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BackgroundCosmetic breast surgery (CBS) can be subdivided into augmentation, mastopexy, reduction, and reconstruction.ObjectivesThe aim of this study was to retrospectively analyze a multi-institutional national database to investigate the outcomes of CBS and identify clinical patterns to optimize care.MethodsThe American College of Surgeons National Surgical Quality Improvement Program database (2008-2020) was reviewed to identify female patients who underwent CBS. Postoperative outcomes (30-day surgical and medical complications, reoperation, readmission, and mortality) and risk factors for complications were assessed.ResultsIn total, 4733 patients were identified (mean age, 40 [13] years; mean BMI, 24 [4.5] kg/m2) with augmentation accounting for 54% of cases. There were complications in 2.0% of cases. Age >65 years (P = .002), obesity (P < .0001), setting (P < .0001), and diabetes (P = .04) were risk factors for any complication. Age >65 years (P = .02), obesity (P = .03), diabetes (P = .01), history of chronic obstructive pulmonary disease (COPD) (P = .002) and congestive heart failure (P < .0001), smoking in the past year (P = .003), setting (P = .007), and increased American Society of Anesthesiology score (P < .0001) were predictors of surgical complications such as dehiscence and infection. Multivariable analysis confirmed that chronic obstructive pulmonary disease, obesity Class 1 and 3, and inpatient status were independent risk factors for occurrence of any complication (P = .0005, .0003, < .0001 and ConclusionsThis study confirms the positive safety profile of CBS. Healthy BMI is a protective factor, while complications were more likely among inpatient procedures. A correlation between multiple procedures and increased surgical complications was identified. Awareness of these risk factors can assist surgeons to further refine their perioperative protocols.

Background Defects at the forefoot frequently require microsurgical reconstruction; however, reconstructive failure can lead to results inferior to primary amputation. The purpose of this study was to identify independent factors affecting surgical outcomes and hospitalization time in these patients. Methods All patients that underwent free flap reconstruction of the forefoot between 2008 and 2019 were reviewed retrospectively. Statistical evaluation included binary logistic regression and correlation analysis. Results A total of 93 free flap procedures were performed in 87 patients. The most common defect etiologies were acute trauma (30 cases; 32.3%), diabetic foot syndrome (20 cases; 21.5%), and infection (17 cases; 18.3%). Muscle flaps were used in 50 cases (53.8%) and fasciocutaneous flaps were used in 43 cases (46.2%). Major complications occurred in 24 cases (25.8%) including 11 total flap losses and 2 partial flap losses. Minor complications occurred in 38 cases (40.9%). Patients aged 60 years or above were at significant higher risk of major complications (p = 0.029). Use of fasciocutaneous flaps (odds ratio [OR]: 14.341; p = 0.005), arterial hypertension (OR: 18.801; p = 0.014), and operative time (min) (OR: 1.010; p = 0.029) were identified as individual risk factors for major complications. Two venous anastomoses significantly reduced the risk of major complications (OR: 0.078; p = 0.022). Multiresistant bacterial wound colonization (OR: 65.152; p Conclusion Our study identified independent risk factors that might help to make individual decisions whether to target microsurgical forefoot reconstruction or primary amputation. Two venous anastomoses should be performed whenever feasible, and muscle free flaps should be preferred in patients at higher risk of major surgical complications.

The physiological differences between genders have significant implications for health and disease. With regard to microsurgery, results remain elusive as to whether male or female gender is an independent risk factor for free flap reconstruction. This study evaluated the impact of gender on outcomes of lower-extremity free-flap reconstructions. Within 7 years, 358 patients received 393 microvascular lower limb free flap reconstructions. The cases were divided into two groups according to patients' gender: male vs. female. Retrospective data analysis evaluated patients' demographics, perioperative details, surgical complications and flap outcomes over a 3-month follow-up period. Major and minor surgical complications, including total and partial flap loss, showed no significant differences between the investigated groups (p>.05). In addition, there was no significant difference with regard to the rate of surgical revision surgery, or the incidence of arterial and venous thrombosis (p>.05). Comparison of different flap types (fasciocutaneous ALT vs. gracilis muscle flaps) and type of anastomosis (end-to-end vs. end-to-side) also revealed no difference in outcomes in respect to gender. In conclusion, gender cannot be regarded as an independent risk factor for free flap reconstructions in patients with lower-extremity defects.

Plastic surgeons are trained to perform a wide repertoire of surgeries-ranging from standard local procedures to highly specialized operations. Therefore, plastic surgeons treat a plethora of clinical presentations and address multiple patient needs. Their daily workflow is increasingly entwined with legal topics. The concrete legal interpretation falls within the remit of legal experts. However, by understanding the legal basics of selected surgical procedures, plastic surgeons may generate synergies in patient care and clinical practice. The legal situation is to be elucidated based on the German Basic Law (GBL) and the European Convention on Human Rights (ECHR). LEVEL OF EVIDENCE V: "This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 ."

BACKGRUND: The coagulation status of burn patients is generally impaired and is a major factor of the deteriorating burn patients’ overall situation. In trauma and other patient groups, the differential diagnosis of coagulation impairment has been largely improved by the use of rotational thromboelastometry (ROTEM®). The aim of this prospective observational study was the differentiated observation of coagulopathy in severely burned patients using standard parameters and ROTEM® thrombelastometry during the relevant stages of burn disease. PATIENTS AND METHODS: Twelve patients that sustained at least 20% third degree burns of total body surface area (TBSA) were included in the study. Standard and ROTEM® coagulation analyses were performed on admission and then twice daily during the first 14 days following burn trauma. RESULTS: Although the initial assessment of DIC was similar for both standard labs and ROTEM® measurements, more patients were detected to be in a state of worsening coagulation status for a longer time in ROTEM® than in standard measurements. In addition, one patient was rated in to be in decompensated DIC for 3 days according to ROTEM® measurements, while no patient was rated to be in a decompensated DIC based on standard parameters. CONCLUSION: This study points towards a more complex picture and higher occurrence of DIC in burn patients when thrombelastometric measurements like ROTEM® are taken into account in addition to standard coagulation parameters.

