Blepharoptosis is present when the upper eyelid is lower than its normal anatomic position in primary gaze. This is secondary to a neuromuscular imbalance with weakening of the upper eyelid retractors in relation to the protractors. As the degree of ptosis worsens, significant functional and cosmetic concerns often arise. To adequately address these concerns, ptosis is divided into categories based on the underlying pathogenesis: aponeurotic, myogenic, neurogenic, mechanical, or traumatic. Within these categories, it is important to determine if the ptosis is congenital or acquired as diagnostic and therapeutic approaches often vary between these two distinctions. The goal of this review is to summarize the classification, evaluation, management, and potential pitfalls of both acquired and congenital ptosis.

Collagen-based supplements have become a keystone in the management of the ageing process, with proven ability to repair skin damage, bestowing a youthful and healthy appearance sought in the pursuit of beauty. Collagen is an essential scaffold protein that gives smoothness and elasticity to skin, but its production declines with age. Finding ways to tackle this problem is now strongly promoted as an effective way to transform skin and hair, repairing age-related deterioration. A growing number of scientific studies show exciting evidence that it is possible to rejuvenate ageing or damaged skin, improve function of worn joints, and support personal wellbeing and vitality. In recent times, research on the mechanisms which impact the production of collagen in skin and the ideal organization into functional fibres which give skin its characteristic elasticity and firmness has provided new insights into how this bio-scaffold can support cells, tissues and organs. The factors which influence collagen production over a lifetime (e.g., puberty, pregnancy, menopause, andropause), intrinsic factors (e.g., genetics, age, ethnicity) and extrinsic factors (e.g., UV-radiation, pollution, smoking) and the potential for new technologies, ingredients and devices to restore collagen and matrix components to their optimal condition are improving the ability to deliver anti-aging strategies with unprecedented results. This paper will review skin collagen production, structure and function throughout the lifestages, emphasizing its relationship with health, appearance and beauty.

Periodontal tissue engineering involves a multi-disciplinary approach towards the regeneration of periodontal ligament, cementum and alveolar bone surrounding teeth, whereas bone regeneration specifically applies to ridge reconstruction in preparation for future implant placement, sinus floor augmentation and regeneration of peri-implant osseous defects. Successful periodontal regeneration is based on verifiable cementogenesis on the root surface, oblique insertion of periodontal ligament fibers and formation of new and vital supporting bone. Ultimately, regenerated periodontal and peri-implant support must be able to interface with surrounding host tissues in an integrated manner, withstand biomechanical forces resulting from mastication, and restore normal function and structure. Current regenerative approaches utilized in everyday clinical practice are mainly guided tissue/bone regeneration-based. Although these approaches have shown positive outcomes for small and medium-sized defects, predictability of clinical outcomes is heavily dependent on the defect morphology and clinical case selection. In many cases, it is still challenging to achieve predictable regenerative outcomes utilizing current approaches. Periodontal tissue engineering and bone regeneration (PTEBR) aims to improve the state of patient care by promoting reconstitution of damaged and lost tissues through the use of growth factors and signaling molecules, scaffolds, cells and gene therapy. The present narrative review discusses key advancements in PTEBR including current and future trends in preclinical and clinical research, as well as the potential for clinical translatability.

Aim: Improving the cervical contour is one of the main goals of patients seeking face and neck rejuvenation. However, little attention has been dedicated to refine the anterior border of the sternocleidomastoid muscles and to improve the inferior neck. In this study, the authors sought to describe new surgical tactics to address these issues.

Methods: The records of 1,019 patients were evaluated retrospectively. Surgical strategies to treat the neck were reviewed and two new approaches, described. Plication of the sternohyoid muscles and lateral plication of the platysma along the anterior border of the sternocleidomastoid muscles are detailed and supplemented with a video.

Results: Of the 1,019 patients, 937 patients (91.9%) underwent subplatysmal neck lift. Three-hundred-and-forty-eight patients (34.1%) underwent sternohyoid muscles plication, and 784 patients (76.9%) had rejuvenation of the sternocleidomastoid muscles. The most common complication was weakness of the lower lip depressors [79 patients (7.7%)].

Conclusion: Approaching the sternohyoid muscles and rejuvenating the sternocleidomastoid muscles are new reliable and effective tactics to optimize results in neck lifts.

Aim: Combined neurectomy & myectomy and functioning free muscle transplantation is proposed as an aggressive surgical intervention for postparalytic facial synkinesis (PPFS) to effectively resolve the problem since 1985 and this treatment continues to be the standard. We aim to describe our experiences with 103 PPFS patients who underwent the surgical treatment.

Methods: A total of 103 patients with PPFS were investigated (1985-2020), but 94 were selected with all having at least one year of postoperative follow-up. Among them 50 were Type II and 44 were Type III PPFS. All patients underwent extensive removal of the synkinetic muscles and triggered facial nerve branches in the cheek, nose and neck regions, followed by gracilis transplantation for facial reanimation.

Results: The incidence of receiving the aggressive surgical intervention increased from 15% prior to 2012 up to 24%. The mean postoperative follow-up period was 10 years. Young adult (79%) and female patients (63%) were the dominant populations, showing their great ambition for a treatment. Results showed a significant improvement in facial smile with more teeth visible, and a significant decrease in facial synkinesis. About 96% (90 patients) did not require botulinum toxin A injection after surgery. Revision surgery for secondary deformity was approximately 53%.

Conclusion: Treatment of PPFS is primarily reconstructive. Combined myectomy & neurectomy and functioning free muscle transplantation for Type II and III patients are well accepted, and leads to promising and long-lasting results despite higher revision rates. Refined techniques to decrease revision rates are needed.

Nerve transfer procedures have the potential to restore innervation and function to the native facial musculature. This review summarizes the existing literature on facial nerve injury, regeneration, and reinnervation techniques with a focus on nerve transfer and its various options. Utilizing nerve transfer as early as possible, and ideally during the first 12 months of paralysis, is recommended. Prolonged paralysis is frequently not amenable to nerve transfer. The masseteric nerve provides excellent smile restoration after coapation to midfacial nerve branches with minimal morbidity. Several modifications to the hypoglossal nerve transfer have been described to limit its morbidity in speech and swallowing. The cross facial nerve, while appealing and able to achieve a true spontaneous smile, has limitations in terms of axonal load, time to reinnervation, unpredictable outcomes, and utility in older patients, who have less regenerative potential. Finally, there are exciting new developments in the field, combining reanimation techniques to harness advantages of various donor nerves, and research in peripheral nerve regeneration.

Aim: The utilization and outcomes of abdominal wall reconstruction (AWR) using advanced techniques such as component separation for incisional hernia (IH) repair following laparotomy in trauma populations has not been described. The objective was to describe AWR with component separation (AWR-CS) utilization in this setting and to assess postoperative complications and readmissions.

Methods: We identified adult patients admitted for IH repair (IHR) with a history of and admission for traumatic injuries with concurrent laparotomy in six geographically diverse statewide inpatient databases (2006-2015). AWR-CS was defined by ICD-9 codes corresponding to myocutaneous flap. Risk-adjusted logistic regression and generalized linear models were used to compare postoperative complications, 30-day readmissions and cumulative costs associated with AWR-CS.

