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Background: Recurrent ptosis may occur after mastopexy procedures over time. The volume distribution mastopexy technique provides breast lifting with projection enhancement and maintains breast suspension., Method: Since 2010, 50 patients underwent volume distribution mastopexy procedures. The technique consists of a superior or superomedial pedicle, dissection of a Würinger-septum-based chest wall flap, suspension of the flap to the pectoralis major muscle using a prosthetic mesh, gland suture to the mesh, and fat grafting if required. A prospective study was conducted. Nipple position and length of the lower pole distance of the breast were noted. Patient satisfaction and results evaluation were reported using a Likert scale., Results: A Vicryl mesh was used in the first 23 patients and a mixed polyester/Vicryl mesh was used in the following 27 patients. Wound dehiscence occurred in one patient. At an average follow-up of 3 years, nipple position remained stable in position, but lower pole distance elongation was observed in five patients (20 percent) and in one patient (3 percent) who had Vicryl mesh and mixed mesh respectively (p < 0.05). Only four breasts (4.7 percent) demonstrated significant lower pole elongation over time (>15 percent), all in the Vicryl mesh group. Worth noting, both the patients and the independent evaluators provided high ratings of the result of 4.7 and 4.6, respectively, on a Likert scale., Conclusions: The volume distribution mastopexy technique repositions the ptotic gland with a mesh to suspend the breast gland and to maintain the lifting effect. However, the synthetic mixed mesh proved to be significantly more effective in achieving this goal., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Background: Fat graft ischemia impedes us from having satisfying long-term results. The quality and quantity culture is a 1-week cell culture that increases the vasculogenic potential of peripheral blood mononuclear cells (PBMNC). This in vivo murine model investigates whether enrichment with quality and quantity-cultured human mononuclear cells (MNC-QQ) improves the vascularization in the human fat graft and whether this decreases the tissue loss., Methods: Human adipose tissue, PBMNC, MNC-QQ, and stromal vascular fraction were prepared. First, PBMNC, MNC-QQ, and stromal vascular fraction were compared in vitro for vasculogenic potential by endothelial progenitor cell colony-forming and culture assays. Second, 0.25-g fat grafts were created with 1 × 106 PBMNC (n = 16), 1 × 106 MNC-QQ (n = 16), 1 × 106 stromal vascular fraction (n = 16), or phosphate-buffered saline as control (n = 16) before grafting in BALB/c nude mice. Grafts were analyzed for weight persistence, vessel formation by CD31 immunohistochemistry, and angiogenic markers by quantitative polymerase chain reaction., Results: MNC-QQ develop more definitive endothelial progenitor cell colonies and more functional endothelial progenitor cells compared to PBMNC and stromal vascular fraction. Weight persistence after 7 weeks was significantly higher in grafts with MNC-QQ (89.8 ± 3.5 percent) or stromal vascular fraction (90.1 ± 4.2 percent) compared with control (70.4 ± 6.3 percent; p < 0.05). MNC-QQ-enriched grafts had the highest vessel density (96.6 ± 6.5 vessels/mm2; control, 70.4 ± 5.6 vessels/mm2; p < 0.05). MNC-QQ exerted a direct vasculogenic effect through vascular integration and a potential paracrine vascular endothelial growth factor-mediated effect., Conclusion: Quality and quantity-cultured human mononuclear cells containing endothelial progenitor cells stimulate fat graft vascularization and enhance graft survival in a rodent recipient., (Copyright © 2020 by the American Society of Plastic Surgeons.)

Background: Fat grafting has become a valuable technique for soft-tissue reconstruction; however, long-lasting success depends on several determinants. An early blood supply to the transplanted adipocytes is important to prevent ischemia. The recently developed quality and quantity (QQ) culture increases the vasculogenic potential of endothelial progenitor cells. The authors used a murine fat grafting model to address the hypothesis that QQ-cultured endothelial progenitor cells stimulate the establishment of a blood vessel network and increase graft success., Methods: c-KitSca-1Lin (KSL) cells were isolated as endothelial progenitor cell precursors from C57BL/6 mice. Adipose tissue was grafted with QQ-cultured KSL cells (QQKSL group), uncultured KSL cells (KSL group), adipose-derived stem cells (ASC group), and a combination (QQKSL+ASC group), and compared to a control group. Five and 10 weeks later, grafts were weighed, histologic and immunohistochemical parameters were evaluated, and gene expression was quantified by quantitative polymerase chain reaction., Results: The highest vessel density was observed in the combined QQKSL+ASC group (68.0 ± 4.3/mm; p < 0.001) and the QQKSL group (53.9 ± 3.0/mm; p < 0.001). QQKSL cells were engrafted in proximity to the graft vasculature. QQKSL cells decreased the fibrosis percentage (13.8 ± 1.8 percent; p < 0.05). The combined QQKSL+ASC group (22.4 ± 1.8/mm; p < 0.001) showed the fewest local inflammation units. A significant up-regulation of platelet-derived growth factor and adiponectin expression was observed in the QQKSL group and QQKSL+ASC group. Graft weight persistence was not significantly different between groups., Conclusions: Supplementing fat grafts with quality and quantity-cultured endothelial progenitor cells improves graft quality by stimulating vascularization. The increased vessel density is associated with less fibrosis, less inflammation, and better adipose tissue integrity. Enriching fat grafts with QQ-cultured endothelial progenitor cells is a potential solution to their clinical shortcomings.