Background Several patient-related factors have been identified with regard to the safety and efficacy of breast reconstructions. Using the largest database available in Europe, the presented study investigated the impact of cigarette smoking on deep inferior epigastric artery perforator (DIEP) free-flap breast reconstructions. Methods In total, 3,926 female patients underwent 4,577 free DIEP-flap breast reconstructions after malignancies in 22 different German breast cancer centers. The cases were divided into two groups: nonsmokers (NS) and smokers (S). Impact of smoking on surgical complications, controlled for covariates, and cluster effects within the cancer centers were analyzed by using generalized linear mixed models. Results Overall, there was no significant difference between the groups of patients regarding the rate of total flap loss. However, the rate of partial flap loss (0.9 vs. 3.2%, p Conclusion Our findings suggest that successful free tissue transfer can be achieved in smokers despite higher rates of partial flap losses and wound-healing disturbances. However, patients with a history of smoking requiring DIEP flap reconstruction should be critically evaluated preoperatively, informed in detail about the higher risk of complications and encouraged to quit smoking prior to surgery.

Abstract Plastic surgeons are trained to perform a wide repertoire of surgeries—ranging from standard local procedures to highly specialized operations. Therefore, plastic surgeons treat a plethora of clinical presentations and address multiple patient needs. Their daily workflow is increasingly entwined with legal topics. The concrete legal interpretation falls within the remit of legal experts. However, by understanding the legal basics of selected surgical procedures, plastic surgeons may generate synergies in patient care and clinical practice. The legal situation is to be elucidated based on the German Basic Law (GBL) and the European Convention on Human Rights (ECHR). Level of Evidence V "This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266."

Background An oncologic tumor resection of the scalp can result in complex wounds that result in challenging scalp reconstructions. This study aimed to evaluate the outcomes of microvascular-based scalp reconstructions (MSR) in oncologic patients and to propose an algorithmic treatment approach. Methods Within a 5-year period, 38 patients having undergone 41 MSR (15 anterolateral thigh (ALT), 15 gracilis muscle (GM), and 11 latissimus dorsi muscle (LDM) flaps) after extensive scalp tumor resections fulfilled inclusion criteria for this study. Results Malignant skin disease included superficial and/or deep infiltration of the calvarium in 26 and combined intracranial infiltration in 12 patients. In case of bone replacement (24 patients), MSR was done concomitant, otherwise MSR was performed after pathological confirmation of tumor-free margins. LDM flaps were used in cases with defect sizes of 400 to 1250cm2, whereas ALT- and GM flaps were chosen for defects ranging from 40 to 350cm2. The average length of the pedicle was comparable in ALT- and LDM flaps and longer than in GM flaps. Total flap loss with need for revision surgery and minor donor site morbidity occurred in four and three patients, respectively. Conclusion Microsurgical reconstruction of moderate-to-extensive scalp defects remains a reliable method with overall low risks and satisfactory aesthetic results, while, according to our experience, muscle flaps show the best functional and aesthetic results. However, in cases of central scalp defects and in situations when a long vascular pedicle of the flap is important, the ALT flap seems to be the best solution.

Background Secondary breast reduction is complex and poses significant challenges to surgeons. Complication rates exceed those of primary reduction, commonly caused by impaired vascular supply of the nipple-areolar complex (NAC). Literature on the topic is scare and provides contradicting recommendations, especially with regard to pedicle choice in cases with unknown primary reduction technique. Aim of this study was to investigate international trends and to compare findings with literature. Methods A large-scale web-based questionnaire on international trends in mammaplasty (mastopexy and breast reduction) was designed and distributed to over five thousand surgeons in eight geographic regions. The presented manuscript evaluated information regarding pedicle choice in secondary breast reduction and compared data to literature identified in a systematic review. Results The survey was completed by 1431 participants. Overall, secondary procedures were performed in less than 5% or in 5 to 10% of cases. The preferred pedicle for secondary reductions differed significantly between geographic regions (p Conclusions Secondary breast reduction is challenging and there remains international disparity with regard to pedicle choice for secondary procedures. Studies investigating outcome when the primary pedicle is unknown are scarce and provide incoherent recommendations. High-quality data is needed to provide evidence-based practice guidelines. Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266

Background Reconstruction of complex chest and upper back defects can pose a challenge to microsurgeons, especially when prior surgery, scarring, tumor resection, or radiotherapy, have caused a shortage of recipient vessels. Although already being a standard approach for head and neck reconstructions, we investigated whether the indication of the superior thyroid artery (STA) as a safe and universal recipient vessel could be extended for reconstruction in aforementioned regions. Methods Seventeen patients received free myocutaneous vastus lateralis (MVL) muscle flaps for reconstruction of upper body defects (chest n = 11; upper back n = 6). In all cases, the STA was used for microvascular anastomosis because of a lack of standard recipient vessels. A retrospective chart review was performed and the data was screened for patients' demographics, intraoperative and perioperative details, flap survival, surgical complications, and overall long-term outcomes. Patients had a minimum follow-up of 6 months. Results Defects resulted from infections after cardiac surgery (n = 10), infections after spinal neurosurgery (n = 2) or tumor resection (n = 5). Average defect size measured 144.6 (range, 40-286 cm; ±67.9 cm), with a mean size of the MVL free flaps of 266.8 (range, 160-384 cm; ±69.5 cm). The flap success rate was 100%, with minor complications in 4 patients. No major complications were observed in any of the patients. Conclusions The STA is a viable and safe alternative as a recipient vessel for reconstruction of upper body defects, especially when other vessels in proximity to the defect are deprived.

Background When faced with plantar defects, reconstruction of the weight-bearing areas presents unique surgical challenges. Several free flap modalities have been described in this respect, but there remains debate regarding the best-suited flap modality. Aim of this study was to compare free muscle and non-neurotized fasciocutaneous flaps for plantar reconstruction with respect to long-term functional outcomes. Methods Overall, 89 patients received 100 free flaps (anterolateral thigh [ALT] n = 46; gracilis n = 54) for plantar reconstruction. The data were screened for patients' demographics, as well as perioperative details. Postoperative complications were accounted for and the two groups compared accordingly. All patients were contacted for a long-term follow-up examination. Results There were no significant differences between the two groups regarding major (24 vs. 17%; p = 0.366) and minor surgical complications (61 vs. 70%; p = 0.318). However, the ALT group showed a significantly higher need for secondary surgeries (39 vs. 19%; p = 0.022). Sixty-eight patients (76%) returned for long-term follow-up evaluation (mean: 51.2 months, range: 13–71 months). The ALT group showed significantly less pain at the recipient (p = 0.0004) and donor (p = 0.010) sites, and scar assessment revealed significantly better results (p Conclusion Both the free ALT and gracilis flaps are well suited for plantar reconstruction, yielding overall similar functional outcomes. However, the ALT flap produces less scarring and pain, while showing better recovery of sensation and enabling better shoe provision. The ALT flap thus presents our preferred option.