Results: Of 952 patients with a history of trauma laparotomy who were admitted electively for IHR, 6.8% underwent AWR-CS. Patients who underwent AWR-CS experienced increased complications [adjusted odds ratio 2.6 (95%CI: 1.48-4.57); P < 0.001], cumulative costs (median $ 20,805 vs. $ 15,529; P < 0.001) and longer length-of-stay (median days 6 vs. 5; P = 0.002). These differences were driven by postoperative complication, which were independently associated with increased length of stay [predicted mean difference 6.53 days (95%CI: 4.66-8.41); P < 0.001], costs [$ 14,550 (95%CI: $ 9,258-19,841); P < 0.001] and 30-day cumulative costs [$ 20,176 (95%CI: $ 12,621-27,731); P < 0.001] within risk-adjusted analyses.

Conclusion: AWR-CS is part of the armamentarium needed to manage trauma laparotomy survivors who develop complex IH defects requiring surgical repair. It can result in increased complications that amplify postoperative healthcare utilization. Leverage of tools for the identification of high-risk patients, prehabilitation and enhanced surgical techniques is warranted to minimize postoperative complications in these patients.

Understanding the methods and rationale for managing erectile function in cis- and trans-male patients after neophallus reconstruction is of clinical value to the practicing urologists who encounter such patients. We describe a brief overview of the urologist’s role in the management of sexual function. This communication focuses on pre- and post- construction of a neophallus, considerations for surgical techniques that are largely dependent on whether the patient is cis- or transgender, the traditional method of placing of inflatable penile prosthesis in a neophallus, and in conjunction with the management of complications post implantation. This manuscript is both a review of the current literature in the field, as well as an overview of experience gained from managing a cohort of patients over the years. Additionally, we discuss novel advances that aim to decrease the risk of complications, including distal erosion of the cylinders of the penile prostheses and the proximal dislodgement of cylinders in these unique patients.

Survival from burn injury has improved considerably over the past two decades such that the quality of life of the victim of thermal injuries has become a major concern. Severe proliferative scarring or hypertrophic scarring (HTS) is an all too frequent complication of burn wound healing that severely compromises quality of life for surviving burn victims. Prevention of such scarring in burn patients involves better understanding of the pathophysiology of scar formation, development of newer methods for determining depth of burn injury and earlier and advanced surgical interventions. Many established and evolving novel treatments for HTS in patients after thermal injury exist and include antifibrotic pharmaceuticals and cellular-based therapies as reviewed herein.

Aim: We developed R lift, a modified en-bloc facelift, in response to growing demand for long-lasting, effective facelift procedures associated with minimal downtime and a low risk of complications. Conventional facelift procedures can be invasive, involve long recovery times, and can be disfiguring in the early postoperative period. However, nonsurgical modalities for facelift tend to yield a weaker, less noticeable lift and may require earlier revision.

Methods: Eighty-five patients who underwent R lift were evaluated retrospectively. Minor and major complications and the need for any revisions were recorded.

Results: Patients received follow-up for an average of 16.3 months (range 8-48.8 months). One patient required minor revisional surgery after dental abscess and subsequent soft-tissue infection of the face. Another patient had hypertrophic scarring. No patients experienced nerve damage or other major complications.

Conclusion: R lift is indicated for patients with the spectrum of age-related concerns of the mid/lowerface and neck. This technique yields reliable harmonious results, with a low risk of complications and a short recovery period. Continued follow-up data are needed to confirm the stability of the R lift result.

Neck aesthetics are a vital and indispensable component of cervicofacial beauty. Cosmetic deformities may be due to congenital or acquired etiologies and successful management depends on accurately diagnosing the underlying anatomical problems and applying the appropriate surgical and non-surgical procedures to achieve the desired result. For clinical evaluation and treatment, neck anatomy may be conceptualized into three layers wherein the superficial layer consists of the skin and subcutaneous fat, the intermediate layer of platysma muscle and interplatysmal fat, and the deep layer of subplatysmal fat, digastric muscles, submandibular glands, and skeletal support structures. The goal of this article is to review neck aesthetics, cosmetic deformities, and indications for different treatment techniques by way of a systematic layered approach.

Aim: Head and neck region reconstructions are often delicate procedures that require different solutions at different layers. The use of chimeric flaps offers the interesting characteristic of combining different tissues, which is extremely valuable in this setting. In the present work, we share our experience with different types of conventional flaps, such as the radial flap, the medial sural artery perforator flap, and the fibula osteocutaneous flap.

Methods: Over the last year, a series of five patients received advanced head and neck defects reconstruction employing chimeric flaps. The patients included two females and three males, with the mean age of 68-year-old. The defect was in four cases due to radical tumor resection in the oromandibular region. The fifth case was an osteoradionecrosis which needed a complete resection of the affected soft and bony tissue.

Results: All five patients were successfully treated. Two of them received a chimeric free flap composed of multiple skin islands while the other three also comprised bone tissue transfer for mandible reconstruction. The mean follow-up period was ten months (range 3-8 months), and during this period neither postoperative complications nor signs of disease relapse were noted.

Conclusion: The results obtained resorting to the chimeric fashion of various free flaps suggests that they are an excellent solution from both the functional and aesthetic point of view. Specific technical modifications are proposed according to the case requirements.

Medical modeling and 3-dimensional (3D) virtual surgical planning represent a rapidly expanding, technological advancement especially useful in complex mandibular or maxillary defects in head and neck reconstruction. With utilization of 3D surgical planning, the reconstructive surgeon can initiate dental rehabilitation during the primary surgery with osseointegrated implants (OI), streamlining a typically lengthy process to full oral rehabilitation. Careful patient selection is important to optimize outcomes with immediate OI, and factors to consider during the evaluation process include pathology, prognosis, anticipated defect, dental status, donor site availability, and patient motivation and resources. Synthesizing this information and developing a reconstructive plan with a multidisciplinary team approach is critical to expedite dental rehabilitation for select patients. A review of relevant literature and our surgical planning algorithm for selecting candidates for immediate OI is provided, along with our experience using this decision algorithm in a uniquely complex clinical case.

Free tissue transfer has become the gold standard for reconstruction within the head and neck. However, there are still many instances where pedicled locoregional flaps are the optimal reconstructive option. When myofascial tissue is needed, several options have been described throughout the literature. Various trapezius flaps have been used, although these have variable vascular anatomy and significant donor site morbidity. The pectoralis major myofascial flap has become a mainstay in head and neck reconstruction for its ease of harvest and reliability but suffers from similar issues with donor site morbidity. The pedicled latissimus dorsi flap (PLDF) is another reliable option that has been used for multiple different ablative sites within the head and neck. The thin, pliable structure of the latissimus dorsi makes it a viable option for many defects, and recent reports also support its feasibility for use in an interdisciplinary two-team approach. Furthermore, the donor site morbidity of the PLDF is minimal compared to other similar myofascial options. In this article, we describe the surgical considerations and operative techniques for PLDF transfer along with a review of its associated donor site morbidity.

This case report describes a modified connective tissue graft wall technique with enamel matrix derivative proposed to treat vertical bony defects. The surgical procedure consisted of a coronally advanced flap with a porcine-derived acellular dermal matrix placed below, acting as a buccal soft tissue wall of the bony defect. The patient showed a bony defect between #12 and #13 with horizontal bone loss and a deep infrabony component at the mesial area of the canine. At one year after surgery, the position of the interdental papilla and the clinical attachment level gain were improved along with radiographic bone defect fill.

Aim: The reason why non-calibrated hair variables poorly estimate scalp hair coverage during hair growth studies was studied.

Methods: Hair productivity integrates density, diameter and daily hair growth rate. Cross-sectional studies have established hair productivity in female and male patients (480 vs. 90 controls) with self-evaluation of hair loss, phototrichogram (CE-PTG-EC) and scalp coverage scoring, (SCS). Tracking productivity of individual hair follicular units from longitudinal studies challenged the application of our methods during drug trials.

