is no clear advantage or reduction in complications associated with particular sequences of urethral and phallic reconstruction. Because no single technique or staging strategy has proven superior for gender confirming genital surgery, it is paramount that surgeons are knowledgeable of all available options and the associated advantages, disadvantages, and risks.

Penile skin grafting is an effective technique for managing skin deficiency resulting from a variety of causes. A thorough understanding of penile anatomy and the pathophysiology of the underlying condition being treated are essential. We provide an overview of penile anatomy as well as the pathophysiology of conditions that may lead to penile skin deficiency, as a result of either the underlying condition or its management. The conditions discussed include lichen sclerosus, buried penis, hidradenitis suppurativa, lymphedema, necrotizing fasciitis, cancer, and trauma. We also discuss surgical technique for penile skin grafting with an emphasis on technical considerations unique to the penis. Finally, we review the available literature on penile skin grafting.

The eyes and periocular region are critical for emotive display and play a key role in social interactions. This region includes the upper and lower eyelids, brow-lid complex, and lid-cheek complex. Perturbances in this area can lead to a prematurely aged appearance and patients complain of emotive misinterpretation. It often shows the earliest signs of facial aging, leading to a tired, sad, or angry appearance. With the evolution of medical and surgical knowledge on facial aging, there has been a shift from isolated volume reducing interventions for periorbital aging to volume replacement techniques. The treatment of periocular aging is multifactorial and often includes resurfacing, chemodenervation, surgical interventions, and volumization. The minimally-invasive, office-based nature of fillers has resulted in their increased popularity and filler placement has become one of the most commonly performed cosmetic oculoplastic interventions. With a multitude of fillers emerging over the past decade or so, facial plastic surgeons have been equipped with the means to address age-related periorbital hollowing and skeletonization in an outpatient setting. An appropriate knowledge of periocular anatomy, types of fillers, proper injection technique, and management of potential complications is required for safe injection and to achieve optimal aesthetic outcomes. This paper reviews the use of hyaluronic acid fillers for periocular rejuvenation.

Inflammation is a key phase in the cutaneous wound repair process. The activation of inflammatory cells is critical for preventing infection in contaminated wounds and results in the release of an array of mediators, some of which stimulate the activity of keratinocytes, endothelial cells, and fibroblasts to aid in the repair process. However, there is an abundance of data suggesting that the strength of the inflammatory response early in the healing process correlates directly with the amount of scar tissue that will eventually form. This review will summarize the literature related to inflammation and cutaneous scar formation, highlight recent discoveries, and discuss potential treatment modalities that target inflammation to minimize scarring.

A healthy, nine-year-old boy presented to the oculofacial plastic service with left upper eyelid ptosis progressively worsening for the past two years. On eyelid eversion, a cystic mass was found on the medial palpebral conjunctiva. Magnetic resonance imaging confirmed a fluid-filled cystic structure without posterior orbital extension. Based on imaging and clinical findings, the patient was diagnosed with dacryops of the accessory lacrimal duct of the Wolfring gland. Although prior literature suggests that the risk of Wolfring dacryops may be associated with conjunctival scarring, this report presents a case of spontaneous Wolfring dacryops without history of ocular manipulation or inflammation. Small, asymptomatic cases of dacryops can be safely monitored with serial eye exams.

Adult-acquired buried penis (AABP) is a condition associated with penile entrapment, penile shaft skin loss, and an enlarged pannus which engulfs the penis. The increased prevalence, awareness, and availability of surgical repair have led to a relative standardization in repairs. The surgical approach to AABP has evolved from a lengthy procedure with extended inpatient stay to one that may be done in an outpatient setting. The critical steps for surgical management of AABP have remained largely consistent over time, including: release of the penis with removal of diseased skin, suprapubic and/or abdominal panniculectomy, and skin coverage (usually with grafts). In contrast, the finer points of the procedure and perioperative care have undergone evolution. The aim of our approach was to optimize postoperative aesthetic and functional outcomes. Our perioperative management was modeled after enhanced recovery after surgery principles to minimize morbidity and expedite recovery. There remains room for improvement in the care of individuals with AABP, specifically multi-institutional collaboration, development of disease-specific outcome measures, and standardization of treatment algorithms.

The importance of photoprotection against the deleterious effects of excessive and chronic exposure to sunlight is now well established. Photoprotective measures include behavioral modifications such as seeking shade, wearing photoprotective clothing, wide-brimmed hat and sunglasses, and applying sunscreen to exposed areas. Data on botanical topical and oral preparations have demonstrated photoprotective potential in in vitro, animal, and human studies. This review will focus on botanicals that have been most extensively studied, namely, Polypodium leucotomos extract, green tea, pomegranate, resveratrol, curcumin, and silymarin. These agents have shown promise in mitigating ultraviolet-induced acute changes on the skin, chronic photodamage, and even skin cancer prevention. However, it must be emphasized that current evidence indicates that these agents should be used as adjunctive measures rather than as a replacement of the photoprotective behavioral modifications described above.

