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BACKGROUND: Among breast reduction mammoplasty, the inferior pedicle-based (IFP) technique is considered the most performed by plastic surgeons. A growing interest for the supero-medial based pedicle (SMP) mammoplasty technique has been documented in literature and clinical practice. However, no real evidence exists on the superiority of one technique over another. METHODS: This study represents a retrospective multimodal analysis, using a prospectively maintained database, comparing wise pattern breast reduction techniques (IFP vs. SMP) over a 24-month follow-up. From January 2015 to July 2017, all patients undergoing wise pattern bilateral reduction mammoplasty, using either an IFP or a SMP technique, were included in the study and divided in two groups. Pre-operative breast measurements included sternal notch-to-nipple distance (SN-N), infra-mammary fold to inferior border of Nipple Areolar Complex (NAC) distance length and ptosis. The same measurements were recorded at 2 weeks, 6 months and 24 months post-op. Complications were recorded and aesthetic outcomes were evaluated. RESULTS: A total of 58 patients were included in the study, among which 36 (62%) were treated with a SMP technique and 22 (38%) with an IFP technique. At the 24-month follow-up timepoint, the SN-N distance was significantly shorter (*P

Radical surgical debridement after Fournier gangrene (FG) can totally change anatomical balance between structures and compromise urogenital function. This is particularly true when the suspensory ligament and the lower abdominal wall are involved, leading to erection and sexual intercourse dysfunction.We present the case of a 48-year-old man, who underwent emergency debridement and split-thickness skin graft (STSG) of inferior abdominal wall, pubis, scrotal bag and penile shaft after Fournier gangrene.Five months after the emergency procedure, bilateral medial thigh flaps recreated the scrotal compartment, whereas a pedicled composite anterolateral thigh flap including fascia lata could cover the lower abdominal wall and rebuilt the penile suspensory ligament (PSL).Healing was uneventful and the patient returned to a normal sexual life with satisfactory erection and intercourse.Composite and/or chimeric anterolateral thigh fascia lata flaps have been previously used as a reliable option for complex defects, including tendon and ligaments. We describe here, the first case in the literature of a penile suspensory ligament reconstruction.

Introduction: Pilonidal disease is a chronic inflammatory process resulting from impaction of natal cleft hair into the subcutaneous tissues creating an abscess or a draining sinus over the sacrococcygeal area. Malignant transformation occurs in around 0.1%, mainly into squamous cell carcinoma (SCC) type. Wide excision with tumor-free margins remains the treatment of choice. Multiple closure techniques were settled and the best one ought to be chosen in a context malignancy and future radiological treatment. Case Presentation: We describe the management of a case of a 69-year-old male with chronic pilonidal disease, recurrent after 25 years found on final pathology to undergo malignant transformation into SCC. Wide and aggressive excision were performed with new margins and with periosteal excision of the sacrum and coccyx. rotational myocutaneous gluteal flap was done for closure of the wound in order to ensure better satisfactory esthetic results without a delay in future treatment. Conclusion: The progression of a chronic pilonidal disease into SCC is a rare but serious complication. The diagnosis is confirmed by biopsies. Workup for metastasis should be made before aggressive surgical excision. Oncoplastic surgeries is recommended for satisfactory results. Routine follow-up postoperatively should be considered due to high rate of recurrence by physical examination and imaging.

BACKGROUND/AIM Large full thickness abdominal wall defects following malignancies can be a reconstructive challenge. The purpose of this study was to analyze long-term outcomes and complications following abdominal wall reconstruction using composite antero-lateral thigh (ALT) flaps. PATIENTS AND METHODS The study retrospectively investigated 16 consecutive patients who underwent abdominal wall reconstruction with autologous flap between May 2003 and March 2018. Volumetric flap analysis was used to assess flap atrophy over time, evaluating the role of denervation and reinnervation. The long-term outcome was assessed to compare the two groups (free vs. pedicled ALT flap reconstructions). RESULTS All flaps successfully covered the defects. We found a significant increase in flap resorption in free flaps when compared to pedicled ones. Abdominal bulging was seen in 3 out of 16 (19%) patients after more than 12 months follow-up, in close correlation with mesh absence. CONCLUSION Free flaps were shown to be equally effective as their pedicled counterparts, without significant increase in complication rate.