Background: Breast reconstruction with the lumbar artery perforator flap is indicated in patients with unfavorable abdominal donor site. In addition to their clinical experience with lumbar artery perforator free flap breast reconstruction, the authors present an anatomical study of the origin and course of the perforators., Methods: Images of multidetector computerized tomography scans were used to visualize the location of the dominant lumbar artery perforator in 20 patients. The medical files of the authors' patients who underwent lumbar artery perforator flap breast reconstruction were also analyzed., Results: Multidetector computed tomographic imaging in 20 female patients with a mean age of 47 years revealed an equal number of dominant perforators (10 left and 10 right); 60 percent were third lumbar artery perforators, 30 percent were fourth, and the remaining were second. The dominant perforators were mainly located 42.6 mm from the y axis at their origin at the transverse process, and 69.5 mm when emerging in the subcutaneous tissue. Six patients had nine successful lumbar artery perforator flaps for breast reconstruction. Average operative time was 270 minutes. Due to shortness of pedicle and mismatching between diameter of lumbar artery and internal mammary artery, vascular bypass (harvested from the deep inferior epigastric vessels) was required in 50 percent of the cases. The major complication at the donor site was seroma (80 percent)., Conclusions: The lumbar artery perforator has a constant anatomical location. The free lumbar artery perforator flap provides an ample amount of tissue for breast reconstruction; however, its major disadvantages are the small artery diameter, shortness of the pedicle, and high seroma rate at the donor site., Clinical Question/level of Evidence: Therapeutic, IV.

Background: Breast cancer-related lymphedema affects multiple aspects of patients' daily lives. The main aim of this study was to assess the impact of vascularized lymph node transfer on the quality of life in patients with lymphedema., Methods: Between 2007 and 2012, 25 female patients with breast cancer-related lymphedema underwent vascularized lymph node transfer. In 22 cases, the patients underwent a simultaneous deep inferior epigastric artery perforator flap breast reconstruction based on the superficial circumflex iliac artery. The influence on quality of life was evaluated using the Upper Limb Lymphedema-27 questionnaire, which includes physical, psychological, and social dimensions. The authors also investigated risk factors for lymphedema, such as body mass index, smoking, age, and time between start of lymphedema and vascularized lymph node transfer, and their impact on quality of life., Results: Twenty-one patients (84 percent) had an improvement of quality of life after vascularized lymph node transfer. The mean physical, psychological, and social scores were significantly improved postoperatively (p < 0.001). Risk factors for the development of lymphedema did not influence quality of life among patients with breast cancer-related lymphedema. Skin infections disappeared in 50 percent of the cases. Eleven patients (44 percent) discontinued compression therapy at a mean postoperative time interval of 29 months (range, 8 to 64 months). In the other patients (56 percent), the average frequency of compression therapy decreased from three sessions to one session per week., Conclusion: Vascularized lymph node transfer significantly improves quality of life among patients with breast cancer-related lymphedema., Clinical Question/level of Evidence: Therapeutic, IV.

Background: The temporal lift by galeapexy is a short-scar lifting of the lateral third of the eyebrow and temporal region described in 2003 by Alain Fogli. The senior authors (A.M.V., P.L.T.) have been early adopters of this technique, albeit with some modifications., Methods: The technique was used in 923 cases, of which 20 percent were performed as an isolated procedure and 80 percent were performed in combination with a minimal access cranial suspension lift., Results: Over 8 years of experience has proven the technique to have good reliability, and to be predictable and safe. Patients with follow-up of 5 years or more were reviewed, and showed a marked improvement of both lateral hooding and eyebrow position in more than 90 percent of cases, with a relapse rate of less than 10 percent after 5 years. The complication rate was below 5 percent., Conclusion: Both surgeon satisfaction and patient satisfaction with this technique are high.

Background: The transverse myocutaneous gracilis flap provides adequate autologous tissue for breast reconstruction from the high thigh region, but flap harvest may affect the patient's activities of daily living, sexuality, and quality of life. The authors evaluated the reconstruction outcome, postoperative donor-site complications, and quality-of-life outcomes., Methods: All patients who underwent transverse myocutaneous gracilis breast reconstruction performed by the senior author (M.H.) since 2007 were included in the study. Patient files were reviewed, and a questionnaire was used to assess patient satisfaction., Results: Forty-nine transverse myocutaneous gracilis flaps were performed in 36 patients for breast reconstruction. Total flap necrosis occurred in two flaps (4 percent). Additional fat grafting was required in 61 percent of flaps, and donor-site complications occurred in 59 percent of patients. Wound dehiscence and infection were the most commonly encountered donor-site complications. However, by harvesting less skin and gracilis muscle, there was a statistically significant (p<0.001) lower complication rate in the last 16 patients. Twenty-two patients with at least 6 months of follow-up were included in the questionnaire study. Eighteen returned questionnaires. Most patients were happy to very happy with their result and could go about their activities of daily living. There was no statistically significant correlation between the independent variables (e.g., age, body mass index, and radiotherapy) and the dependent variables (e.g., breast satisfaction, sexuality, and donor-site morbidity). There was a statistically significant difference regarding donor-site satisfaction when comparing patients with and without donor-site complications (p=0.01)., Conclusions: Although fat grafting was often required, patients were happy with the result of their transverse myocutaneous gracilis breast reconstruction. Donor-site complications correspondence inversely to patient satisfaction., Clinical Question/level of Evidence: Therapeutic, IV.