In the Sustainable Development Goals era, there is a new awareness of the need for an integrated approach to healthcare interventions and a strong commitment to Universal Health Coverage. To achieve the goal of strengthening entire health systems, surgery, as a crosscutting treatment modality, is indispensable. For any health system strengthening exercise, baseline data and longitudinal monitoring of progress are necessary. With improved data capabilities, there are unparalleled possibilities to map out and understand systems, integrating data from many sources and sectors. Nevertheless, there is also a need to prioritize among indicators to avoid information overload and data collection fatigue. There is a similar need to define indicators and collection methodology to create standardized and comparable data. Finally, there is a need to establish data pathways to ensure clear responsibilities amongst national and international institutions and integrate surgical metrics into existing mechanisms for sustainable data collection. This is a call to collect, aggregate, and analyze global anesthesia and surgery data, with an account of existing data sources and a proposed way forward.

BACKGROUND The authors assess the impact of rhinoplasty on public perception of a patient's appearance and personality. METHODS A survey was created using standardized before-and-after photographs of 10 Caucasian women who had undergone primary rhinoplasty. Photographs of two additional women who had not undergone facial surgery were randomly included as controls, for a total of 12 survey items. Preoperative and postoperative photographs were placed side by side. The survey was administered by means of crowd-sourcing. Respondents were asked to evaluate which photograph better represented 11 traits of appearance or personality, according to a seven-point Likert scale. A score of 1 meant the preoperative photograph was much better, 7 meant the postoperative photograph was much better, and 4 meant no difference. T tests and analyses of variance were used to evaluate rating changes for each trait and differences between demographic groups. RESULTS There were 264 responses received. Averaged scores across the 10 survey patients produced a value for each appearance or personality trait. In 10 of 11 categories (i.e., symmetry, youthfulness, facial harmony, likeability, trustworthiness, confidence, femininity, attractiveness, approachability, and intelligence), the postoperative photograph was significantly favorable compared with the preoperative photograph (p < 0.00001). The preoperative photograph was rated higher only in aggressiveness (p < 0.001). The same scores were calculated for the controls; no significant difference in any category was seen except confidence, where the right image was viewed as more confident (mean, 4.19; p < 0.005). CONCLUSION Aesthetic rhinoplasty improves the public perception of a person's appearance and personality in multiple aspects.

When treating burn injuries, to date, there still remains significant disagreement whether presence of hypothermia (HT) on burn centers' intensive care unit (BICU) admission improves or worsens outcomes. The presented single burn center experiences set out to further evaluate the incidence, cause, and potential effects of HT on outcomes in severely burned patients. Between January 2015 and February 2017, 142 severely burned patients were admitted to a BICU. Temperature at BICU admission of36.0°C was defined as HT and ≥36.0°C as normothermia (NT). The cases were divided into two groups: HT vs NT. Fifty-four patients met inclusion criteria and were analyzed retrospectively regarding encountered complications, time of hospitalization, and overall survival. The overall incidence of HT on arrival was 62.9%. Mean duration from burn accident to BICU admission did not differ significantly, but the groups showed significant differences regarding total body surface area (TBSA; P.05). Both groups showed a similar distribution, regarding number of surgeries, duration until first burn excision, length of ventilation, and mortality rate of patients (P.05). However, time until death was significantly shorter in the HT group. HT at admission remains a common problem following burn injury. Main risk factors include inappropriate temperature management after injury and during transport, extent of TBSA burn, and quantity of resuscitation. Given the high incidence, the involved health care and, especially, also prehospital providers should be further educated about existing recommendations and guidelines to prevent HT.

Background Free tissue transfers have become standard for a wide variety of reconstructive purposes. In an era of increasing economic pressure, it is important to precisely define appropriate candidates and indications for a complex surgery to optimize efficiency and patient outcomes. This study evaluates the feasibility to perform microsurgical procedures in a medically compromised patient cohort at a major academic microsurgical center. Methods Within 7 years, 897 patients underwent 969 microvascular free flap reconstructions. The data were retrospectively screened for patients' demographics, perioperative details, flap survival, surgical complications, and outcomes. The cases were divided into two groups in “low-risk” (American Society of Anesthesiologists [ASA] I and II) or “high-risk” (ASA III and IV) as per the preoperative medical status classified according to the ASA score of physical status. Results Despite the significantly high prevalence of hypertension, peripheral artery disease, diabetes, obesity, and smoking status in the “high-risk” group (p 0.05). Conclusion In this study, free flap reconstruction in medically compromised patients was not associated with higher rates of revision surgeries, overall complication rates, or surgery-related costs. Complex microsurgical free flap reconstruction can therefore also be advocated in patients with high preoperative risk constellation.

Background Free tissue transfers are routinely performed for reconstruction of the upper limb. Main complication in free flap surgery still stems from vascular compromise and many technical controversies exist regarding the technical details of how to perform the microvascular anastomosis. This study evaluates outcomes regarding the execution of one versus two venous anastomoses for upper limb reconstruction. Methods In this study, 79 patients underwent 86 free anterolateral thigh (ALT) or groin flaps for upper limb reconstruction after trauma, infection, or malignancies. The data were retrospectively screened for patients' demographics, perioperative details, flap survival, and surgical complications. The cases were divided into two groups regarding the number of performed venous anastomoses: one versus two veins. Results No significant differences existed between the two groups regarding preoperative comorbidities (ALT: 16 one, 21 two veins; groin: 16 one, 33 two veins). Overall, there was no significant difference regarding the rate of major (1 vein: 18.8% vs. 2 veins: 20.4%; p > 0.05) and minor (1 vein: 3.1% vs. 2 veins: 3.7%; p > 0.05) surgical complications during the 3-month follow-up period. Major complications included total flap losses of 9.4% (1 vein) versus 7.4% (2 veins) (p > 0.05). Conclusion This study analyzed a series of microsurgical reconstructions with a focus on the impact of the number of performed venous anastomoses. The findings suggest that successful free tissue transfer for upper limb reconstruction can be achieved independent of the number of venous anastomoses. However, to promote additional safety, a second vein should be performed whenever technically possible.