Aim: In this study, we systematically review the current literature regarding partial flap loss (PFL) for the two most commonly performed types of phalloplasty, the radial forearm and the anterolateral thigh flaps. The primary purpose is to synthesize the available information to clarify anatomic location, etiology, extent of flap loss, and management thereof. Second, we utilize this information to inform strategies to mitigate the risk of PFL.

Methods: A systematic review of all abstracts published on phalloplasty on PubMed was performed. Abstracts were reviewed by two senior authors who included all studies discussing flap-related outcomes after radial forearm free flap (RFFF) phalloplasty or anterolateral thigh flap (ALT) phalloplasty for the treatment of gender dysphoria. Primary variables collected include: flap type, PFL rate, anatomic location, extent of and management of PFL.

Results: A total of 17 papers that reported on RFFF and/or ALT phalloplasty were included. A total of 780 RFFF and 182 ALT phalloplasties were identified. The PFL rate was 4.5% and 7.1% respectively. Only 4/17 papers commented on the anatomic location of PFL; none commented on the exact extent of PFL and only 4/17 commented on the management of PFL.

Conclusion: The current literature suggests a higher rate of PFL in the ALT cohort (7.1% vs. 4.5%). The information available on PFL lacks detail as to the anatomic location, extent, and management of this complication. Future studies should strive to report on the above variables and include pertinent patient demographics and flap characteristics that may affect the rates and management of PFL. This information will assist in optimizing outcomes.

The appearance of aging is determined primarily by extrinsic factors through exposure to environmental sunlight and airborne pollution. That solar ultraviolet B (λ = 290-320 nm) directly causes photoaging (with wrinkles, dryness, and mottled pigmentation) and skin cancer has been recognized for decades; the contribution by ultraviolet A (λ = 320-400 nm) was only more recently understood. New research further implicates visible light (λ = 400-700 nm) as well as the heat rays of infrared radiation (λ > 800 nm). Particularly in urban environments, airborne pollutants such as ozone (O₃), polycyclic aromatic hydrocarbons, particulate matter (PM) in smog, and tobacco smoke contribute to photoaging and skin cancer. Furthermore, exposure simultaneously to both solar ultraviolet (UV) and these pollutants results in even greater synergistic damage. The volatile pollutants generate reactive oxygen species which oxidize surface lipids leading to deeper damaging inflammatory reactions. PM carries high concentrations of environmental organic compounds and trace metals. These pollutant-laden particles deliver toxins to the skin transcutaneously through hair follicles and through the blood after respiratory inhalation. The predominant natural mechanism of clearing these xenobiotic chemicals is through the ligand-activated transcription factor the arylhydrocarbon receptor (AHR) found on all skin cells. AHR activity regulates keratinocyte differentiation and proliferation, maintenance of epidermal barrier function, melanogenesis, and immunity. With chronic activation by UV exposure and pollutants, AHR signaling contributes to both extrinsic aging and carcinogenesis.

Surgical techniques for ptosis repair continue to evolve as we gain a better understanding of the anatomy and physiology of the eyelid. External repair by levator advancement and internal repair by Muüller’s muscle-conjunctiva resection are the most established surgical techniques used for acquired ptosis today. Controversy over their relative indications, advantages, and disadvantages exist. The advent of new surgical techniques and modifications has further complicated traditional algorithms that guide a surgeon towards choosing an external vs. internal approach. Specifically, the use and interpretation of pre-operative phenylephrine testing has recently been challenged. The purpose of this study is to review the evolution of external and internal ptosis repair techniques, and current trends in pre-operative evaluation and surgical management of acquired ptosis.

Aim: A variation of the ring metoidioplasty has been performed for masculinizing transgender surgery by the senior surgeon since 2010. It does not require buccal grafts or vaginal wall flaps. An excisional vaginectomy was completed in all patients. We sought to evaluate the urologic outcomes and complications for this technique. Further, we provide a detailed technical description of the technique, including ancillary masculinizing procedures.

Methods: This is a retrospective, single surgeon chart review of all patients undergoing metoidioplasty from 2010 to 2020. Demographics, outcomes, and complications are reported. A self-reported patient questionnaire provided data on patient-perceived urologic outcomes.

Results: Ninety-one patients were included in the study, with 80 (87.9%) patients reporting ability to stand and void with a strong stream. We observed five strictures (5.5%) and one fistula (1%). Scrotoplasty with tissue expanders and testicular implants were performed in 75 (82.4%) patients, while monsplasty was performed in 54 (59%) patients.