Background: The thoracodorsal artery perforator flap was described mainly for partial breast reconstruction by Hamdi. The purpose of this article is to describe the use of the pedicled thoracodorsal artery perforator flap for total autologous breast reconstruction without using an implant., Methods: Between January of 2009 and December of 2011, seven patients underwent total breast reconstruction with a pedicled thoracodorsal artery perforator flap. The mean age of the patients was 53 years (range, 43 to 62 years), and the mean body mass index was 27 kg/m (range, 24 to 32 kg/m)., Results: The mean size of the harvested skin paddle was 23.7 × 8.8 cm (range, 15 × 7 cm to 39 × 14 cm). The flaps were based on one to three perforators and successfully transferred with an average operative time of 3 hours. No seroma occurred at the donor site. Average hospital stay was 4 days (range, 3 to 6 days). At an average follow-up of 21.5 months, two patients underwent additional revisions using autologous fat grafting, with overall fat injection volumes of 240 and 280 cc, respectively., Conclusion: The pedicled thoracodorsal artery perforator flap offers an alternative for total autologous breast reconstruction in small to medium breasted patients when abdominal tissues are not available., Clinical Question/level of Evidence: Therapeutic, IV.

Background: The indications for fat grafting are increasing steadily. In microfat grafting, thin injection cannulas are used. The authors describe their experience of fat injection with even thinner injection needles up to 27 gauge. The fat used for this purpose is processed into "nanofat." Clinical applications are described. Preliminary results of a study, set up to determine the cellular contents of nanofat, are presented., Methods: Nanofat grafting was performed in 67 cases to correct superficial rhytides, scars, and dark lower eyelids. Three clinical cases are described. In the research study, three fat samples were analyzed. The first sample was a classic lipoaspirate (macrofat). The second sample was microfat, harvested with a multiport small-hole cannula. The third was microfat processed into nanofat. Processing consisted of emulsification and filtering of the lipoaspirate. Fat samples were analyzed for adipocyte viability. Cells from the stromal vascular fraction and the CD34+ subfraction were quantified. The stem cell quality was investigated by culturing the cells in standard and adipogenic media., Results: No viable adipocytes were observed in the nanofat sample. Adipose-derived stem cells were still richly present in the nanofat sample. Cell cultures showed an equal proliferation and differentiation capacity of the stem cells from the three samples. Clinical applications showed remarkable improvements in skin quality 6 months postoperatively. No infections, fat cysts, granulomas, or other unwanted side effects were observed., Conclusions: Nanofat injections might become a new concept in the lipofilling area. In clinical situations, nanofat seems to be suitable for skin rejuvenation purposes.

The anterolateral thigh flap is currently the frontline choice for head and neck reconstruction. The authors used a chimeric anterolateral thigh flap for reconstruction of a through-and-through oropharyngeal defect. Because of the absence of suitable recipient vessels in the proximity of the defect, the authors recruited the internal mammary vessels. To gain extra pedicle length, the authors converted the chimeric anterolateral thigh flap into a sequential iatrogenic chimeric anterolateral thigh flap. This new flap concept consists essentially of the division of the skin paddle of the anterolateral thigh that is based on two perforators, and the creation of a sequential chimeric flap by reconnecting the pedicles in the opposite order. A functionally good and aesthetically pleasing result was obtained.

Background: Abdominal incisions and their subsequent scarring alter the vascular architecture of the abdominal pannus. This is of significance when reconstructing the breast with the deep inferior epigastric perforator (DIEP) flap. This study aimed to objectively investigate the impact of the lower abdominal Pfannenstiel scar in utilizing the DIEP flap., Methods: A retrospective study of breast reconstruction with DIEP flaps was conducted on patients who had a Pfannenstiel scar (n = 36) compared with patients who did not (n = 36). Computed tomography angiograms were analyzed for the numbers, positions, and dimensions of perforator vessels. Influence of the scar on the reconstructive outcome was assessed., Results: The number of perforators was greater in the control group (mean, 9.14) compared with the study group (mean, 8.3) but was not significant, with marginal significance (p = 0.09). The percentage of found perforators with 4 mm or greater was significantly higher in the study group than in the control group (21.7 percent compared with 14.3 percent, respectively; p = 0.04). The position of perforators was more or less the same, and complications were also comparable in both groups., Conclusions: Pfannenstiel incisions result in undermining of the lower abdominal apron and, in most cases, division of the superficial epigastric vessels. This results in "ischemic preconditioning" of the flap, as has been evidenced by the increased dimensions of the perforators. Hence, flaps raised from these abdomens are not only safe but may even be better vascularized., Clinical Question/level of Evidence: Therapeutic, III.

Background: Salvage of a failed autologous breast reconstruction is a complex and challenging problem. The purpose of this study was to analyze the indications, methods, and outcomes of tertiary surgery in patients with a failed autologous breast reconstruction., Methods: A retrospective chart review was performed for all patients who underwent breast reconstruction with autologous tissue performed by the senior author (M.H.) between 2002 and 2009. Special emphasis was made to evaluate the first reconstruction performed, causes of failure, indications for tertiary reconstruction, and outcomes. A preoperative hematologic workout was performed. For patients who were classified within the highest group of thromboembolism, specific prophylactic measurements were taken for the tertiary surgery., Results: Of 688 patients who underwent autologous breast reconstruction, a total of 14 patients required tertiary breast reconstruction. Hypercoagulability was found in three patients resulting from disorders such as lupus anticoagulant positivity and antiphospholipid syndrome. Six patients (43 percent) underwent a combination of local skin flaps and/or implant reconstructions. Eight patients (57 percent) underwent nine microvascular breast reconstructions: five superior gluteal artery perforator flaps, three transverse myocutaneous gracilis flaps, and one deep inferior epigastric artery perforator flap. Two of nine flaps (22 percent) required quaternary reconstructions because of a failure of the second free flap. Additional corrections such as revision lipofilling, scar revision, contralateral breast shaping, implant change, and capsulotomies were performed in 92.7 percent of the patients, with a mean follow-up of 37 months (range, 6 months to 7 years)., Conclusions: Tertiary surgery after autologous breast reconstruction failure has limited options and further reoperations are often needed. Careful patient history and selective blood tests may reveal hidden coagulation disorders. When a second free flap is planned, primary and secondary antithrombotic therapy should be considered.