Pilonidal disease can be treated medically; however, surgical excision remains the gold standard. Nonetheless, all current surgical approaches are still associated with potential for tissue loss, wound healing disorders, and high rates of recurrence. Aim of this study is to assess the long-term outcomes of the minimal-invasive pit-picking operation in comparison to the well-established technique of Karydakis flap-closure. Medical records of all patients undergoing either Karydakis flap-closure or the pit-picking operation for pilonidal disease at our department were reviewed retrospectively. A total of 101 patients were treated either by excision and Karydakis flap-closure (n = 62) or by the pit-picking operation (n = 39). Mean follow-up time was 65.5 (range: 38–101) months, including data collection using a standardized questionnaire. Analysis of the outcomes revealed no significant differences between the Karydakis flap-closure- and the pit-picking groups; however, the latter was associated with faster recovery, no need for hospitalization and overall low complication rates. In summary, the main advantages of the pit-picking operation lie in its’ outpatient character, the simplicity of the procedure, low complication rates, short recovery time, and predictably good results.

The choice of microsurgical anastomotic technique, end-to-end (ETE) or end-to-side (ETS), is a relevant point in free tissue transfer. The decision-making process of choosing ETE or ETS technique depends on several clinical and perioperative factors. This study evaluates the outcomes of microvascular procedures in a large single centre patient series, focusing on ETE vs ETS arterial anastomoses.Between January 2009 and June 2015, 838 patients underwent free flap surgery for reconstruction after trauma, infection, or malignancies. The cases were divided according to the microsurgical technique of the arterial anastomosis into an ETE (n = 693) and an ETS (n = 145) group. The series was retrospectively analysed and the two groups compared regarding outcomes.Overall, there was no significant difference in rates of surgical complications, flap failures, and re-explorations between the patient groups during the 3-months follow-up period.The presented analysis includes a large series of microsurgical reconstructions evaluating outcomes in respect to type of performed arterial anastomosis. While the decision of performing an ETE or ETS arterial anastomosis must be made according to recipient vessel quality and accessibility, given no change in outcomes, an ETS anastomosis should be performed whenever feasible in order to preserve distal perfusion.

Following Achilles tendon rupture and repair, reruptures or infections are not infrequent. Consequently, several surgical techniques have been described to decrease complication rates. This study aimed to evaluate the outcomes of the free composite fasciocutaneous anterolateral thigh flap including fascia lata for reconstruction of combined complex soft-tissue and Achilles tendon defects.Within an 8-year period, 34 patients having undergone microvascular Achilles tendon reconstruction fulfilled inclusion criteria for this study: 25 of these patients (73.5 percent) returned for follow-up examination, seven of whom (28.0 percent) underwent additional bilateral contact pressure and power measurements. The data were screened for patients' demographics, intraoperative and perioperative details, flap survival, surgical complications, and overall long-term outcomes.Mean follow-up time was 40.8 months. The Thompson test was negative in all patients. The pain score assessed by the Numerical Rating Scale at the reconstructed site was low overall, but showed significant differences between rest and activity (p0.05). The assessment of the Vancouver Scar Scale showed very good results with both techniques. The measurements of the peak pressures, power while walking, and foot contact area did not show differences between the operated and nonoperated sides (p0.05), whereas range of motion revealed significant differences (p0.05).In patients who suffer complex Achilles tendon injury requiring free flap coverage, the composite anterolateral thigh flap including fascia lata provides a reliable and safe approach with very good functional and aesthetic outcomes. It should be considered one of the first reconstructive options.Therapeutic, IV.

Introduction Free tissue transfers are a highly reliable procedure routinely performed for reconstruction of a wide range of defects. Main complication in free flap surgery is usually venous thrombosis. Many technical controversies exist regarding the technical details of the microvascular anastomosis in order to prevent occurrence of thrombosis and optimize outcomes. We therefore evaluated our results regarding the execution of one versus two venous anastomoses in a variety of free flaps (fasciocutaneous- or muscle free flap) utilized for lower limb reconstruction. Patients and methods Between 2009 and 2015, 354 patients underwent 386 free ALT- or gracilis flaps for lower limb defect reconstruction after trauma, infection, or malignancies at our institution. The data was retrospectively screened for patients’ demographics, perioperative details, flap survival, and surgical complications. The cases were divided into two groups regarding the number of microsurgically performed venous anastomosis: one versus two veins. Results Regarding the preoperative evaluation, there were no significant differences regarding comorbidities between the two groups. Overall, there was no significant difference regarding the rate of major (1 vein: 20.38% versus 2 veins: 18.78%, p > 0.05) and minor (1 vein: 1.27% versus 2 veins: 2.18%, p > 0.05) surgical complications during our 3-months follow-up period. Major complications included total flap losses of 5.73% (1 vein) versus 8.78% (2 veins). Conclusion This study analyzed a large series of microsurgical reconstructions, with a focus on the impact of the number of venous anastomosis. The findings suggest that successful free tissue transfer for lower limb reconstruction can be achieved independent of the number of venous anastomoses, however two should be performed when technically feasible.

Obtaining quality global statistics about surgical procedures remains an important yet challenging task. The International Society of Aesthetic Plastic Surgery (ISAPS) reports the total number of surgical and non-surgical procedures performed worldwide on a yearly basis. While providing valuable insight, ISAPS' statistics leave two important factors unaccounted for: (1) the underlying base population, and (2) the number of surgeons performing the procedures.Statistics of the published ISAPS' 'International Survey on Aesthetic/Cosmetic Surgery' were analysed by country, taking into account the underlying national base population according to the official United Nations population estimates. Further, the number of surgeons per country was used to calculate the number of surgeries performed per surgeon.In 2014, based on ISAPS statistics, national surgical procedures ranked in the following order: 1st USA, 2nd Brazil, 3rd South Korea, 4th Mexico, 5th Japan, 6th Germany, 7th Colombia, and 8th France. When considering the size of the underlying national populations, the demand for surgical procedures per 100,000 people changes the overall ranking substantially. It was also found that the rate of surgical procedures per surgeon shows great variation between the responding countries.While the US and Brazil are often quoted as the countries with the highest demand for plastic surgery, according to the presented analysis, other countries surpass these countries in surgical procedures per capita. While data acquisition and quality should be improved in the future, valuable insight regarding the demand for surgical procedures can be gained by taking specific demographic and geographic factors into consideration.