Conclusion: Our technique has a low complication rate and patients report a strong urinary stream and the ability to stand in the large majority of cases. Ancillary masculinizing procedures are common. The limitations of metoidioplasty, in general, still persist, which are the small phallus size and variable ability to clear the zipper without lowering the pants to void.

Periorbital aging has been identified as one of the most important aesthetic concerns of the face, so that lower eyelid rejuvenation has become a topic of major interest. Not every patient requires surgical blepharoplasty and selected lower eyelid problems and defects due to the aging process have been treated with hyaluronic acid (HA) gel injections since 2004. With this as the premise, the current work serves to review the published medical literature on the use of HA for lower eyelid and tear trough rejuvenation. A PubMed search was carried out in May 2020 using the search terms: “Tear trough [and] HA [and] filler”; “Tear trough [and] HA”; “HA [and] lower eyelid [and] filler”; “HA [and] lower eyelid”. A large number of relevant studies were identified. Surgical management remains the gold standard for lower eyelid rejuvenation but increasingly, non-surgical correction of selected deformities with HA injection may provide a reliable option based on the available evidence. Further, prospective randomized controlled studies and systematic reviews of the literature are nevertheless desirable and a standardized, widely accepted grading system of the deformity and its treatment outcomes will allow us to codify this procedure better.

Skin aging is a major cosmetic concern and associated with extensive changes in skin function and structure. The understanding of the basic science underlying skin aging is rapidly progressing, anchored around nine fundamental hallmarks of aging defined in 2013. Here we present the evidence for the relevance of each hallmark of aging to skin aging, emphasizing the uniquely prominent roles of oxidative damage and the extracellular matrix in photoaging. We review the existing evidence for how established treatments of skin aging target each fundamental hallmark and discuss targets for potential future treatments.

Dorsal shearing injuries of the hand and wrist can be seen with high-energy motor vehicle accidents and present challenging problems to the reconstructive surgeon. At the time of initial injury, care must be taken to adequately debride the mangled extremity and extensive wounds. Following debridement, a series of decisions must be made regarding bony stabilization, extensor tendon reconstruction, and soft tissue coverage. These reconstructions often require staged procedures, and appropriate planning is warranted from the start. Reasonable function of the hand can be expected from the patient following such injuries.

A fundamental goal of phalloplasty includes the construction of a sensate neophallus. Both tactile and erogenous sensation are important for protective sensation (including retention of implantable penile prosthesis) as well as sexual satisfaction. This article will describe the sensory innervation of flaps commonly used for phalloplasty including the radial forearm flap, anterolateral thigh flap, and musculocutaneous latissimus dorsi flap. The sensory innervation of the perineum and external genitalia will be reviewed as a basis for selecting recipient nerves. Additionally, surgical techniques, such as neurorrhaphy, will be discussed. Finally, outcome data, although limited, will be assessed.

Scarring is a major concern for patients. From acne scarring to surgical scars, scars can have a dramatically negative effect on one’s self-esteem and are a common complaint for which patients seek treatment. This review will focus on the treatment of acne scarring including ice pick, boxcar and rolling scars, and also the treatment of surgical scars including atrophic and hypertrophic scars.

Laser (light amplification by the stimulated emission of radiation) skin resurfacing is currently one of the most widely adopted technologies in facial rejuvenation. While most often used for aesthetic purposes, lasers also have applications in the management of scars. Since the introduction of the CO₂ laser for skin rejuvenation in the 1990s, the last three decades have seen significant growth in the number of laser devices available to the physician. More recently, promising alternatives to light-based resurfacing technologies have emerged that include radiofrequency and intense focused ultrasound. To help the physician navigate the most current laser technologies as they apply to periocular scars, this review discusses the available treatment modalities, pre-treatment assessment of periorbital scars, treatment selection, and reported outcomes and complications. The recommendations described herein are based on published literature and the authors’ experience in an academic oculoplastics practice.

Aim: Marcus Gunn jaw-winking synkinesis (MGJWS) is characterized by congenital ptosis in conjunction with rapid and involuntary elevation of the affected upper eyelid upon contraction of the ipsilateral external pterygoid muscle. Selecting an approach to the surgical management of eyelid malposition in this syndrome is challenging and requires careful discussion with each patient’s family. In this systematic review, we describe reported surgical approaches, assess outcomes data, and attempt to identify areas of consensus in the management of MGJWS.

Methods: Twenty-seven peer-reviewed studies were identified, describing a variety of interventions.

Results: The most commonly-used surgical techniques included: bilateral levator excision with bilateral frontalis sling, unilateral levator excision with bilateral or unilateral frontalis sling, the Neuhaus/Lemagne method, and levator plication surgery. However, no clear outcomes-based consensus regarding choice of surgical approach was identified, highlighting the ongoing role of surgeon and family preference in the selection of management strategy. Further, there was considerable variability in the literature for reporting outcome measures, including grading schemes for ptosis and jaw-wink.