The popularity of breast conservation therapy for the management of women with breast cancer continues to rise. To preserve cosmesis or broaden the indications for breast conservation therapy in some situations, plastic surgeons are now being challenged with the reconstruction of partial mastectomy defects. Numerous techniques exist, either at the time of resection or following radiation, and the decision of which to use depends on breast size, tumor size, and tumor location. Women with unfavorable defects in smaller breasts will often benefit from volume replacement techniques, such as local fasciocutaneous or myocutaneous flaps, without the need for a symmetry procedure. Women with moderate or larger breasts (with or without ptosis) and the potential for an unfavorable result also have the option for volume displacement procedures using local tissue rearrangement techniques to reshape the breast mound. As these are volume reduction procedures, they often require a contralateral procedure for symmetry. The extent of resection (lumpectomy versus quandantectomy) will also influence the type of reconstruction. Patient selection, surgical technique, margin status, and appropriate follow-up are crucial to maximize both oncological safety and cosmesis. The reconstruction of partial mastectomy defects will likely gain popularity as we continue to demonstrate safe and effective treatment algorithms with larger series and longer follow-up in an attempt to minimize locoregional disease and maximize cosmetic outcome.

Background: The ideal goals in penile reconstruction are well described, but the multitude of flaps used for phalloplasty only demonstrates that none of these techniques is considered ideal. Still, the radial forearm flap is the most frequently used flap and universally considered as the standard technique., Methods: In this article, the authors describe the largest series to date of 287 radial forearm phalloplasties performed by the same surgical team. Many different outcome parameters have been described separately in previously published articles, but the main purpose of this review is to critically evaluate to what degree this supposed standard technique has been able to meet the ideal goals in penile reconstruction., Results: Outcome parameters such as number of procedures, complications, aesthetic outcome, tactile and erogenous sensation, voiding, donor-site morbidity, scrotoplasty, and sexual intercourse are assessed., Conclusions: In the absence of prospective randomized studies, it is not possible to prove whether the radial forearm flap truly is the standard technique in penile reconstruction. However, this large study demonstrates that the radial forearm phalloplasty is a very reliable technique for the creation, mostly in two stages, of a normal-appearing penis and scrotum, always allowing the patient to void while standing and in most cases also to experience sexual satisfaction. The relative disadvantages of this technique are the rather high number of initial fistulas, the residual scar on the forearm, and the potential long-term urologic complications. Despite the lack of actual data to support this statement, the authors feel strongly that a multidisciplinary approach with close cooperation between the reconstructive/plastic surgeon and the urologist is an absolute requisite for obtaining the best possible results.

Background: One of the goals of genital construction in female-to-male transsexuals is the creation of an aesthetically acceptable result, both for phallus and scrotum, leaving minimal morbidity and recreating function. In the last 15 years, transsexuals have become more demanding, and scrotoplasty has received more attention than before. Traditional flaps for scrotal reconstruction in a biological male do not really apply in transsexuals: the labia majora seem to achieve the best results; still, they may not provide enough tissue and can be located much too posteriorly., Methods: Since November of 1993, more than 300 scrotal reconstructions (and radial forearm flap phalloplasties) have been performed in female-to-male transsexuals by the authors' gender team. Based on the authors' large experience, they modified previous techniques and developed a novel scrotoplasty consisting of a V-Y advancement of the major labia together with a rotation of these superiorly based labial flaps. Refinements (to achieve better sensation and shaping) are described. Twelve months after the original operation, one testicle implant and erection prosthesis procedures were performed., Results: No major complications related to scrotoplasty occurred in the authors' series. Patients were all pleased at short- or long-term follow-up with their scrotum, located in its natural position in front of the legs., Conclusion: The authors' novel scrotoplasty can become the ultimate surgical technique to reconstruct the scrotum in female-to-male transsexual patients, further improving the final cosmetic result, with the possibility of enhanced erogenous sensitivity.

Background: During the past 7 years, the senior author (M.H.) has been performing septum-based mammaplasty. The aim of this article is to report the safety and ease of breast shaping by using this technique., Methods: A series of 110 consecutive patients underwent septum-based breast reduction performed by a single surgeon. This technique uses a lateral or medial pedicle based on Würinger's horizontal septum, which carries the main nerve supply to the nipple in addition to intercostal perforators., Results: Mean nipple-to-sternal notch distance was 33 cm (range, 22 to 45 cm). Mean resection was 658 g (range, 160 to 1980 g). Nipple elevation was 9 cm on average (range, 3 to 17 cm). A retroareolar hematoma occurred in three breasts. Total areola necrosis occurred in one breast (0.5 percent) as a result of an infection in a diabetic patient. Limited wound dehiscence occurred in 15 breasts (7.7 percent). A secondary scar revision was needed in 10 patients (9 percent). One patient required a revision., Conclusions: Based on a well-vascularized and constant anatomical septum, a septum-based pedicle is safe, even in large breasts. This technique is safe and demonstrates ease of pedicle shaping and breast remodeling in patients undergoing reduction mammaplasty.