Results: Hair loss means decreased productivity and increased “time to complete coverage”. The hair mass index (HMI) linearly connects productivity with clinical perception of coverage, i.e., SCS. The ensuing HMI abacus translates independently of gender, age, pattern or severity and unravelled unequal intervals between categories of the Ludwig and Hamilton classifications. With one severity grade shift, time to complete coverage varied from 21-51 days, i.e., no equality. During longitudinal studies, SCS detected improved productivity, reflecting clinically relevant responses, but remained stable in the absence of significant productivity variations. Follicular unit labelling and individual hair growth tracing showed that reversal of miniaturised hair follicles does not play a major role during drug-induced hair regrowth. The latter reflects re-activation of resting-dormant terminal hair follicles. The recovered productivity would not be possible once hair follicles enter the phase of structural-functional irreversible miniaturisation.

Conclusion: Besides pattern identification, density of nanohair and HMI appear as innovative diagnostic approaches. Abrupt transformation (within one cycle) of terminal hair follicles into miniaturised ones and its reversal as the effect of active FDA-approved drugs remain highly improbable.

Aim: Facial paralysis inflicts devastating functional and aesthetic deficits. Several solutions are being developed, including implantable bionics to correct paralytic lagophthalmos. The temporal fossa has been postulated to be a suitable location for such devices. Anatomical studies of this fossa have limited application in the design of implants with complex internal components that are constrained by specific functional requirements. In this study, we assess the variation in temporal fossa volumes that could be utilized by a functional implantable device.

Methods: CT scans of 18 hemifaces were used to create a 10-point template for measuring tissue thickness in the temporal fossa. Using this data, linear models were used to perform a volumetric analysis of the temporalis muscle and temporal fat pad concerning key anatomical landmarks.

Results: The estimated temporalis muscle, temporal fat, and total combined volumes were 19.2 mL (95%CI: 10.4-32.9), 10.3 mL (95%CI: 6.1-16.1), and 29.5 mL (95%CI: 16.7-48.9) respectively, consistent with other publications. The temporalis muscle volume increases rapidly and then plateaus moving posteriorly along the zygomatic arch and superiorly along the lateral orbital rim. Whereas the temporal fat increases similarly along the lateral orbital rim, it increases at a uniform rate along the zygomatic arch.

Conclusion: Simple geometric modelling of the functional soft tissue space in the temporal fossa is feasible and can be readily applied to aid in the development of implantable devices.

Virtual surgical planning (VSP) applicability has recently expanded to include midface reconstruction with free tissue transfer. For the midface, an area that is crucial both functionally and aesthetically, even minor reconstructions (in the millimeter range) can make profound differences in form and function. The use of VSP allows the surgeon to improve accuracy and precision in areas where millimeters drastically impact outcomes. This review focuses on complex midface reconstruction requiring free tissue transfer and assesses the role of VSP in this patient population.

Aim: The aim of this study was to analyze nose shape and size in subjects with sagittal facial deformities.

Methods: One hundred fifteen subjects were included for orthognathic surgery; the previous cone bean computed tomography was used to perform the analysis. The sample consisted of 46 males (40%) and 69 females (60%); the nasal morphology in frontal view and profile, the deviation of the nasal septum, the skeletal class and the sagittal position of the maxilla were compared using the Spearman test, considering a P value < 0.05.

Results: Males had a greater vertical nasal skeletal measurement (P = 0.0006), greater cartilaginous nasal height (P = 0.0001) and greater horizontal distance between the A point and Prn (P = 0.001). Considering the sagittal position of the maxilla, subjects with maxillary prognathism had a higher nasal morphology value than subjects with a retrognathic maxilla. In addition, nasal septum deviation was statistically related to facial class II (P = 0.03) with significantly more deviation than class III subjects.

Conclusion: It may be concluded that there are variables in facial deformities related to nose shape and have to be included in the surgical plan for orthognathic surgery or rhinoplasty.

Laser technology has evolved significantly over the last 30 years, and laser devices have become integral tools for skin rejuvenation in the hands of many plastic surgeons practicing today. The purpose of this article is to briefly review the history of aesthetic laser technology, to discuss patient selection and expectations for various laser devices, and finally to review the technology and applications of these devices.

Head and neck reconstruction has evolved substantially in the last three decades to rely heavily on microvascular free tissue transfer, including bony composite flaps that improve form and functional outcomes. The technologies available for planning and executing bony reconstruction have undergone concurrent innovation, leaving the modern surgeons with a host of options to consider. In this review, the techniques of external fixation, virtual surgical planning and rapid prototyping are discussed with the aim of familiarizing surgeons and comparing these approaches. External fixation, though not new to head and neck surgery, has seen a revival and has considerable utility in vascularized bony reconstruction with the potential for improved efficiency and cost control. We explore the clinical situations in which virtual surgical planning is best employed, and the varying levels to which it can be applied throughout the reconstructive process. The ever-expanding realm of rapid prototyping, or 3D printing, is also examined to explore potential applications for surgical modeling, tissue engineering and even clinical training. Finally, we present a discussion of the cost-effectiveness of the technologies and future directions for research in the field.

Anterior skull base (ASB) defects present a significant challenge in head and neck reconstructive surgery. The main goal of skull base reconstruction is to create a watertight separation between the intracranial cavity and aerodigestive tract. Successful reconstruction aims to prevent cerebrospinal fluid (CSF) leak, pneumocephalus, and a range of infectious manifestations. Functional outcomes and cosmesis are also critical considerations when developing a reconstructive plan. Advancements with endoscopic endonasal approaches have revolutionized skull base surgery but also have created new reconstructive challenges due to the narrow operative corridor, especially for extensive defects or salvage cases where microvascular free tissue transfer is required. Though a variety of techniques including local, regional, and free flaps have been described, ASB reconstruction remains a difficult undertaking due to the complex anatomy and high risk for post-operative complications. This review provides a comprehensive discussion of available reconstructive techniques that can be used after both open and endoscopic ASB resections to help determine the optimal reconstruction for a variety of defects.

Aim: Transconjunctival CO₂ laser lower blepharoplasty is considered to be a safe and reliable approach. A retrospective review of transconjunctival approached CO₂ laser lower blepharoplasty associated with fractional CO₂ laser ablation or fractioned non-ablative Fraxel laser resurfacing for lower eyelid rejuvenation is presented for comparison.

Methods: From February 1996 to February 2016, 250 patients underwent CO₂ laser lower blepharoplasty with a male to female ratio of 1:7.5. The age ranged from 43 to 68 years (mean 52 years). A CO₂ laser was applied to make a transconjunctival lower blepharoplasty. Immediately after CO₂ laser lower blepharoplasty, 40 patients received fractional CO₂ laser and 40 patients took Fraxel laser for resurfacing.

Results: Swelling occurred in all patients postoperatively. Complications related to transconjunctival CO₂ laser lower blepharoplasty were 6 (2.4%) patients with conjunctival chemosis, 5 (2.0%) with ecchymosis, and 3 (1.2%) with granulomas. The early complications (≤ 1 month) related to fractional CO₂ laser ablation were 40 (100%) patients with mild erythema, 40 (100%) with mild edema, 1 (2.5%) with hyperpigmentation, 1 (2.5%) with infection, and 1 (2.5%) with scarring. These problems resolved in all patients after 3 months. There was no complication after Fraxel laser right after lower blepharoplasty. The Fraxel group had short recovery time. However, there was no statistically significant difference between the two groups in final outcome (≥ 6 months).