Post-traumatic defects of the distal third of the leg often require skipping a few steps of the well-established reconstructive ladder, due to the limited local reliable reconstructive options. In rare cases, the reconstructive plan and flap choice may encounter challenges when the patient has psychiatric illness affecting compliance with postoperative care. We describe a case of a patient with severe intellectual disability and an open fracture of the distal lower limb. After fracture management and debridement of devitalized tissues, the resultant soft tissue defect was covered with a free gracilis flap. On postoperative day 7, the patient ripped out the newly transplanted flap. The flap was too traumatized for salvage, so a contralateral free gracilis muscle flap was used. The patient showed good aesthetic and functional outcomes at a 1-year follow-up. When planning the postoperative management of patients with psychiatric illness, less complex and more robust procedures may be preferred over a long and complex surgical reconstruction requiring good compliance with postoperative care. The medical team should be aware of the risk of postoperative collapse, focus on the prevention of pain, and be wary of drug interactions. Whenever necessary, free tissue transfer should be performed despite potential compliance issues.

The authors of this review present a comprehensive assessment of the techniques and indications in the treatment of the long upper lip. Setting aside the maxillofacial malformations, the review is focused on senescence as the most frequent etiology. A graphical reminder of the anatomical entities and of the upper lip proportions allows optimal preoperative planning. All current treatment options, from fillers to surgical excision and dermabrasion, are reviewed and summarized in order to provide an overview of each technique's expected results and contraindications.

In breast reduction, traditionally the inferior pedicle (IFP) technique is considered the most performed by plastic surgeons. A growing interest for the superomedial pedicle (SMP) mammoplasty technique has been documented in literature and clinical practice. Sensory recovery of the nipple-areolar complex (NAC), final areolar shape and scarring may also have a significant impact on patient satisfaction.This study represents a retrospective multimodal analysis comparing NAC sensation and appearance outcomes in IFP and SMP wise pattern breast reductions with 2-year follow-up.From 2013 to 2017, all performed reduction mammoplasty were included and divided in two groups (IFP or SMP technique). Testing included pressure perception (Semmes-Weinstein monofilaments), NAC measurement (diameters ratio and circumference) and circumareolar scar hypertrophy assessment. Measurements were repeated at 2 weeks, 6 and 24 months postoperatively.amongst the 73 patients, 42 (58%) had SMP technique and 31 (42%) had IFP technique. Values at 6-months showed better sensory return in the SMP (p 0.01**). NAC enlargement, showed no difference between groups. However, there was a statistically significant increase in both the SMP (p 0.001***) and the IFP (p 0.01**) groups when comparing the 2-week and 24-month follow-up visits measured ratios confirming a more oval appearance over time with both techniques. Scar hypertrophy showed statistically significant reduction in both the SMP (p 0.001***) and the IFP (p 0.01**) groups over time.This 2-year follow-up study showed little difference in outcomes between the two techniques, but some advantages in NAC sensory recovery with the SMP.

BACKGROUND Surgical procedures interfering with the draining nodes in the inguinal region carry the intrinsic risk of lymphatic complications. Lesions of the inguinal lymphatic network can lead to lymphocele or lymphocutaneous fistulas and can eventually be associated to limb lymphedema with consequent high morbidity. OBJECTIVES This article describes a new surgical algorithm based on wound properties to properly address lymphatic complications of the inguinal area. Based on our experience, surgical solutions ranged from selective lymphatic vessel ligation to microsurgical lymphatic fistula treatment and free tissue transfer. METHODS Fourteen consecutive patients underwent surgery in our department following failed attempts to address persistent lymphatic leaks. Patient characteristics such as smoking, previous surgeries, comorbidities, and wound properties were considered. Identification of the leak was performed using blue patent dye and indocyanine green fluorescence. Surgical reconstruction occurred, according to our algorithm. RESULTS Lymphatic leaks were visualized in 11 of 14 patients. Direct closure of the wound after leak ligation could be performed in 4 of 14 patients. Multilymphatic into vein anastomosis was performed in 3 of 14 patients, and the remaining patients benefited from flap surgery based on the wound defects. All 14 patients had successful outcomes (100%) with early drain removal (average, 6 [SD, 6] days) and definitive wound healing 2 weeks postoperatively. After a mean follow-up of 12 (SD, 2.9) months, no clinical infection, lymphatic complication, or wound breakdown occurred. One patient had a partial recurrence that did not require surgical intervention. CONCLUSIONS A stepwise approach, combining lymphatic surgery principles and plastic surgery flap techniques, can lead to an effective treatment algorithm where surgical options are wound tailored to guarantee the best functional outcomes.