Background: Converting the latissimus dorsi musculocutaneous flap to a thoracodorsal artery perforator flap has been reported for breast reconstruction. The goal of this article is to evaluate the donor site after harvesting a thoracodorsal artery perforator flap in patients who underwent breast surgery and to show the advantages of sparing the latissimus dorsi muscle on the function of the shoulder., Methods: Between 2002 and 2004, 22 patients who had a partial breast reconstruction using a pedicled thoracodorsal artery perforator flap were enrolled in a functional study to evaluate shoulder function postoperatively. Latissimus dorsi muscle strength, shoulder mobility, and latissimus dorsi thickness were measured by using the MicroFet2, a goniometer, and ultrasound examination, respectively. The measurements of the operated and contralateral (unoperated) sides were analyzed statistically., Results: When comparing the operated sides to the unoperated sides, latissimus dorsi strength seemed to be maintained after surgery. Shoulder mobility was also similar in all movements, but both active and passive forward elevation and passive abduction were reduced significantly after surgery, and latissimus dorsi thickness was not affected by harvesting the thoracodorsal artery perforator flaps. No seroma formation was found in any of the donor sites., Conclusions: Donor-site morbidity after harvesting a thoracodorsal artery perforator flap was reduced to a minimum. Therefore, perforator flaps should be considered in reconstruction whenever adequate perforators can be identified and safely dissected.

Background: The thoracodorsal artery perforator flap is considered a technically difficult flap because of significant anatomical variations in perforator location. The authors' strategy to facilitate the harvest of these flaps includes careful preoperative mapping of perforators and a standardized planning and harvesting technique. The authors evaluated 99 pedicled thoracodorsal artery perforator flaps, with an emphasis on preoperative planning, surgical technique, and analysis of complications., Methods: Between May of 2000 and October of 2006, 99 patients underwent pedicled thoracodorsal artery perforator flaps in the authors' department. Their charts and postoperative results were reviewed retrospectively., Results: A thoracodorsal artery perforator flap was harvested in 90 cases. The perforators were unsuitable in the other 10 flaps; therefore, a muscle-sparing technique was used (type I or type II). Unidirectional Doppler imaging was used exclusively in 92 percent of cases to map the perforator preoperatively. The average flap size was 20 x 8 cm. Average operative time for flap harvest was 80 minutes. Perforators were located at 8 to 13 cm from the axillary crease (average, 10.8 cm). Major flap necrosis occurred in one case (1 percent). Limited partial or palpable fat necrosis occurred in three cases (3 percent). Seroma formation was not encountered in any of the thoracodorsal artery perforator flaps or muscle-sparing thoracodorsal artery perforator type I flaps., Conclusion: Careful preoperative perforator mapping and a standardized approach to flap planning and harvest can significantly reduce the difficulty of executing pedicled thoracodorsal artery perforator flaps.

Background: In female-to-male transsexuals, the first surgical procedure in their reassignment surgery consists of the subcutaneous mastectomy. The goals of subcutaneous mastectomy are removal of breast tissue, removal of excess skin, reduction and proper positioning of the nipple and areola, and ideally, minimization of chest-wall scars. The authors present the largest series to date of female-to-male transsexuals who have undergone subcutaneous mastectomy., Methods: A total of 184 subcutaneous mastectomies were performed in 92 female-to-male transsexuals, using the following five techniques: semicircular, transareolar, concentric circular, extended concentric circular, and free nipple graft. The technique used depended on the breast size and envelope, the aspect and position of the nipple-areola complex, and the skin elasticity. To best meet the goals of creating a normal male thorax, the authors have developed an algorithm to aid in choosing the appropriate procedure., Results: The overall postoperative complication rate was 12.5 percent (23 of 184 subcutaneous mastectomies), and in eight of these cases (4.3 percent), an additional operative intervention was required because of hematoma, infection, and/or wound dehiscence. Despite this low complication rate, additional procedures for improving aesthetic results were performed on 59 breasts (32.1 percent). The semicircular and concentric circular techniques produced the highest rating of the overall result by patient and surgeon, whereas the extended concentric circular technique produced the lowest rating., Conclusions: Skin excess and skin elasticity are the key factors in choosing the appropriate technique for subcutaneous mastectomy, which is reflected in the algorithm. Although the complication rate is low and patient satisfaction is high, secondary aesthetic corrections are often indicated.

Background: The lateral intercostal artery perforator flaps are based on intercostal perforators that arise from the costal groove. Cadaver dissections have been performed to improve the understanding of lateral intercostal perforator anatomy. The clinical applications of this study are demonstrated., Methods: The intercostal perforators were dissected in 24 fresh cadavers and evaluated in a field that extended between the third and the eighth intercostal spaces and between the latissimus dorsi and pectoralis major muscles. Their relationship with the anterior border of the latissimus dorsi muscle and the serratus anterior vessels was investigated., Results: A mean value of 3.91 perforators per side was found. The majority of the intercostal perforators were found between the fifth and the eighth intercostal space level (88.4 percent). Mean distances of intercostal perforators to the anterior border of the latissimus dorsi muscle varied between 2.67 and 3.49 cm. The largest or "dominant" perforator was most frequently found in the sixth intercostal space (38.6 percent of cases) at an average of 2.5 to 3.5 cm from the anterior border of the latissimus dorsi muscle. In 10 of 47 sides (21 percent), vascular connections were found between the serratus anterior branch and the intercostal perforators. The connection was observed more frequently in the seventh and the sixth intercostal spaces, in 38 percent and 30 percent of cases, respectively. This vascular connection enables harvest of a serratus anterior artery perforator flap., Conclusion: Lateral intercostal artery perforator flaps can be used to address challenging defects over the breast without sacrificing the pedicle of the latissimus dorsi muscle.