Conclusion: Transconjunctival CO₂ laser lower blepharoplasty associated with fractional CO₂ laser ablation or Fraxel laser resurfacing assisted the appearance around the periorbital regions.

Scalp and cranial defects can occur as a result of cutaneous or bony malignancies, trauma, or surgical intervention for intracranial tumors. Soft tissue cranial reconstruction of composite defects presents a unique challenge given the relative tissue inelasticity of the scalp, need for tension free closure, and convex shape of the cranium. An added complexity is found in patients with large defects, cerebrospinal fluid leak, prior failed reconstruction, infection, or previous radiation. Methods and materials for skull reconstruction have evolved significantly over the years, allowing surgeons to repair even the most challenging composite defects with excellent success rates. This review aims to discuss and evaluate the available soft tissue options for cranioplasty coverage, with particular focus on hostile reconstructive fields and the use of free tissue transfer.

Soft tissue augmentation at the implant site is one of several techniques suggested in the case of soft and hard tissue deficiency after implant rehabilitation. The gold standard in this procedure is connective tissue graft (CTG), which is considered an autologous material with a high proliferative pattern. Today, several collagen matrices (VCMXs) are on the market as CTG substitutes and are recommended for this type of procedure. The aim of this case report is to compare the resorption process and the volume gain of two potential collagen matrices (VCMXA and VCMXB) of porcine origin for soft tissue augmentation around single implants. 3D analysis with dedicated software (GOM inspect® Braunschweig, Germany) was performed to understand the volumetric and surface changes on the vestibular aspect and the amount of resorbed biomaterial at 7 days from the surgery and at 3 months of follow up. Considering the limitation of the four included patients and the different surgical sites (13 and 17 for VCMXA and 26 and 25 for VCMXB), both VCMXs showed interesting results with respect to the baseline at 7 days (VCMXA gain, + 2.93 ± 1.65 mm; VCMXB, + 2.58 ± 1.11 mm); however, after 3 months of follow up, an important remodelling process was present in both treated sites (VCMXA, + 2.00 ± 0.99 mm; VCMXB, + 0.41 ± 0.73 mm). Soft tissue augmentation at the implant site resulted in a similar increase in volume for both the matrices. On the other hand, VCMXA seemed to preserve more volume at 3 months. Future randomised clinical trials are needed to confirm these results.

The microbiota changes as the host ages, but also the relationship between host and bacteria impacts host aging and life expectancy. Differences in the composition of certain bacterial species in the human gut and skin microbiome have been identified between the elderly and the young. In this sense, it has been suggested that the manipulation of the microbiota of older adults would be an innovative strategy in the prevention and treatment of age-related comorbidities.

Computer-aided design, three-dimensional printing, and additive manufacturing are revolutionizing craniomaxillofacial trauma surgery. Traditionally, this is completed via third-party vendors during online web meetings. Although this is effective, it can take several weeks to have custom plates arrive, negating its use in acute facial trauma. The price of 3D printers and software needed to complete this in-house are decreasing. This allows for expedited turn around, facilitating treatment in the acute setting. This article serves as a review of fundamental 3D printing principles and describes the process of virtually reducing facial fractures, 3D printing the reduced models, and having a plate ready for surgery in hours.

Aim: Hypopharyngeal squamous cell carcinoma is reportedly one of the most aggressive primary cancers, and surgical resection continues to be the standard therapeutic choice. In patients with hypopharyngeal cancer involving the esophagus or synchronous hypopharyngeal and esophageal cancer, total pharyngolaryngoesophagectomy (TPLE) is indicated to control both malignancies at the same time. Reconstruction remains challenging with regard to the length of the substitute for the esophagus as well as the donor site morbidity. We reported our long-term follow-up and the outcome of the quality of life (QoL).

Methods: We retrospectively reviewed the records of all patients who underwent TPLE between January 2012 and December 2020. Information was collected on sex, age, surgical indications, operative time, postoperative complication, swallowing function, hospital stay, and survival. Quality of life scores were acquired by World Health Organization Quality of Life-Brief (WHOQOL-BREF) questionnaires and completed at the outpatient clinic. Gaussian kernel-smoothing was applied to estimate the dynamic changes of QoL function.

Results: A total of 40 patients undergoing oncologic pharyngolaryngoesophagectomy were enrolled in this study. There were 26 patients (65%) undergoing gastric tube reconstruction with direct anastomosis to the oropharynx (GP group), 7 patients (18%) undergoing additional free jejunal flap to bridge the gap between the gastric tube and oropharynx (GP-JF group), 4 patients (10%) undergoing additional free anterolateral thigh flap to bridge the gap and resurface the neck skin (GP-ALT group), and 3 patients (8%) undergoing colon interposition (CI group). The leakage rate in each group was 50% for GP group, 29% for GP-JF group, 50% for GAP-ALT group, and 67% for CI group. The mean operation time was 1010 ± 195 min. Although the overall leakage rate was 47.5%, only 15% of the patients needed further surgical intervention. One patient (2.5%) died with persistent leakage and pneumonia. In terms of life quality assessment, the response rate for the QoL questionnaire was 50%. We found the overall QoL deteriorated for the first year after operation, but it gradually improved and even surpassed the patient pretreatment scores by the end of the second year after operation.

Conclusion: The gap caused by TPLE in patient, perioperative morbidity, and postoperative quality of life could be managed by the evolution of esophageal substitute, surgical techniques, perioperative wound care, and evaluation of the quality of life.

Axillary lymph node dissection-dependent chyle leakage is a rare complication with an incidence of < 0.7%. The morbidity could be high, and the management prolonged and not clear. The literature offers us many therapeutical tools, yet there is no consensus about the management of this complication. Usually, the management focuses on reducing the chyle flow in the thoracic duct (central origin), neglecting the possibility of a parallel lymphorrhea from other regional lymphatic vessels (peripheral origin), which causes a prolonged approach with high morbidity. In this paper, we introduce the supermicrosurgery technique as a surgical therapeutic option for chyle leakage. To decrease morbidity and shorten treatment duration, we offer a therapeutic algorithm based on the literature and our experience.

Juvenile idiopathic arthritis (JIA) can create severe jaw deformities affecting function, esthetics and psychosocial health of teenagers afflicted with this disease. The aim of this chapter is to present the dentofacial manifestations of this disease and the proven surgical protocol to correct these debilitating deformities. Clinical and imaging characteristics of JIA patients with temporomandibular joint (TMJ) involvement and severe jaw deformities are presented as well as the surgical protocol to produce predictable stable outcomes. Clinical research studies documenting the efficacy of this surgical protocol will be reviewed. The most predictable, successful, and stable surgical protocol to treat JIA patients with severe dentofacial deformities includes: bilateral TMJ reconstruction and mandibular counterclockwise rotation-advancement with patient-fitted TMJ total joint prostheses (TJP) and concomitant maxillary osteotomies, as well as adjunctive procedures, performed in a single operation. This protocol provides improvement in jaw function, facial esthetics, pain, and airway. Research studies document the predictability of the treatment protocol. Case presentations illustrate the deformity and the expected outcomes with this surgical protocol. Patient-fitted TJP for TMJ and mandibular reconstruction in conjunction with maxillary orthognathic surgery provides long-term skeletal and occlusal stability in the JIA patient as well as improvement in jaw function, pain, esthetics and airway.