Background Worldwide obesity has more than doubled since 1980. Given this epidemic change, surgical and medical care has become more complex as obesity is a known risk factor for complications. Consequently, one could expect a higher prevalence of medical and surgical complications in an obese patient collective in the setting of free tissue transfer. Goal of this study was to evaluate whether this assumption holds true. Material and Methods Between January 2009 and June 2015, 838 patients underwent free tissue transfers at a single institution. The cases were divided into three groups using the World Health Organization body mass index (BMI) criteria into a nonobese ( n = 751), a moderately obese ( n = 59), and a severely to very severely obese group ( n = 28). The series was retrospectively analyzed and the groups were compared regarding the potential influence of BMI in respect to surgical complications and outcomes. Results Overall, there was no significant difference in morbidity between the groups of patients regarding the rate of surgical complications during our 3-month follow-up period. Conclusion This study analyzed a large series of microsurgical reconstructions, with a focus on the impact of patient obesity on outcomes. Our findings suggest that despite higher rates of patient comorbidities, successful free tissue transfer can be achieved in this population with acceptable risk for complications.

Extensive full-thickness burns pose a great challenge to the burn surgeon. Lack of autograft donor sites is an important limiting factor to achieving wound closure. To overcome this problem, various methods of treatment have been suggested in the past, including the MEEK technique. This study was carried out at the Bogenhausen Hospital Burn Unit, Munich, Germany from 2006 to 2015. There were a total of 148 skin grafting operations. The modified MEEK technique was performed on 67 patients. Patients included 34 males and 33 females, with an average age of 39·6 years. The mean percentage body surface burned was 65%, and full-thickness injury occurred in 52%. The mean area graft per procedure was 20%. The viability of the graft as assessed between the 7th and 10th day was generally in the range of 60-90%. The average number of operations required was 2·21. The mean length of stay was 27 days. Infection was documented in five patients, and seven deaths occurred. The mean follow-up was 3·2 years. When faced with large surface area burns and limited donor sites, the MEEK technique is a satisfactory method for coverage.

Pain reduction as well as preservation and improvement in range of motion remain the main aims in the treatment of thumb carpometacarpal (CMC) osteoarthritis (OA). We performed a retrospective outcome analysis of patients with symptomatic stage II-III thumb CMC joint arthritis treated with denervation, joint lavage and capsular imbrication.73 patients with stage II to III OA of the thumb CMC-joint underwent the described technique. A total of 42 patients complied with follow-up assessment and were included in this study. Mean follow-up was 41.2 (range 12-81) months.Mean operative time was 28.4 (±6.5) minutes. The follow-up assessments showed a significant decrease in pain (preoperative Numerical Rating Scale (NRS): 7.5 - postoperative NRS: 1.1) (p 0.0001) and a significant improvement in function of the thumb (preoperative DASH-Score: 46.8; Cooney-Wrist-Score: 35.4; Krimmer-Wrist-Score: 38.3 - postoperative DASH-Score: 18.1; Cooney-Wrist-Score: 73.7; Krimmer-Wrist-Score: 80.0) (p 0.0001).The findings of our study indicate that the presented treatment approach could be a good alternative to more invasive surgical options in patients with stage II-III CMC OA of the thumb, without impairing more invasive surgical options like trapeziectomy or arthroplasty for the future.

The American Society of Plastic Surgeons publishes yearly procedural statistics, collected through questionnaires and online via tracking operations and outcomes for plastic surgeons (TOPS). The statistics, disaggregated by U.S. region, leave two important factors unaccounted for: (1) the underlying base population and (2) the number of surgeons performing the procedures. The presented analysis puts the regional distribution of surgeries into perspective and contributes to fulfilling the TOPS legislation objectives. ASPS statistics from 2005 to 2013 were analyzed by geographic region in the U.S. Using population estimates from the 2010 U.S. Census Bureau, procedures were calculated per 100,000 population. Then, based on the ASPS member roster, the rate of surgeries per surgeon by region was calculated and the interaction of these two variables was related to each other. In 2013, 1668,420 esthetic surgeries were performed in the U.S., resulting in the following ASPS ranking: 1st Mountain/Pacific (Region 5; 502,094 procedures, 30 % share), 2nd New England/Middle Atlantic (Region 1; 319,515, 19 %), 3rd South Atlantic (Region 3; 310,441, 19 %), 4th East/West South Central (Region 4; 274,282, 16 %), and 5th East/West North Central (Region 2; 262,088, 16 %). However, considering underlying populations, distribution and ranking appear to be different, displaying a smaller variance in surgical demand. Further, the number of surgeons and rate of procedures show great regional variation. Demand for plastic surgery is influenced by patients’ geographic background and varies among U.S. regions. While ASPS data provide important information, additional insight regarding the demand for surgical procedures can be gained by taking certain demographic factors into consideration. This journal requires that the authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

IntroductionDespite an estimated one-third of the global burden of disease being surgical, only limited estimates of accessibility to surgical treatment in sub-Saharan Africa exist and these remain spatially undefined. Geographical metrics of access to major hospitals were estimated based on travel time. Estimates were then used to assess need for surgery at country level.MethodsMajor district and regional hospitals were assumed to have capability to perform bellwether procedures. Geographical locations of hospitals in relation to the population in the 47 sub-Saharan countries were combined with spatial ancillary data on roads, elevation, land use or land cover to estimate travel-time metrics of 30 min, 1 hour and 2 hours. Hospital catchment was defined as population residing in areas less than 2 hours of travel time to the next major hospital. Travel-time metrics were combined with fine-scale population maps to define burden of surgery at hospital catchment level.ResultsOverall, the majority of the population (92.5%) in sub-Saharan Africa reside in areas within 2 hours of a major hospital catchment defined based on spatially defined travel times. The burden of surgery in all-age population was 257.8 million to 294.7 million people and was highest in high-population density countries and lowest in sparsely populated or smaller countries. The estimated burden in children ConclusionThe study provides an assessment of accessibility and burden of surgical disease in sub-Saharan Africa. Yet given the optimistic assumption of adequare surgical capability of major hospitals, the true burden of surgical disease is expected to be much greater. In-depth health facility assessments are needed to define infrastructure, personnel and medicine supply for delivering timely and safe affordable surgery to further inform the analysis.