Conclusion: The existing literature on management of MGJWS does not enable the development of an evidence-based consensus algorithm regarding the selection of an appropriate surgical technique. The disorder is treated according to a case-by-case approach governed by surgeon and family preference. Standardization of nomenclature and outcome measures is crucial for obtaining higher-quality, generalizable data in futures studies.

The impact of the interaction of all combined environmental agents to which an individual is exposed during his/her lifetime, as well as how his/her organism responds to these influences, defines health, aging, and disease. The systematic, integrative characterization of the different elements making up the “exposome” is thus necessary to identify and exploit the potential of compounds capable of conferring protection with minimal side effects. Extracts from the natural world, containing synergistic combinations of compounds with antioxidant and protective properties, have long been used in traditional medicine. Modern science has the opportunity to leverage these substances honed by evolution and use them safely and reliably, with a profound mechanistic knowledge and guaranteeing standardization and absence of toxicity. Here, we discuss our current knowledge regarding the potential of a soluble extract of the hair grass Deschampsia antarctica (as its standardized commercial preparation Edafence^®) to counteract the skin exposome and its impact on skin aging and disease.

Aim: Scarring is a physiological process in adult wound repair. Although keratinocytes and fibroblasts are the main cell types of the skin, they differ in migration behaviour and inflammatory responses depending on their location in the body. The aim of this article is to describe wound repair in genital skin and to depict differences with regard to skin anatomy and cellular responses to inflammatory stimuli in acute and chronic wound healing.

Methods: This report reviews data from patients undergoing reconstructive and aesthetic plastic surgery as well as published studies on genital wound repair. Genital surgery comprised plastic reconstructive surgery after urological interventions of biological men and women, tissue from trans-males and trans-females undergoing gender reassignment surgery and tissue from patients undergoing aesthetic genital surgery. The cohort comprised a total of 68 patients (32.9 ± 11.3 years), of which 31 were male (mean 30.4 ± 9.3 years) and 37 were female (34.9 ± 12.5 years; mean ± SD).

Results: Wound healing in genital skin markedly differs from other areas of the body due to its anatomical features, microbiome, and elevated hormonal responsiveness. Human genital skin is highly extensible and unusually rich in elastic fibres, and it lacks the mechanical anchorage and tensile properties typical of non-genital regions. Acute injury resolves rapidly due, in part, to rapid resolution of the inflammatory response. In contrast to scarring responses on other body surfaces, genital skin wounding is resolved by shrinkage or fistula formation.

Conclusion: The embryological origins of genital skin fibroblasts, together with the gender-specific hormonal environment, contribute to the unique phenotype and healing properties of genital skin. When performing genital surgery, it is of utmost importance to be aware of the differing responsiveness of genital tissue to trauma, surgery, and repair.

Since the U.S. Food and Drug Administration approved botulinum toxin (BoNT) type A in 2002 for glabellar rhytids, BoNT has been used successfully for many clinical indications in facial plastic surgery. The current usage of BoNT as a non-invasive procedure for rhytids of the aging face include but are not limited to rhytids of the forehead, glabella, lateral orbit, nasal sidewall, upper lip, vertical perioral rhytids, melomental fold, and chin. In addition to facial rhytids, BoNT has been shown to be effective for a variety of other clinical indications in facial plastic surgery, including masseter hypertrophy, facial paralysis, brow ptosis, and wound healing. This article will review the pharmacology and mechanism of action of BoNT. In addition, the suggested dosage and instruction for injection for facial rhytids will be discussed along with BoNT usage for clinical indications other than rhytids.

As the demand for noninvasive facial rejuvenation continues to grow, it is imperative that plastic surgeons maintain a mastery of nonsurgical techniques for restoring a youthful facial appearance. In this article, noninvasive interventions for skin resurfacing, tissue tightening, rhytid reduction and volume restoration are discussed with an emphasis on technical outcomes and potential complications. Overall, this review should serve as a primer for the aesthetic plastic surgeon who aims to offer safe, effective facial rejuvenation to patients who desire maximal results with minimal downtime.

Nonsurgical rhinoplasty, also known as liquid rhinoplasty, is a filler-based approach to treating deformities of the nose. Despite the potential for serious complications such as tissue necrosis and blindness, patients’ desires for rapid results with minimal downtime and low costs have served as an impetus for rhinoplasty surgeons to become skilled injectors. Additionally, many physicians that are less skilled in rhinoplasty may be emboldened to perform a simpler procedure. While soft tissue filler is not always a viable alternative to rhinoplasty, it can be a useful adjunct or stand-alone treatment for managing a drooping nasal tip, minor asymmetries, or a dorsal hump. This article provides an overview of liquid rhinoplasty and how to best obtain the patient’s desired aesthetic result.