Aim: Lymphaticovenular anastomosis (LVA) is the mainstay of surgical treatment of lymphedema now. Indocyanine green (ICG) lymphography is a method for detecting lymphatic pathways and for the clinical evaluation of patients with extremity lymphedema. The essential point of LVA is to find more functional lymphatic vessels. Sometimes, in cases of lymphatic dysfunction, ICG injections into the distal extremities are insufficient. The purpose of this study was to elucidate the effect of multi-injection of ICG lymphography on LVA.

Methods: In this study, we injected ICG into the second web of the hands or the first web of the feet. In the multi-injection group, we injected additional ICG in other sites. We observed the presence or absence of a linear pattern at each injection site with a near-infrared camera. Then, we performed LVA and evaluated the circumference change and the operation time.

Results: In the multi-injection group, we injected ICG into the upper limb at an average of 2.2 sites (range: 1-3 sites) and the lower limb at an average of 3.2 sites (range: 1-5 sites). The circumference change of upper limbs in the control group was -3.95% ± 1.34% and in the multi-injection group was -6.96% ± 0.88% (P < 0.05). The change in circumference of lower limbs was -5.01% ± 2.2% in the multi-injection group and -2.33% ± 1.77% in the control group (P = 0.003). The mean surgical duration was significantly shortened in the multi-injection group (P < 0.05).

Conclusion: By injecting ICG into multiple sites of the affected limbs, we could detect more functional lymphatic vessels during LVA, which was helpful for achieving a successful surgical result.

Aim: To describe a novel technique for the reconstruction of geometrically complex defects of the midface using an osteotomized folded scapular tip-free flap.

Methods: Five patients underwent maxillectomy with defects disrupting two or more of the following facial axes: orbital, nasofacial, and palatal axes. Patients underwent primary reconstruction using an angular artery-based scapular tip-free flap with an osteotomy to fold the flap. Harvest techniques, including placement of osteotomies, folding and plating, surgical esthetic, and functional outcomes, are presented.

Results: Osteotomies placed in the scapular tip-free flap allowed folding of the osseous flap and improved restoration of all three facial axes with a single flap. In one patient, the tip of the scapula was used to reconstruct the nasofacial axis, while the body and lateral border were used to reconstruct the palate. In four patients, the tip of the scapula was used to reconstruct the orbital axis, while the body and lateral border were used to reconstruct the nasofacial axis. Patients had successful oronasal separation, healed wounds withstanding adjuvant therapy, satisfactory orbital positioning and facial projection, preserved masticatory surfaces and opportunity for dental implants.

Conclusion: The midface is geometrically complex and is one of the most challenging head and neck sites to reconstruct. Ablative defects in this area can disrupt facial axes resulting in poor esthetic and functional outcomes. This study demonstrates the reconstructive advantages of a novel osteotomized folded scapular tip-free flap.

Aim: Currently, prepectoral breast reconstruction (PBR) is widely used in clinical practice, but its safety lacks high-level epidemiological evidence. This meta-analysis intended to clarify the safety of PBR for clinicians.

Methods: The study followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Two independent reviewers systematically searched six databases from 1 January 2000 to 27 March 2020 to identify eligible studies. Statistical analysis was performed using R GUI 3.6.3, and a random effects model was used to calculate the proportion with 95% confidence intervals (CIs). Subgroup analysis was conducted based on body mass index, proportion of patients receiving preoperative radiotherapy, surgical technique, and follow-up time.

Results: In total, 19 studies involving 1686 cases and 2551 breasts were included. The percentage of surgical success was 96.2%, while the total complication rate was 15.4% (95%CI: 10.6%-20.9%), hematoma rate was 4.3% (95%CI: 2.3%-6.9%), infection rate was 3.4% (95%CI: 2.0%-5.1%), and capsular contracture rate was 0.9% (95%CI: 0.1%-2.6%). The results of the subgroup analysis show that: (1) the incidence of capsular contracture was higher in patients with lower weight, while other complications were minimal; (2) compared with the patients who underwent two-stage expander-assisted PBR, those with direct to-implant PBR had lower incidences of surgical complications; (3) preoperative radiotherapy could be a risk factor for various postoperative complications; and (4) with the extension of follow-up time, the incidence of long-term complications increases.

Conclusion: This present work confirmed that PBR is a safe and reliable therapy with a higher success rate and a relatively lower rate of complications. Overall, PBR can be used as an alternative for sub-pectoral breast reconstruction.

Free tissue transfer (FTT) is a cornerstone of head and neck reconstruction. Although rare, complications of FTT surgery can be devastating, including failed flap harvest, wound breakdown, or flap loss ultimately. Thus, modern microvascular surgeons bolster surgical and clinical expertise with a growing number of technological advances to optimize patient care and outcomes. These technologies can be applied in the preoperative, intraoperative, and postoperative period. Various preoperative imaging modalities can assist in selecting the optimal donor site and advanced perforator planning. Intraoperatively, novel technologies can assist with microvascular anastomoses, operative magnification and visualization, and assess free tissue perfusion. Postoperatively, routine clinical assessment can be augmented by a variety of adjunctive monitoring techniques designed to assess tissue health, arterial inflow and venous drainage. The overall ease and success of performing FTT can be improved by employing novel technologies at every phase of the surgical process. This article will expand upon established and upcoming technological advances and the existing literatures to support their use.

Aim: To evaluate the effectiveness of lymphovenular anastomosis (LVA) under local anesthesia for patients with high American Society of Anesthesiologists Physical Status (ASA PS) score.

Methods: From January 2019 to January 2021, we collected a total of 29 patients with lymphedema stage III and IV, operated upon with LVA by a single surgeon in a medical center. These patients had poor responses to compression therapies. After surgery, the patients underwent complex decongestive therapy consisting of the continuous wearing of an elastic stocking. To examine the effect of LVA, all data were collected, and differences in preoperative and postoperative means were analyzed.

Results: Twenty-nine patients with high ASA PS score (> 3) were followed after lymphovenular anastomosis and postoperative compression therapies. Twenty-one of 29 patients were survivors of oncological diseases and continued oncological therapies. The average duration of edema of these patients before LVA was 25 ± 5.0 years. The average number of anastomosis for each patient was 6.8 ± 2.2; the methods of anesthesia had no significant influence on these numbers. The average follow-up period was 7.8 ± 0.85 months, and the result was considered effective (26/29 patients; 89.7%). The average reduction of the circumference in affected limbs was 4.40% ± 3.67% of the preoperative excess length. There were no perioperative complications in this study.

Conclusion: Lymphovenular anastomosis can be performed under local anesthesia, especially in patients with high risks of general anesthesia (ASA PS score > 3). By this way, we could achieve adequate anastomosis and effective treatment of lymphedema in advanced cancer patients as well.

Maxillomandibular ablation and reconstruction includes a series of procedures that can be disfiguring and emotionally traumatic for a patient while treating maxillofacial disease. Often times, the process of regaining full form and function may take months to years for a patient. With the advent of modern day technology and virtual surgical planning, some patients may benefit from a single operation that includes disease ablation, microvascular reconstruction, and immediate dental rehabilitation, also known as “Jaw in a Day”.

Tracheal stenosis represents a significant challenge. Surgeons continue to search for appropriate reconstructive techniques and grafting materials for long tracheal segment reconstruction. Grafts can be classified as synthetic, allogenic, autogenic, transplant, and engineered. Although none of these grafts have provided overwhelming success, acellular composite engineered grafts have shown early promise and can be applied in benign and malignant tracheal diseases. Intraluminal granulation tissue causing re-stenosis is the biggest challenge in tracheal reconstruction. Tracheal wound healing and tissue regeneration pathways must be deeply explored and better characterized to advance the field of tracheal reconstruction.