Due to inflammatory and hypermetabolic responses and to extensive exudative trace element (TEs) losses, major burn patients have substantially increased nutritional requirements. To date, information is only available for Cu, Se, and Zn. We aimed at analyzing losses of 12 TEs and Mg through burn wound exudation and corresponding plasma concentrations during the first week after burn injury, and to evaluate the impact of current TE repletion protocols.Burn wound exudate was collected under negative pressure in 15 adult patients burned 29 ± 20% of body surface (TBSA) for 8 days after injury. Two samples were collected daily. The TE concentrations were measured by inductively coupled plasma mass spectrometry (ICP-MS). Losses and serum concentrations were compared to intakes.For the majority of 12 TEs, the highest losses were observed on day 1, and declined thereafter. Despite Cu supplementation (4.23 mg/day) serum levels remained below reference values. Se supplements (745 μg/day) normalized and even increased serum levels to upper normal value. Despite large supplements (Zn 67.5 mg/day), serum Zn values remained below reference range. Large exudative losses of B, Br and Mg were found, as well as of Fe and I, with the latter being probably due to contamination.Current nutritional Cu, Se, Zn repletion protocols in major burn patients which were based on measured exudative losses should be revised to include higher Cu and lower Se doses, as well as planned Mg administration. In burns20% TBSA and for the other TEs the recommended parenteral nutrition TE doses appear sufficient.

Background The term “symmastia” defines a confluence across the mid-sternal line of the breast mounds and subsequent loss of adhesion between sternum and pre-sternal skin. This condition can be congenital or, more frequently, iatrogenic. Despite the number of different treatments published in literature, no systematic review or surgical techniques classification has been attempted in literature. There is, therefore, a concrete need to elucidate surgical options and propose a treatment algorithm, improving surgical practice and patient's care. Objective This systematic review aims to collect and evaluate the published evidence on surgical procedures to correct symmastia deformities (both congenital and acquired) in order to clearly overview possible treatments and outcomes related to this surgery, providing a surgical classification guide as well. Methods In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, PubMed database was queried for papers describing symmastia surgical treatment, along with operative indications, outcomes, and complications. Results In this review, 23 articles and 118 patients were finally included. Four main categories of treatment were identified: dermo-sternal adhesions, capsulorrhaphy, neopocket creation, and muscle repair. Symmastia correction was achieved and satisfactory in 108 of patients, despite varying techniques. Globally, recurrence was the most frequent complication, reported in the 8.5% of cases. Conclusion Symmastia represent a difficult condition to treat and recurrence is a common problem. Because of the low number of patients involved in the studies, it is difficult to make conclusions as to the superiority of one technique over another. However, this review, collecting comprehensively for the first time the surgical knowledge over this topic, could guide the surgeon to choose the best surgical treatment based on nowadays evidence.

Supplemental Digital Content is available in the text., Background: Mastopexy is one of the most performed cosmetic surgery procedures in the United States. Despite the numerous mastopexy techniques that were published in the past decades, preventing pseudoptosis to ensure longer lasting results remains the principal challenge. Objectives: This paper describes a new mastopexy technique developed for moderate to severe ptosis/pseudoptosis associated with upper pole deflation. Considering some of the commonest risk factors generally considered predictive of worse outcomes (massive weight loss, multiple pregnancies, skin quality, smoking, age), we aimed to assess whether this technique could be beneficial in the support of the desired breast shape over time. Methods: Twelve patients, all featuring 1 or more of the abovementioned preoperative risk factors, were operated on by the same senior surgeon with the hammock mastopexy technique using dermal flaps as a support for the glandular reshaping (6 bilateral mastopexies and 6 unilateral mastopexies for contralateral symmetrization after breast reconstruction). Patients’ characteristics, such as smoking, weight loss, or multiparity with consequent inelastic skin, age, and lengthy nipple–areola complex lift, were considered as independent risk factors for ptosis recurrence and bottoming out. Patients were divided into 3 subgroups according to the number of their risk factors. Aesthetic results were assessed at 12 months postoperatively. Changes in postoperative were assessed for each patient by breast measurements and a superposition of the standardized breast photographs. Long-term outcomes were compared with a control group of 6 patients who benefited from mastopexy without “hammock technique.” Results: Satisfactory maintenance of shape and stable nipple–areola complex position was seen at 12 months regardless of the number of risk factors. However, a statistically significant difference was found in lower pole lengthening between patients with more than 3 risk factors compared to other groups. Aesthetic measurement results were consistent between the patient and surgeon reporting a satisfying cosmetic result, regardless of the number of risk factors. In the control group, we found a significant increase in breast lower pole measurements at 12 months when compared with the hammock group. Conclusions: This mastopexy technique improves projection and reinforces the lower pole support with lateral and medial dermal flaps. The technique is safe and reliable and provides easily reproducible results for patients with risk factors for postoperative pseudoptosis.