Background: The ideal dermal filler should be nonpermanent but with a durable effect lasting between 1 and 2 years, which is not the case with the resorbable fillers that are currently available. Evolence30 is a new, porcine-derived collagen gel based on the Glymatrix cross-linking technology, which results in a more natural and longer-lasting collagen product., Methods: In this first clinical trial of Evolence30 (30 mg/ml), the safety and efficacy of this new filler were tested and compared with those of Zyplast (bovine cross-linked) collagen, after treatment of nasolabial folds in 12 volunteers. Safety assessments included two hypersensitivity tests, physical examination of injections sites, punch biopsies for histopathology, adverse events, and blood sample analysis. The seven-grade, validated Modified Fitzpatrick Wrinkle Scale was used by three independent blinded assessors to evaluate efficacy., Results: No treatment-related adverse events were reported. Only transient erythema was observed in both treated sides, and there were no abnormal laboratory findings. None of the sera contained immunoglobulin (Ig) M, IgA, or IgE antibodies against porcine collagen at any time during the study. Initially, Evolence30 and Zyplast improved wrinkle severity to a similar extent. However, in an average follow-up of 18 months, assessment by the blinded assessors showed that the treatment effect on the Evolence30-treated side was superior in 9 of the 11 participants who were treated (p = 0.022)., Conclusions: Evolence30 is a new, porcine-derived collagen product based on the Glymatrix cross-linking technology that enables a safe and effective correction of the nasolabial folds. This correction lasts significantly longer than that with Zyplast.

Learning Objectives: After studying this article, the participant should be able to discuss: 1. The terminology related to male-to-female gender dysphoria. 2. The different theories regarding cause, epidemiology, and treatment of gender dysphoria. 3. The surgical goals of sex reassignment surgery in male-to-female transsexualism. 4. The surgical techniques available for sex reassignment surgery in male-to-female transsexualism., Background: Gender identity disorder (previously "transsexualism") is the term used for individuals who show a strong and persistent cross-gender identification and a persistent discomfort with their anatomical sex, as manifested by a preoccupation with getting rid of one's sex characteristics, or the belief of being born in the wrong sex. Since 1978, the Harry Benjamin International Gender Dysphoria Association (in honor of Dr. Harry Benjamin, one of the first physicians who made many clinicians aware of the potential benefits of sex reassignment surgery) has played a major role in the research and treatment of gender identity disorder, publishing the Standards of Care for Gender Dysphoric Persons., Methods: The authors performed an overview of the terminology related to male-to-female gender identity disorder; the different theories regarding cause, epidemiology, and treatment; the goals expected; and the surgical technique available for sex reassignment surgery in male-to-female transsexualism., Results: Surgical techniques available for sex reassignment surgery in male-to-female transsexualism, with advantages and disadvantages offered by each technique, are reviewed. Other feminizing nongenital operative interventions are also examined., Conclusions: This review describes recent etiopathogenetic theories and actual guidelines on the treatment of the gender identity disorder in male-to-female transsexuals; the penile-scrotal skin flap technique is considered the state of the art for vaginoplasty in male-to-female transsexuals, whereas other techniques (rectosigmoid flap, local flaps, and isolated skin grafts) should be considered only in secondary cases. As techniques in vaginoplasty become more refined, more emphasis is being placed on aesthetic outcomes by both surgeons and patients.

Background: Raising perforator flaps is said to be a tedious procedure. The benefits, however, are great. In adults, perforator flaps have proved their usefulness and reliability in various clinical situations. In children, donor sites for free flaps are particularly scarce because of the need for a long and reliable vascular pedicle of sufficient size. There is also the need to minimize donor-site morbidity from aesthetic, functional, and psychological perspectives., Methods: The authors present a series of 23 consecutive free perforator flaps performed by the first author in 20 children; ages at the time of operation ranged from premature (born at 28 weeks) to 16 years (mean age, 7 years 5 months). Three children presented with upper limb defects; the remaining 17 children sustained major soft-tissue defects of the lower limb. All the lesions necessitated extensive coverage with a free flap. Flaps used in this series included nine deep inferior epigastric artery perforator flaps, seven thoracodorsal artery perforator flaps, and seven compound ("chimera") thoracodorsal artery perforator flaps., Results: All flaps but one were successful. With a follow-up of up to 7 years, the results in this series compare favorably with those of perforator flaps in adults or pediatric free flaps in the literature., Conclusions: In children, as in adults, perforator flaps are a valuable alternative to the traditional muscle or myocutaneous free flap. Because of the added advantage of reducing donor-site morbidity, perforator flaps have become the authors' preferred option in reconstructive cases in children.