Treatment aimed at preventing and reversing the facial aging process has grown in popularity. The aging midface is defined by classic deepening of the nasolabial folds, formation of marionette lines around the mouth, and significant atrophy of deep facial fat. While surgical options have been investigated with satisfactory and long-lasting results, nonsurgical alternatives such as soft tissue fillers are a safe and effective strategy for facial rejuvenation. This review focuses on a variety of injectable fillers available for the treatment of the aging midface, including hyaluronic acid, calcium hydroxylapatite, poly-L-lactic acid, and polymethyl methacrylate. Mechanism of action, relevant anatomy, indications/contraindications, technique, and any evidence of efficacy and safety are described. The benefits of injectable fillers include reduced patient discomfort and shorter recovery times. Understanding the advantages and limitations of injectable fillers for midface augmentation can allow providers to counsel and treat patients seeking care appropriately.

Lymphoedema is a chronic and debilitating condition commonly caused by cancer therapies, including lymph node dissection and radiotherapy in developed countries. A range of imaging modalities is used to view the lymphatic system for proper diagnosis, staging, and management of lymphoedema. Lymphoscintigraphy is the current gold standard imaging modality of the lymphatic system. However, magnetic resonance lymphography (MRL) is showing potential benefits in lymphoedema assessment and surgical planning. A literature review was compiled from published articles, incorporating their background literature, research outcomes, and recommendations to review the technique, application, and limitations of MRL. MRL is minimally invasive with no ionizing radiation, providing both functional and anatomical details of the lymphatic system with a higher spatial resolution than conventional lymphoscintigraphy. It shows promising results in the staging, surgical work-up, and surveillance for individuals with both primary and secondary lymphoedema.

Evolutions in skull base surgery and reconstructive technique have given surgeons the confidence to resect and repair increasingly advanced skull base pathologies. Free tissue transfer (FTT) provides a versatile option capable of addressing numerous simultaneous reconstructive goals. This review highlights some of the nuances, challenges, and considerations of performing FTT for skull base reconstruction in the anterior, central and lateral skull base. This review combines the expert opinion of the senior authors with those of the field at large as queried through PubMed searches regarding skull base reconstruction and FTT. Reconstructive goals include separation of intracranial from extracranial cavities, obliteration of dead space, and protection of vascular and neural structures. Atypical vascular pedicle management is commonly needed, especially for endonasal and central skull base resection. Virtual surgical planning may be beneficial for complex bony reconstruction. Familiarity with common complications such as cerebrospinal fluid leak, nasocutaneous fistula, and inferior flap displacement, as well as associations for their development, can help plan the reconstruction to minimize morbidity.

Protocols to enhance and expedite recovery after surgery originally developed through efforts in gastrointestinal, colorectal, and thoracic surgery populations. Implementation of specific evidence-based interventions undertaken in the perioperative setting has been shown to decrease the length of stay, reduce cost, and improve patient outcomes and satisfaction. The basic tenets of enhanced recovery protocols are to reduce physiologic stress in the perioperative setting, improve nutritional status before and after surgery, promote respiratory and physical rehabilitation, and encourage frequent and recurring reassessment for quality improvement. Some interventions, such as the use of deep vein thrombosis prophylaxis in the perioperative setting, are now well established across surgical populations; however, the increased attention to these protocols has led to new innovative interventions in the head and neck population. This review highlights these innovative interventions designed to enhance recovery after major surgery, lends particular focus to the biological mechanisms behind these interventions, and describes their relevance to the head and neck population.

Surgical treatment for lymphedema has undergone tremendous advancements over the years, with the earliest techniques focusing on ablative procedures such as liposuction and direct excision. With modern advancements in technology, equipment, imaging, and microscope optics, physiologic procedures have emerged as the standard of care for lymphedema at high-volume institutions and centers of excellence. The lymphovenous bypass and the vascularized lymph node transfer operations have both proven to be effective means for treatment and improving the quality of life of patients suffering from lymphedema. However, with the established foundation of knowledge and experience, innovative approaches to optimize outcomes in patients undergoing supermicrosurgical treatment are constantly evolving. The present review presents a historical review of the lymphovenous bypass and vascularized lymph node transfer procedures and introduces some novel expansions of both techniques in the field of lymphedema surgery.

Lymphaticovenular anastomosis (LVA) is a highly effective, minimally invasive surgical treatment for lymphedema. The effect of LVA appears immediately after the creation of lymph-to-venous pathway. However, the long-term outcome of LVA is not always promising when the lymph-to-venous anastomosis has any potential risk of occlusion. The reasons of postoperative LVA occlusions are considered both a technical matter in performing LVA and a strategic matter in preoperative planning. This report focuses on intraoperative techniques of LVA to avoid postoperative occlusions. Depending on the types of undesirable surgical procedures, lymphaticovenular anastomoses are at risk of future occlusions in early, mid-, or late-postoperative course. The authors describe fundamental and essential techniques to perform supermicrosurgical LVA, and the true concept of Isao Koshima’s supermicrosurgery, in which the pith and marrow of the doctrine is not only the way of handling the small vessels or needles, but also the surgeons’ skills to feel intima of the vessels and lymphatic flow itself.

The various elements used in assessing the lymphedema patient are presented. These include the History and Physical examination and the various measurements that include limb circumference, limb volume, and bio-impedence spectroscopy. In addition, the different imaging techniques used to assess the lymphatic system are discussed. Finally, a treatment algorithm is presented for the treatment of the lymphedema patient.

Lateral abdominal wall (LAW) defects are defined as hernias, bulges, or surgical wounds that occur within the anatomic region bounded by the linea semilunaris, costal margin, iliac crest, and paraspinous musculature. Reconstruction of the LAW is complicated by the relatively complex anatomy, asymmetric biomechanical forces on the repair, and progressive nature of concomitant denervation injuries. Furthermore, the relative rarity and varied nature of these defects have complicated comparative analysis and the development of consensus regarding optimal surgical management. Although mesh reinforcement of LAW defects is a universal component of available repair techniques, significant variation exists regarding mesh material selection, anatomic plane utilization, and extent of mesh reinforcement. Special consideration must be given to extirpative defects that extend beyond the aforementioned boundaries of the LAW. In this review, we outline the incidence of LAW defects, pertinent risk factors, common history and physical examination findings, supplementary diagnostic modalities, defect classification systems, surgical indications, and available repair techniques. The outcomes data in this review are presented to help guide surgical management and optimize outcomes for affected patients.

Early surgical intervention for lymphedema can delay, prevent, and even reverse lymphatic degeneration. Vascularized lymph vessel transplant (VLVT) has emerged as an alternative to vascularized lymph node transplant (VLNT) for the treatment of advanced, fluid-predominant lymphedema, providing highly favorable outcomes with reduced donor-site complications. Lymphaticovenular anastomosis (LVA) has traditionally been reserved for early disease. However, technical refinements have improved its results and expanded its efficacy, creating an overlap between the indications for VLVT/VLNT and LVA. This article describes our technical approach to VLVT and LVA and explores the nuances of treatment selection in the light of their shifting indications.