In the Sustainable Development Goals era, there is a new awareness of the need for an integrated approach to healthcare interventions and a strong commitment to Universal Health Coverage. To achieve the goal of strengthening entire health systems, surgery, as a crosscutting treatment modality, is indispensable. For any health system strengthening exercise, baseline data and longitudinal monitoring of progress are necessary. With improved data capabilities, there are unparalleled possibilities to map out and understand systems, integrating data from many sources and sectors. Nevertheless, there is also a need to prioritize among indicators to avoid information overload and data collection fatigue. There is a similar need to define indicators and collection methodology to create standardized and comparable data. Finally, there is a need to establish data pathways to ensure clear responsibilities amongst national and international institutions and integrate surgical metrics into existing mechanisms for sustainable data collection. This is a call to collect, aggregate, and analyze global anesthesia and surgery data, with an account of existing data sources and a proposed way forward.RéSUMé: À l’époque des objectifs du développement durable, on constate une nouvelle sensibilisation au besoin d’une approche intégrée dans les interventions en soins de santé et un fort engagement en faveur d’une couverture médicale universelle. Pour atteindre l’objectif du renforcement de systèmes entiers de santé, la chirurgie en tant que modalité thérapeutique transversale est indispensable. Pour toute activité de renforcement du système de santé, des données de référence et un suivi longitudinal des progrès sont nécessaires. Avec de meilleures données, il existe des possibilités sans équivalent de cartographier et de comprendre les systèmes, en intégrant des données provenant de multiples sources et secteurs. Néanmoins, il est également nécessaire de prioriser les indicateurs pour éviter une surcharge d’informations et une fatigue dans la collecte des données. Il existe un besoin similaire de définition des indicateurs et de la méthodologie de collecte afin de créer des données standardisées et comparables. Enfin, il est nécessaire d’établir des cheminements de données pour garantir des responsabilités claires entre les institutions nationales et internationales et intégrer les paramètres chirurgicaux dans les mécanismes existants pour une collecte durable des données. Ceci est un appel à la collecte, au regroupement et à l’analyse de données globales en anesthésie et en chirurgie avec un compte rendu des sources de données existantes et une proposition d’avancée.

Summary Purpose Several operative approaches and various implants for osseous fixation have been described to achieve four-corner fusion of the wrist. Given the discordance and to aid in further standardizing the technique, this study directly compares the outcomes of K-wire, fusion plate, and headless retrograde compressive screw fixations to achieve four-corner arthrodesis. Methods Sixty-four patients underwent four-corner fusion over a period of 5 years and were reviewed retrospectively. Twenty-one patients underwent bone fixation with conventional K-wires, 26 with locking plates, and 17 patients were treated by headless retrograde compressive screw fixations. Patients of the different groups were comparable regarding age, sex, hand dominance, and stage of disease. Results All study groups showed significant improvements in grip strength, decrease in pain (NRS) at rest and with activity, range-of-motion of the wrist, and wrist function (measured by the DASH-score). When evaluating the three groups amongst each other, overall complication and nonunion rates were low and revealed no significant differences between the groups of patients. However, regarding postoperative NRS at activity, dorsal flexion, and DASH-scores, the "screw" group showed significantly better results than the "wire" group. Conclusion The results show that all examined techniques of four-corner fusion can improve wrist function when compared to preoperative baseline (NRS at rest and activity, postoperative DASH-scores). However, headless retrograde compressive screw fixation had significant better results regarding pain relief (NRS) at activity and postoperative DASH-scores.

Background Free tissue transfers can successfully address a wide range of reconstructive requirements. While the negative influence of cigarette smoking is well documented, its effects in the setting of microsurgical free flap reconstruction remain debated. This study evaluates the impact of cigarette smoking on microsurgical reconstructions. Methods Over a 7-year period, 897 patients underwent 969 microvascular free flap reconstructions at a single surgical center. The cases were divided into “smoker” (S) and “nonsmoker” (NS) groups according to their cigarette smoking status. The data were retrospectively screened for patients' demographics, perioperative details, surgical complications, free flap types, recipient sites, flap survival, and overall outcomes. Results Both groups were comparable regarding comorbidities including hypertension, peripheral artery disease, diabetes, American Society of Anesthesiologists scores, types of performed free flaps, and recipient sites. While patients in the NS group were significantly older and had a higher prevalence of obesity (p 0.05). Conclusion While minor and major complications were increased regarding virtually all examined parameters, cigarette smoking did not have significant effects on the overall outcomes of microsurgical free flap reconstructions.

Introduction While periorbital and -ocular surgery ranks amongst the most frequently performed plastic surgical procedures, only scarce information exists regarding the contributing factors of aging and its systematic anatomic assessment. The presented study, based on measuring distinct physical landmarks, aimed to gather data to provide a foundation of in-depth periorbital analysis in order to more clearly define female eye attractiveness. Methods 80 probands (age range: 30–50 years, M = 38.4 ± 6.5 years) were asked to judge 60 standardized high-resolution digital pictures of female eye regions in respect to the perceived age (in years) and attractiveness (7-point Likert scale). All photographs were objectively evaluated and measured utilizing a total of 38 distinct landmarks. The data was analyzed by calculating correlations between relevant measured eye area parameters and mean attractiveness ratings including age estimations. Results Overall, it was found that several specific eye shape features correlate with attractiveness and perceived age. For instance, large visible height of the iris and large upward and lateral inclination of both eye axis and eyebrows correlated moderately to strongly with attractiveness (p Conclusion Regarding the female eye, there exist distinct periorbital anatomic features and landmarks which contribute to a youthful appearance and attractiveness. Knowledge regarding these facts may serve as an important guideline for pre- and post-operative patient analysis.