Large full thickness abdominal wall defects following malignancies can be a reconstructive challenge. The purpose of this study was to analyze long-term outcomes and complications following abdominal wall reconstruction using composite antero-lateral thigh (ALT) flaps.The study retrospectively investigated 16 consecutive patients who underwent abdominal wall reconstruction with autologous flap between May 2003 and March 2018. Volumetric flap analysis was used to assess flap atrophy over time, evaluating the role of denervation and reinnervation. The long-term outcome was assessed to compare the two groups (free vs. pedicled ALT flap reconstructions).All flaps successfully covered the defects. We found a significant increase in flap resorption in free flaps when compared to pedicled ones. Abdominal bulging was seen in 3 out of 16 (19%) patients after more than 12 months follow-up, in close correlation with mesh absence.Free flaps were shown to be equally effective as their pedicled counterparts, without significant increase in complication rate.

Introduction The “traditional” method to perform vaginoplasty in male-to-female transgender surgery consists in inverting the penoscrotal skin into a surgically created cavity in the perineum between the rectum and the bladder creating a neovagina. To overcome the noteworthy disadvantage of lack of depth, the use of a rectosigmoid graft can be preferred over the penile skin inversion. Aim The aim of this study was to compare 2 methods for vaginoplasty in male-to-female transgender surgery in regard of the functional and cosmetic long-term result. Additionally this study aims to understand key factors leading to secondary sigmoid vaginoplasty in patients with previous penile skin inversion. Methods This is a retrospective survey of outcomes and complications of 43 patients who underwent neovaginoplasty by the same senior surgeon, between 2007 and 2017. 13 patients underwent a secondary rectosigmoid neovagina later (30.2%). Moreover, we performed an aesthetic and functional evaluation on 28 patients (65%) at long-term follow-up. Mean follow-up was 32.6 ± 3.5 months (average ± SEM). Patients were also evaluated by a questionnaire to assess both aesthetic and functional (penetration, orgasm, and pain) outcomes. Statistical analysis was used to compare results between groups. Main Outcome Measure Patient satisfaction was assessed by a questionnaire sent to all 43 patients and was made of 5 questions (Q1 to Q5) designed in a way to evaluate patient outcomes in terms of both functionality and cosmesis of the neovagina. Results Our findings showed that the use of a rectosigmoid graft in secondary cases significantly decreased sexual pain during intercourse. Both techniques had similar aesthetic and functional outcomes with mostly satisfied patients (no statistical significance). Clinical Implications The use of sigmoid vaginoplasty could improve functional outcomes when compared to penile skin inversion vaginoplasty. Strength & Limitations This study strength is its retrospective nature conducted on a prospectively-maintained database limiting biases with 43 consecutive vaginoplasties, performed by the same surgeon. Relative limitation was that not all patients returned our questionnaire and, thus, only 65% of our patients were evaluated for satisfaction. Conclusion This study reports long-term outcomes in transgender surgery using 2 different techniques for neovagina creation. The use of sigmoid vaginoplasty showed better functional outcomes than penile skin inversion, whereas cosmetic results were similar.

Dear Sir, Mastopexy is the 7 th most performed cosmetic surgery in the US according to the latest American Society for Aesthetic Plastic Surgery (ASAPS) statistics (1). Extensive data in the literature show numerous studies in which a wide array of operative techniques are described. These range from a simple dermal manipulation, with or without glandular reshaping, to the use of dermal flaps fixed to the pectoral fascia, to the use of synthetic mesh or sheets. The use of an autologous (usually glandular) flap to increase the upper pole fullness can replace the use of an implant (2). Unlike, dermal reshape, the use of a glandular reshape offers a more durable result with less tension on scars. This concept is often referred to as “auto-augmentation”. The most common type of autoaugmentation is the advancement of an inferior based flap into a space created under the NAC superiorly based pedicle (3-7). The advantage here is that this mobilized gland, responsible for breast projection, does not interfere with NAC lift and vascularization which is still maintained on an independent superior pedicle.