Lymphedema continues to be a very challenging clinical problem. While compression and physical therapy remain the foundation of treatment, recent advances in microsurgery and super-microsurgery have allowed for the development of promising surgical options. One of these options is vascularized lymph node transfer (VLNT), which has gained significant popularity over recent years. However, there is no consensus on the ideal donor lymph node basin for VLNT. In addition, the most commonly reported donor sites, including the groin, supraclavicular, submental, and lateral thoracic nodes, carry the risk of iatrogenic lymphedema and/or visible scarring. In order to avoid these risks, the use of intra-abdominal donor sites for VLNT has been pursued. This article reviews the reported techniques and outcomes for each of the intra-abdominal donor sites for VLNT.

The surgical armamentarium for the treatment of massive facial trauma has undergone a dramatic shift from early management strategies. Although tenants of acute trauma management continue to prioritize airway management and cardiopulmonary support, improved functional outcomes are achievable with an emphasis on early definitive free tissue transfer. The use of workhorse donor flaps, such as the radial forearm, fibula, and latissimus, have become the standard of care. An emphasis is placed on the separation of cranial, sinonasal, and oral contents and restoration of form and function. Here, we also discuss the management of telecanthus, nasal defects, and microstomia - sequelae which represent unique challenges to the reconstructive surgeon. The ability to perform virtual surgical planning and facial transplantation will likely shape future paradigms and represent the need to perform ongoing research.

Aim: This study aimed to clarify the efficacy of the integration of lymphaticovenular anastomosis (LVA) and perioperative reduction treatment in the exploration of optimal combination of surgery and conservative therapy for lymphedema.

Methods: We conducted a retrospective chart review of 134 consecutive patients with lower extremity lymphedema who were treated with LVA. A total of 116 patients were included, and they were divided into two groups: patients who underwent perioperative reduction treatment (PORT) following LVA surgery (PORT group, 51 patients) and patients who underwent no additional perioperative intervention after LVA surgery (control group, 65 patients). PORT included compression therapy and remedial exercise. A total of 41 matched pairs were extracted after propensity score matching analysis. The edema reduction effect was compared between the two groups.

Results: Patients who underwent PORT had a significantly higher edema reduction than those in the control group (reduction in lower extremity lymphedema index, 14.7 vs. 6.7; P = 0.03). No unfavorable complications related to PORT were observed in our cohort.

Conclusion: It would be highly beneficial to combine reduction treatment in the early postoperative period after LVA surgery to maximize treatment outcomes.

Aim: Abdominoplasty has gained in popularity due to the advances in concepts and techniques. The objective of this article is to present a modern abdominoplasty approach, which combines technical elements and evidence-based medicine, in order to achieve consistent aesthetic outcomes and high patient satisfaction rates while limiting the risk of complications.

Methods: A detailed description of the lipoabdominoplasty technique is presented. Liposuction of the trunk is combined with dermolipectomy of the anterior abdomen and rectus abdominis muscle plication in a standardized fashion.

Results: In this study, lipoabdominoplasty was performed on 93 patients. The mean hospital stay and time of drain removal were 1.2 and 8.1 days, respectively. The technique was associated with enhanced aesthetic outcomes, in terms of body contouring and definition, high satisfaction rate, and low rate of complications. Minor revisions were performed in 12% of cases, under local anesthesia.

Conclusion: Safe and consistent outcomes can be achieved by a meticulous lipoabdominoplasty technique, based on the accumulated evidence, thorough anatomical and surgical knowledge, and the artistic acumen of a plastic surgeon.

Genital flaps can provide versatile options for complex penile, genital, and urethral reconstruction. Pedicled muscle flaps can be used in combination with grafting for urethral reconstruction, and genital skin flaps can also be utilized as urethral augmentation or replacement. Penile skin flaps, in particular, offer versatile options for the management of anterior urethral stricture disease. The choice of urethral reconstruction depends on surgeon expertise and patient disease. Given its surgical complexity, flap reconstruction is equally dependent on an appropriate understanding of patient disease and surgeon experience. It is crucial to understand the patients’ comorbid diseases (e.g., smoking status or lichen sclerosis), potential flap tissue quality (i.e., penile/preputial skin quality), and stricture anatomy (length, caliber, location). Of particular importance is any prior intervention that may alter the normal vascular supply to the proposed flap. The ideal skin flap will be (1) hairless; (2) accustomed to the aqueous environment; (3) adaptable; and (4) cosmetic. This review will cover the operative approaches and peri-operative outcomes of genital flaps to manage urethral reconstruction. Particular attention will be paid to penile skin flap urethroplasty.

Aim: The aim of this literature review is to evaluate the efficacy of microneedling treatment with injectable platelet-rich fibrin (i-PRF) for facial skin rejuvenation applications, using an objective skin analysis system and validated patient-reported outcome measures.

Methods: The search approach involved the exploration of electronic databases. An advanced search option was applied to filter our search line, i.e., from February 2011 to April 2021. We performed a search on Medline, Scopus, Embase, and Web of Science, while improving the accessed articles via Ovid interface. Our keywords were chiefly aligned with a combination of MeSH terms and text words. All retrieved articles were written in English.

Results: The search yielded 73 studies. After reviewing their title and summary, nine of them were found to meet the inclusion criteria and, next, the full-text articles were reviewed. Of these, three studies were excluded from systematic research, as they would no longer meet the inclusion criteria. In total, six studies were considered for review.

Conclusion: Microneedling treatments combined with blood concentrates are increasingly being utilized as autologous products for aesthetic purposes. Few works can be found on i-PRF in facial rejuvenation, and even fewer on i-PRF along with microneedling. Combined applications seem to be promising and minimally invasive. Further research on PRP and PRF is warranted to better elucidate their functional roles in medical cosmetic rejuvenation.

Aim: Describe our institutional experience with different forms of reconstruction, including free tissue transfer vs. other newer techniques such as Integra, an artificial dermis composed of bovine collagen lattice with a layer of an artificial synthetic silicon epidermis.

Methods: We performed a retrospective review of patients who underwent full-thickness scalp reconstruction at a single tertiary care institution between January 2016 and March 2021. Patient demographic information, co-morbidities, defect depth and size, reconstruction type, American Society of Anesthesiologists (ASA) score, and postoperative complications were collected.

Results: Of the total 32 patients collected, 68.7% were male and 31.2% were female with an average age of 57.88 years (range 3-91 years). Malignancy (n = 26, 81.2%) was the most common reason for scalp reconstruction, followed by trauma (n = 5, 12.5%) and non-healing wound/exposed hardware (n = 2, 6.2%). The majority of patients underwent reconstruction with Integra +/- split thickness skin graft (n = 15, 46.8%) followed by tissue expander in combination with local flap (n = 6, 18.7%) and microvascular reconstruction (n = 5, 15.6%). Patients who underwent reconstruction with Integra had more medical comorbidities and a higher ASA score (2.93 ± 0.25) than those who underwent free tissue transfer (2.75 ± 0.96). Large defects (> 6.1 cm) were mostly reconstructed via the Integra/Integra + STSG method (n = 13, 59.1%), and all immunosuppressed patients were reconstructed with Integra (n = 3, 100%). Scalp defects with exposed dura were all reconstructed with free tissue transfer (n = 3, 100%). Four Integra-reconstructed patients required revision surgery due to partial graft failure.

Conclusion: Free tissue transfer is widely used to reconstruct large and full-thickness scalp defects. However, Integra can be a viable option in patients with numerous medical comorbidities or extensive scalp defects requiring complex reconstruction.