Background Free tissue transfers have become routine for a variety of reconstructive purposes. During the time of transfer, some period of ischemia time is unavoidable, causing structural and metabolic changes. This study aimed to evaluate whether length of intraoperative ischemia affects the outcomes of microsurgical reconstructions. Methods Within a 7-year period, 638 patients having undergone 690 microvascular free flap reconstructions fulfilled inclusion criteria for this study. The data were retrospectively screened for patients' demographics, intra- and perioperative details, flap survival, surgical complications, and outcomes. The cases were divided into two groups according to the length of intraoperative ischemia time, “< 60” versus “≥ 60 minutes.” Results Both groups were comparable regarding the patient constellation, comorbidities, smoking status, and perioperative characteristics. Operative times were significantly longer in patients which had ischemia times of ≥ 60 minutes (p Conclusion In this study, prolonged ischemia time during free flap reconstructions was associated with higher rates of revision surgeries and complications rates.

Purpose Ear position contributes significantly to facial appearance. However, while objective measurements remain the foundation for esthetic evaluations, little is known about how an ear should ideally be positioned regarding its rotational axis. This study aimed to further evaluate whether there exists a universally applicable ideal ear axis, and how sociodemographic factors impact such preferences. Materials and methods An interactive online survey was designed, enabling participants to change the axis of a female model's ear in terms of its forward and backward rotation. The questionnaire was sent out internationally to plastic surgeons and the general public. Demographic data were collected and analysis of variance was used to investigate respective preferences. Results A total of 1016 responses from 35 different countries (response rate: 18.5%) were gathered. Overall, 60% of survey takers chose the minus 10 or 5° angles to be most attractive. Significant differences were found regarding sex, ethnicity, country of residence, profession and respective ear axis preferences. Conclusion Across multiple countries and ethnicities, an ear position in slight reclination of minus 5–10° is considered most pleasing in Caucasian females. However, sociodemographic factors significantly impact individual ear axis preferences and should be taken into consideration when performing reconstructive ear surgery.

Background Free tissue transfers are routinely performed for extremity reconstruction. In an era of increasing economic pressure in many healthcare systems, efficiency needs to be optimized for any kind of operative procedure. This study is examining the possible benefit of a two-attending approach to microsurgical reconstruction of the limbs using antero-lateral thigh- (ALT) or gracilis-muscle flaps at a major academic microsurgical center. Methods 309 patients underwent 392 free ALT- (206) or gracilis-muscle (186) flaps for limb defect reconstruction at our institution (2009–2015). All available data was retrospectively screened for patients' demographics, perioperative details, surgical complications, and overall flap survival. The cases were divided into two groups according to the number of operating microsurgeons: one versus two attendings. Results No significant differences existed between the two groups (341 “one attending” versus 51 “two attendings”) regarding preoperative comorbidities. Overall, there was no significant difference between both groups regarding operative times, revision surgery rates, total as well as partial flap loss, and hospital length of stay (p > 0.05) during the 3-month follow-up period. Further, evaluating ALT and gracilis flaps separately also showed no significant differences between both groups (one versus two attendings). Conclusion The addition of a second operating attending does not significantly shorten surgery times, hospital length of stay, need for revision surgery, or complications rates. A two-operation surgeon approach may therefore only provide a marginal benefit in microsurgical limb reconstruction.

Objective Burns represent a special form of severe trauma. Due to long hospitalization, rehabilitation, and extensive scar treatment, severe burn injuries rank among the most expensive traumatic injuries regarding associated health care costs. The presented single-burn-center experiences evaluated the effects of primary versus secondary burn intensive care unit (BICU) admissions on outcomes in severely burned patients. Methods Within 30 months, 186 patients were admitted to the BICU. The cases were divided into two groups depending on their admission type: “primary” vs. “secondary”. All patients were analyzed retrospectively regarding the need for surgery, encountered complications, time of hospitalization and overall survival. Results The incidence of primary BICU-admissions was 65.1%. Both patient groups were comparable regarding demographics, comorbidities, % TBSA burn, associated inhalation injuries, ABSI scores and intubation rates (p > 0.05). Both groups received similar numbers of operations and had overall comparable mortality rates (p > 0.05). However, duration until first burn excision, length of ventilation, as well as BICU- and overall hospital length of stay were significantly shorter in the “primary”- compared to the “secondary” group (p Conclusion Several burn societies have published precise criteria of when a patient needs to be referred to a burn center. In the presented series, patients that were primarily treated at a BICU showed significantly better outcomes regarding several parameters. In order to further optimize treatment of burn patients it therefore appears that precise initial assessment and if appropriate respective primary transport to dedicated burn centers needs to be re-emphasized, especially among first- and emergency care providers.

OBJECTIVE The interleukin-1 receptor antagonist (IL-1RA) contributes to tumor survival and progression in multiple cancer entities. IL-1RA polymorphisms influence IL-1RA expression patterns and function. A known polymorphism was correlated with clinical outcomes in melanoma patients with particularly aggressive disease. METHODS DNA of 343 controls and 97 melanoma patients with poor prognostic indicators (time from diagnosis to death, nodal status, metastasis) was analyzed for a variable number of tandem repeat polymorphisms (VNTR) of the IL-1RA gene. Five alleles containing two (allele 2), three (allele 4), four (allele 1), five (allele 3) or six (allele 5) 86-bp repeats were targeted via PCR amplification. RESULTS Genotype 1/2 is less common in the melanoma patient group vs. the control (28.8% vs. 39.6%; p = 0.06). Significant was the stage of the melanoma in order to predict the survivability (p = 0.008). The 1/1 and 1/2 genotype appeared to have lower hazards ratios than the 2/2 genotype (p > 0.05). CONCLUSIONS Compared to the general population, the distribution of alleles coding for IL-1RA is different in melanoma patients. This alteration and the potential impact on tumor protein function and systemic inflammatory response may warrant further investigation.