Since the Syrian conflict erupted in March 2011, the United Nations High Commissioner for Refugees (UNHCR) recorded the number of Syrian refugees registered in Lebanon, as of December 2016, to have reached 1,011,366, making Lebanon a country with the highest refugee population per capita approaching 2:1.1 In addition, close to 27% of households among the displaced Syrian population count at least one member with a specific need such as a chronic disease or disability. More than 50% of the children are deeply traumatized.2 Most refugee camps struggle to access primary care services, and the lack of doctors willing to commit to that particular practice makes it even harder to provide camps with appropriate care.3 In response to those distinctive needs of refugees, some non-governmental organizations try to provide these camps with volunteer doctors that are recognized as “refugee camp doctors”. Nowadays, most modern medical curricula are based on clinical experience that is learned in an almost “ideal setting”. At the hospital or the clinic, medical students and residents will take patients history, perform physical exams, order a workup or start treatment, while issues related to finance, gender, politics or even climate are rarely taken into consideration in their routine. However, when practicing as a refugee camp doctor, one discovers that those factors become part of the main elements that constitute medical practice. The experience gained in the field is somehow different from that offered by the traditional medical education. As a remedy, the adoption of a novel approach that promotes new medical skills is required. Hence, this perspective aims to describe the experience of both authors as volunteer camp doctors and to stress the added value to their medical curriculum. It also identifies the skills that are needed to address the challengesencountered under precarious field conditions adequately. Health and humanitarian response The authors (H.A.N. and W.W.) accepted the commitment as volunteer camp doctors. Armed with insatiable curiosity, hands-on skills, they decided to enrich their experience in community medicine by exploring a new location that had neither a curriculum nor an advanced medical facility. While both completed medical school at the same time, H.A.N. had a one-year internship in internal medicine and an additional year of residency in paediatrics, and W.W. had completed his second post-graduate year in plastic and reconstructive surgery. While their previous experience as residents in an underserved area had already exposed them to complex wound cases, challenging psychosocial issues and common paediatric viral cases, the health problems at the camp were by far more varied. No residency program could have prepared a doctor for the spectrum of issues encountered in the camp.

Supplemental Digital Content is available in the text., Summary: Poland syndrome is a rare congenital anomaly characterized by a unilateral congenital absence of the sternocostal head of the pectoralis major muscle. The absence of the pectoralis major does not only result in chest asymmetry but also in a missing anterior axillary fold, which is essential for natural anatomical appearance in both male and female patients. In Poland syndrome patients, we perform bipolar latissimus dorsi flap transfer, which can be associated with a sublatissimus implant in women. All procedures are performed through a single short midaxillary incision, and tendon translocation in this technique allows the creation of the anterior axillary fold and thus a natural chest appearance. Moreover, this technique can be performed by any plastic surgeon operating under a basic operating room setting.

Abstract Many attempts have been made to improve wound healing using growth factors and a large array of medications. This study reexamined the effect of Botox on second degree burn wound in rats. Histological alterations and temporal evolution of two cytokines TGFβ1, and TNF-α were assessed in presence and absence of Botox. Fifty adult Sprague Dawley rats were used; one group was injected 10 units of Botox into wound. Daily observation and transepidermal water loss were assessed. Punch biopsies were taken on days 0, 3, 8, 14 and 28 for RNA extraction and PCR, and for routine light microscopy. Botox treated rats showed a delayed inflammation, necrosis, and earlier crust detachment compared to controls. On day 14, a better and smoother epithelialization was noted in the Botox groups. Finally, by day 28, the wound surface area was smaller and the quality of the skin was better with more fibroblasts in the regenerated dermis of Botox group, which expressed 2-4 times more TGFβ1. It peaked on days 3 and 8 and then decreased to almost half the control group by day 28. On the other hand, the TNF-α peaked immediately after burn to almost 20 times the control, then decreased between 2.72 to 5.5 times during the rest of the experiment very much like TGFβ1, or lower. Botox could possibly play an alleviating role and have a positive effect on burn wound healing.