The authors present a single center's experience in bilateral breast reconstruction using perforator free flaps. The aim of this study was to show their indications, surgical technique, and results. A series of 53 patients underwent this procedure between February of 1996 and October of 2002. The surgical procedures were performed on patients with bilateral breast cancer (11 patients), patients with unilateral breast cancer and contralateral prophylactic mastectomy (22 patients), patients who had undergone bilateral prophylactic mastectomy (18 patients), a patient with Poland's syndrome, and a patient whose aesthetic breast augmentation had failed. Primary and secondary bilateral breast reconstructions were done in 18 and four patients, respectively. Eighteen patients who had earlier undergone breast reconstruction with implants had a tertiary breast reconstruction. Combined reconstruction (primary with secondary and primary with tertiary reconstruction) was done in 13 patients. Ninety-eight deep inferior epigastric perforator flaps and eight superior gluteal artery perforator flaps were used. The average operative time was 10 hours (range, 8 to 14.5 hours) for the simultaneous bilateral reconstruction. Total flap necrosis occurred in two cases (one deep inferior epigastric perforator flap and one superior gluteal artery perforator flap). Partial flap necrosis was not encountered, and fat necrosis was found in one deep inferior epigastric perforator flap (1 percent). Two pulmonary infections, one deep vein thrombosis, and one cardiac arrhythmia occurred as postoperative complications. The mean hospital stay was 9 days (range, 6 to 20 days). Abdominal bulging was reported in one patient. There were no recurrent disease or cancer manifestations, with an average follow-up of 3.5 years. This series clearly shows that perforator flaps are reliable and useful tools for bilateral breast reconstruction. This technique decreases the donor-site morbidity and offers an excellent aesthetic and long-term outcome and high patient satisfaction.

Traditional skin free flaps, such as radial arm, lateral arm, and scapular flaps, are rarely sufficient to cover large skin defects of the upper extremity because of the limitation of primary closure at the donor site. Muscle or musculocutaneous flaps have been used more for these defects. However, they preclude a sacrifice of a large amount of muscle tissue with the subsequent donor-site morbidity. Perforator or combined flaps are better alternatives to cover large defects. The use of a muscle as part of a combined flap is limited to very specific indications, and the amount of muscle required is restricted to the minimum to decrease the donor-site morbidity. The authors present a series of 12 patients with extensive defects of the upper extremity who were treated between December of 1999 and March of 2002. The mean defect was 21 x 11 cm in size. Perforator flaps (five thoracodorsal artery perforator flaps and four deep inferior epigastric perforator flaps) were used in seven patients. Combined flaps, which were a combination of two different types of tissue based on a single pedicle, were needed in five patients (scapular skin flap with a thoracodorsal artery perforator flap in one patient and a thoracodorsal artery perforator flap with a split latissimus dorsi muscle in four patients). In one case, immediate surgical defatting of a deep inferior epigastric perforator flap on a wrist was performed to immediately achieve thin coverage. The average operative time was 5 hours 20 minutes (range, 3 to 7 hours). All but one flap, in which the cutaneous part of a combined flap necrosed because of a postoperative hematoma, survived completely. Adequate coverage and complete wound healing were obtained in all cases. Perforator flaps can be used successfully to cover a large defect in an extremity with minimal donor-site morbidity. Combined flaps provide a large amount of tissue, a wide range of mobility, and easy shaping, modeling, and defatting.

Trilucent soybean oil-filled breast implants were initially announced as the ultimate prostheses for breast augmentation. However, after an increasing number of reports of local complications and hazardous metabolites attributable to lipid oxidation, first the United Kingdom Medical Devices Agency and later the Belgian National Ministry of Health urged all plastic surgeons to contact their patients and advise them to have the implants removed and, if desired, replaced with another type of prosthesis. In our plastic surgery department, 13 patients received bilateral implants with triglyceride-filled prostheses between February and July of 1996, for primary breast augmentation or replacement of previously implanted prostheses. For 12 of those 13 patients, the prostheses have been explanted, because of unilateral breast enlargement attributable to a ruptured prosthesis for five patients and following the recommendation of the Belgian National Ministry of Health for the other seven patients. Before explantation, all patients underwent standard clinical examinations, with assessments of breast shape, volume, and firmness. Blood analyses were performed, with a special focus on liver enzymes, as were urinalyses. Magnetic resonance imaging scans were obtained before explantation; for two patients, the scans revealed a fluid level separating two liquid layers in an intact prosthesis. This is the first report of such a finding. The removed implants were examined for any damage or shell deterioration and for changes in color and viscosity, the weights and volumes were measured and compared with the initial values for the implanted prostheses, and complete biochemical analyses of the accumulated fluid in cases of ruptured prostheses and of the filler material in cases of intact prostheses were performed. This small but well-documented series illustrates the multitude of problems associated with triglyceride-filled implants, including bleeding of the triglyceride filler; shell deterioration, as indicated by a loss of texture and extreme fragility of the implant (with rupture or delamination with a simple finger touch); an increase in osmotic pressure exerted by the degraded filler material; progressive weakening of the outer silicone shell, with influx of plasma proteins of up to 750 kDa, eventually resulting in rupture of the prosthesis; a lack of oxidative stability and the formation of toxic oxidation products; a lack of biocompatibility, with the formation of insoluble organic soap-like material; and a pronounced inflammatory reaction. It is concluded that the sequential and/or simultaneous occurrence of (1) implant bleeding, (2) lipid infiltration of the silicone elastomer, and (3) inflammation attributable to oxidation products provides an overall explanation or unifying hypothesis for the wide variety of adverse events related to soybean oil-filled implants.

Due to its increasing popularity, more and more articles on the use of perforator flaps have been reported in the literature during the past few years. Because the area of perforator flaps is new and rapidly evolving, there are no definitions and standard rules on terminology and nomenclature, which creates confusion when surgeons try to communicate and compare surgical techniques. This article attempts to represent the opinion of a group of pioneers in the field of perforator flap surgery. This consensus was reached after a terminology consensus meeting held during the Fifth International Course on Perforator Flaps in Gent, Belgium, on September 29, 2001. It stipulates not only the definitions of perforator vessels and perforator flaps but also the correct nomenclature for different perforator flaps. The authors believe that this consensus is a foundation that will stimulate further discussion and encourage further refinements in the future.