Current periodontal regenerative therapies aim at restitution ad integrum of the periodontal attachment apparatus, which involves periodontal ligament, root cementum, and alveolar bone. Guided tissue regeneration, bioactive agents and bone replacement grafts have been utilized in an attempt to fully restore the lost periodontal tissues. But their predictability has been limited and dependent on patient- and defect-related factors. Consequently, the treatment of most periodontal defects still lacks satisfactory and predictable outcomes. Cell therapies, based on the use of mesenchymal stem cells (MSCs), represent a promising therapeutic strategy in light of recently available published preclinical investigations and clinical studies. The application of MSCs in humans is being performed by two different strategies: (1) the ex vivo culture of undifferentiated MSCs from autologous or allogeneic sources, subjected to specific cell expansion and characterization/differentiation tests to obtain the required cell counts for transplantation; and (2) the use of autologous tissue grafts and micrografts, which apart from MSCs, contain other biologically active cell populations and their extracellular matrix. This review evaluates the current status of MSCs therapy applied for periodontal regeneration, describing not only their mechanism of action, but also their efficacy and safety according to the published evidence.

Aim: The importance of nutrition in the prevention of skin aging has been shown by large observational studies. However, there are no studies assessing dietary changes as adjunct procedures to aesthetic interventions. The objective of this study was to assess whether a personalized nutritional plan conveys additional benefits to platelet-rich fibrin (PRF) facial regeneration.

Methods: Forty-seven healthy women (mean age 52.5 years old, SD = 7.7) were offered minimally invasive facial regeneration with the use of PRF liquid matrices, as well as a personalized nutritional plan. The nutritional plan was informed by a nutrigenetic test based on 128 polymorphisms. Horizontal forehead lines, zygomatic wrinkles or mid-cheek furrows, nasolabial folds, perioral expression wrinkles, and marionette line were assessed separately with the use of the Facial Wrinkles Assessment Scale (FWAS).

Results: The total FWAS score change was statistically significantly better in women who reported an at least partial adaptation of nutritional recommendations for at least three months (Z = 2.4, P = 0.008).

Conclusion: Personalized nutritional recommendations based on individual needs as well as generally accepted dietary guidelines can improve treatment outcomes of minimally invasive facial skin aesthetics interventions.

Abdominoplasty techniques have evolved with our improved understanding of vascular anatomy, tissue mechanics, and patient preferences. As a result, today, surgeons are well equipped with an armamentarium of evidence-based techniques and adjuncts that safely and effectively address abdominal lipodystrophy, skin flaccidity, and myofascial laxity. Abdominoplasty is now one of the most common procedures performed by plastic surgeons in the United States, with rates projected to increase with the growing popularity of bariatric surgery, an aging population, and increasing motivation from a generation of patients who have undergone liposuction alone. The present article reviews the authors’ current technique.

Lymphaticovenular anastomosis (LVA) is a highly effective, minimally invasive surgical treatment for lymphedema. The clinical effect of LVA begins immediately after the creation of the lymph-to-venous pathway. However, the long-term effect of LVA is not always promised when the lymph-to-venous bypass has any potential risk of occlusion, especially when the disorder has reached the late stage. The reasons of postoperative LVA occlusion are considered both a technical matter in performing LVA and a strategic matter in planning LVA. This article focuses on the effective preoperative LVA planning methodology of “functional LVA” for peripheral lymphedema, in which continuous and strong lymph flow at the anastomosis is created by the muscle pumping power of patients’ natural motions at the selected incision point. The current functional LVAs which we have developed are the dynamic LVA method for upper extremity lymphedema and the superior-edge-of-the-knee incision method for lower extremity lymphedema. Because these methods reduce the risk of postoperative LVA occlusion by continuous lymph-to-venous flow at the LVA, functional LVAs keep long-term clinical effect in reduction of lymphedema.

The subscapular system can confer numerous flaps for the reconstruction of composite mandibular defects. This chapter aims to review the indications, advantages, and anatomy of subscapular system flaps in the reconstruction of the mandible. The subscapular system can serve as an alternative to the fibula free flap in the presence of significant atherosclerotic disease or other contraindications. The flexibility and abundance of its soft tissue components make this system particularly advantageous for complex composite defects. Avoiding a fibula free flap for osseous reconstruction of the mandible permits early patient mobilization and may prevent adverse postoperative complications. A long pedicle can be harvested with subscapular flaps, which may prove useful in the face of limited available recipient vessels. Critics of the subscapular system cite longer operative times due to the need for patient repositioning and concerns over the integrity of the bone stock. Positioning modifications may permit a two-team approach to subscapular reconstruction, thus limiting operative times. Subscapular harvest does incur shoulder morbidity; however, this does not appear to affect the quality of life significantly. The flap is reliable and can support endosseous implants if properly planned, though it may be more susceptible to bone resorption when compared to the fibula. Overall, the subscapular system remains a versatile donor that can achieve ideal reconstructive outcomes with minimal morbidity.

Gracilis free muscle transfer (GFMT) is considered the gold standard in dynamic smile reanimation in patients with long-standing facial paralysis. There are multiple motor nerves in the head and neck that can be used to provide innervation to the GFMT, either alone or in combination. In this article, we review the literature about these donor nerve options and discuss their advantages and disadvantages in terms of smile excursion, spontaneity, reliability, and timing. Furthermore, we discuss the use of multiple donor nerve sources in dually-innervated GFMT and areas for future investigation.

The submental-cervical angle is an important anatomical landmark in neck beauty. Considered attractive and a sign of youthful when between 105° and 120°, greater values are considered a “heavy” neck or double chin and are related to the aging process and/or weight gain. The submandibular gland can also contribute to the alteration of the submental-cervical angle, increasing the area’s bulging. Neck-lifting techniques have the potential to produce important changes in the lateral view of the face, making it look more youthful, and that is more noticeable in the frontal aspect. This review focuses on the treatment of the neck, including all modifications that occur during the aging process, and postoperative procedures used to decrease the risk of complications.

Osteoradionecrosis (ORN) of the head and neck can be a devastating complication following radiation therapy. ORN is associated with pain, chronic infection, and non-healing wounds. Radiation fibrosis, chronic infection, fistula formation, and necrotic tissues can make treatment challenging. The following review article is a narrative on the management of advanced head and ORN.

Aim: Evaluate the clinical effectiveness of platelet-rich plasma as a treatment for lichen sclerosus.

Methods: A systematic review was performed. The electronic databases PubMed, Ovid MEDLINE®, Web of Science, Cochrane, clinicaltrials.gov were used to identify case studies, case series, prospective uncontrolled, and randomized controlled studies published between 1946 and April 21, 2021. Six prospective uncontrolled studies, one randomized double-blind prospective study, and one case report were included.

Results: Platelet-rich plasma treatment was subjectively reported to improve quality of life, but objective measures demonstrating treatment efficacy were not observed. In addition, platelet-rich plasma preparation and administration between studies lacked standardization.

Conclusion: Platelet-rich plasma may be used for symptomatic adjuvant treatment of lichen sclerosus, though additional double-blind controlled studies with standardized platelet-rich plasma protocols are needed to better characterize the efficacy of platelet-rich plasma.

Skin laxity is an unavoidable consequence of aging and chronic sun exposure. Patients are increasingly turning to non-surgical skin tightening measures for a more youthful look. Non-surgical methods can be effective in treating mild to moderate skin laxity, while offering decreased downtimes and fewer serious complications than surgical interventions. This article reviews the major non-surgical interventions for skin laxity: ablative and non-ablative lasers, radiofrequency, and microfocused ultrasound, noting their physiologic mechanism of actions, clinical benefits, and side effects. Regardless of the procedure, patient selection and expectation setting are crucial to achieving desired results and ensuring patient satisfaction.