There is a strong trend at hand toward less dramatic facial rejuvenation surgery. Most of the authors' patients want a cosmetic improvement but not at the cost of prolonged disfigurement or a high risk of complications. In 1999, a very simple but effective rhytidectomy technique, termed an S-lift, was described in the literature and was adopted by the authors. Its basic principle is the suspension of sagging facial features by a strong, permanent purse-string suture. The procedure is performed with the patient under local anesthesia. Significant modifications were applied to the incision, to the purse-string suture anchoring site, and to the direction and shape of the skin excision. The authors named the modified procedure the minimal access cranial suspension lift to specifically describe the concept of the technique. Through an inverted L-shaped preauricular incision with extension below the sideburn, a limited skin undermining is performed. Two strong, permanent purse-string sutures are woven into the superficial musculoaponeurotic system tissues in a vertical U and an oblique O shape, initiating from a strong anchorage in the deep temporal fascia at the level of the helical crus. Tying these sutures produces a very powerful vertical correction of descended facial features that acts mainly on the jowls and the upper neck. The procedure can be extended by continuing the dissection over the malar fat pad, placing a third vertical purse-string suture with strong action on the nasolabial groove, and vertically repositioning the midfacial volumes. During 20 months, pleasing results and a very low complication rate were obtained in 88 consecutive patients with a mean age of 551/2 years. In this article, the authors provide a detailed description of the anesthetic and surgical technique, a demonstration of the results in different patient age categories, and a discussion comparing the minimal access cranial suspension lift with other types of facial rejuvenation procedures.

Breast sensation after reduction mammaplasty is a major concern for surgeons and patients. The sensitivity of 80 breasts that were reduced using Lejour's technique (a superior dermoglandular pedicle with resection at the lower quadrants) was assessed in a prospective study. Ten points were selected on each breast for this study, including the nipple, four points on the areola, and five points on the breast skin. The measurements were performed preoperatively and at 3, 6, and 12 months postoperatively. Pressure thresholds were measured with 20 Semmes-Weinstein monofilaments, temperature sensitivity with hot and cold metal probes, vibratory thresholds with the Biotesiometer, and static and moving two-point discrimination tests with a Disk-Criminator. To assess the influence of breast ptosis and hypertrophy on sensitivity, the population was divided into two groups. In group I (19 patients), the sternal notch-to-nipple distance was less than 29 cm, and less than 500 g of tissue per breast was removed. In group II (21 patients), the sternal notch-to-nipple distance was more than 29 cm, and more than 500 g of tissue was resected. The sensitivity on the nipple and areola was significantly decreased at 3 and 6 months postoperatively for all modalities. At 1 year, sensitivity recovered, and no breast or nipple-areola complex was insensitive. Pressure sensitivity was not significantly different from the preoperative measurement in any area of the breast or in either group of patients, except for superior breast skin, for which sensitivity was improved in group II (p = 0.0004). Temperature sensitivity in group I was not different preoperatively and postoperatively, but in group II, a significant decrease was observed in sensitivity for the nipple and areola (p = 0.01 and 0.004, respectively). Vibratory sensitivity was significantly decreased on the nipple, the areola, and the inferior breast skin (p = 0.01, 0.01, and 0.001, respectively) in group II but not in group I. In conclusion, ptotic or moderately hypertrophied breasts that were reduced using Lejour's technique recovered their preoperative level of sensitivity after an initial postoperative decline. However, in large breasts, although pressure sensitivity recovered after 1 year, temperature and vibration sensitivity remained diminished on the nipple-areola complex.

Abdominal wall function is a major concern for plastic surgeons performing breast reconstruction with TRAM flaps. The deep inferior epigastric perforator (DIEP) free flap spares the whole rectus abdominis muscle, includes skin and fat only, and therefore, preserves adequate abdominal wall competence. Between January of 1995 and May of 1997, a total of 50 breast reconstructions in 42 patients were performed by using the DIEP flap. Eight patients had bilateral procedures. Five breast reconstructions were immediate and 45 were delayed. All patients were collected prospectively and no patients were excluded from this study. The average age of patients was 47 years (range, 22 to 59 years) and the average weight was 65 kg (range, 51 to 103 kg). Seventy percent of patients had one or more risk factors for TRAM flap reconstruction. The mean postoperative follow-up period was 13 months (range, 3 to 30 months). Twenty consecutive patients (17 single and 3 bilateral DIEP flap breast reconstructions) within this group underwent evaluation of their abdominal wall function preoperatively and then 3 and 6 months postoperatively by using Lacote's muscle grading system. Average flap harvesting time was 120 minutes and average blood loss was 420 cc. Total flap loss and partial necrosis occurred in one (2 percent) and three flaps (6 percent), respectively. Abdominal wound infection occurred in seven patients (17 percent). Unfortunately, one patient died of adult respiratory distress syndrome on the seventh postoperative day. Fat necrosis was found in three flaps (6 percent). Postoperative abdominal wall examination did not reveal any hernia, but bulging was found in two patients (5 percent). All patients were able to resume their daily activities. Abdominal wall function tests in the series of 20 patients showed that all patients had reached or even improved their preoperative level of upper and lower rectus muscle function 6 months after the operation. The external oblique muscles were the most affected by the procedure of flap harvesting, but only two patients (10 percent) were found to have a measurable impairment after 6 months. Patient satisfaction with the reconstructed breast and the donor site was rated high. The free DIEP flap is, therefore, a reliable and valuable method of breast reconstruction. The donor site morbidity was decreased, and the more tedious flap dissection did not affect the overall outcome.