Summary Background Post-surgical pyoderma gangrenosum (PSPG) is a rare inflammatory skin disorder of unknown aetiology. Given its similar presentation to wound infection and lack of reliable diagnostic tests as well as pathognomonic clinical features, PSPG is difficult to diagnose. The aim of this review was to identify factors contributing to PSPG to aid with timely diagnosis and appropriate therapy. Methods A systematic literature review was performed by following PRISMA guidelines, focusing on PSPG after reconstructive and aesthetic breast surgery. The online databases PubMed, Medline, EMBASE, Scopus, and Cochrane were used, and additionally, a Google© search was performed. Results A total of 68 articles describing 87 cases of PSPG following aesthetic and reconstructive breast surgery were found. The majority of PSPG (44%) occurred after breast reduction surgery and microsurgical breast reconstruction (16%). The most common associated conditions were malignancies in 37% and autoimmune deficiencies in 17%. Microbiological examinations were found to have a negative result in 90%. The median time from initial presentation with symptoms to correct diagnosis of PG was on average 12.5 days, with unsuccessful first-line therapy on average for 20.0 days. After the diagnosis of PG, medical therapy most commonly involved steroids in 84% and/or Cyclosporine A in 22% of the cases. On average, the duration of this therapy was 4.7 months. Conclusion The diagnosis of PSPG remains a challenging issue. However, according to the presented review, several distinct clinical signs in combination with lack of treatment response should prompt further investigation to promote timely diagnosis and correct treatment of this potentially debilitating disease.

OBJECTIVEAlthough rare, frontoethmoidal meningoencephaloceles continue to pose a challenge to neurosurgeons and plastic reconstructive surgeons. Especially when faced with limited infrastructure and resources, establishing reliable and safe surgical techniques is of paramount importance. The authors present a case series in order to evaluate a previously proposed concise approach for meningoencephalocele repair, with a focus on sustainability of internationally driven surgical efforts.METHODSBetween 2001 and 2016, a total of 246 patients with frontoethmoidal meningoencephaloceles were treated using a 1-stage extracranial approach by a single surgeon in the Department of Neurosurgery of the Yangon General Hospital in Yangon, Myanmar, initially assisted by European surgeons. Outcomes and complications were evaluated.RESULTSA total of 246 patients (138 male and 108 female) were treated. Their ages ranged from 75 days to 32 years (median 8 years). The duration of follow-up ranged between 4 weeks and 16 years (median 4 months). Eighteen patients (7.3%) showed signs of increased intracranial pressure postoperatively, and early CSF rhinorrhea was observed in 27 patients (11%), with 5 (2%) of them requiring operative dural repair. In 8 patients, a decompressive lumbar puncture was performed. There were 8 postoperative deaths (3.3%) due to meningitis. In 15 patients (6.1%), recurrent herniation of brain tissue was observed; this herniation led to blindness in 1 case. The remaining patients all showed good to very good aesthetic and functional results.CONCLUSIONSA minimally invasive, purely extracranial approach to frontoethmoidal meningoencephalocele repair may serve well, especially in middle- and low-income countries. This case series points out how the frequently critiqued lack of sustainability in the field of humanitarian surgical missions, as well as the often-cited missing aftercare and dependence on foreign supporters, can be circumvented by meticulous training of local surgeons.

Background Perception of beauty is influenced by geographic, ethnic, cultural, and demographic factors. However, objective measurements remain the foundation for aesthetic evaluations. In the quest to better define the "ideal" female buttock, this study assumes interdependence among variables such as country of residence, sex, age, occupation, and aesthetic perception, yielding a waist-to-hip ratio that appears most pleasing across most cultures and geographic locations. Methods An online survey was designed. Modifiable ranges of buttock sizes were achieved by means of digital alteration, enabling participants to interactively change the size and waist-to-hip ratio of a single model's buttocks. The questionnaire was translated into multiple languages and sent to more than 9000 plastic surgeons and to the general public worldwide. Demographic data were collected, and analysis of variance was used to elucidate buttock shape preferences. Results A total of 1032 responses were gathered from over 40 different countries. Significant differences regarding preferences for buttock size were identified across the respondents. Overall, 404 of 1032 of survey takers (39 percent) chose the 0.7 waist-to-hip ratio to be their ideal. Significant relationships were distilled between sex, age, self-reported ethnicity, plastic surgeons' country of residence, and ethnic background. For example, surgeons in Latin America preferred the largest buttocks, followed by surgeons in Asia, North America, and Europe, with non-Caucasians preferring larger buttocks than Caucasians. Conclusion There seems to exist a global consensus regarding the ideal waist-to-hip ratio; however, multiple other factors impact the aesthetic perception of the buttocks significantly.

Background Breast augmentation surgery remains the most frequently performed aesthetic surgical procedure worldwide. However, many variations exist regarding preoperative planning, surgical management, and postoperative care. Objectives The goal was to evaluate current trends and practices in breast augmentation, with a focus on international variability. Methods A questionnaire was sent to over 5000 active breast surgeons in 44 countries worldwide. The survey inquired about current controversies, new technologies, common practices, secondary procedures, and surgeon demographics. The findings and variations were evaluated and correlated to evidence-based literature. Results There were a total 628 respondents equaling a response rate of approximately 18%. While certain approaches and common practices prevail also on an international basis, there exist several geographic controversies. For example, while almost fifty percent of surgeons in the United States and Latin America never use anatomically shaped implants, in Europe and Oceania most surgeons use them. Similarly, in Latin America, Europe, Asia, and Oceania, over 80% of surgeons use silicone implants only, whereas in the United States only 20% use them - meanwhile US surgeons use the largest implants (78% > 300 cc). Internationally dominant practice preferences include preoperative sizing with silicone implants, as well as the use of inframammary incisions and partial submuscular pockets. Conclusions Significant differences exist when comparing most common surgical breast augmentation approaches on an international basis. While certain techniques seem to be universal standards, there still remain several controversies. Further standardizing this most common aesthetic surgical procedure according to evidence-based guidelines will help to improve outcomes.

Pilonidal disease can be treated medically; however, surgical excision remains the gold standard. Nonetheless, all current surgical approaches are still associated with potential for tissue loss, wound healing disorders, and high rates of recurrence. Aim of this study is to assess the long-term outcomes of the minimal-invasive pit-picking operation in comparison to the well-established technique of Karydakis flap-closure. Medical records of all patients undergoing either Karydakis flap-closure or the pit-picking operation for pilonidal disease at our department were reviewed retrospectively. A total of 101 patients were treated either by excision and Karydakis flap-closure (n = 62) or by the pit-picking operation (n = 39). Mean follow-up time was 65.5 (range: 38-101) months, including data collection using a standardized questionnaire. Analysis of the outcomes revealed no significant differences between the Karydakis flap-closure- and the pit-picking groups; however, the latter was associated with faster recovery, no need for hospitalization and overall low complication rates. In summary, the main advantages of the pit-picking operation lie in its' outpatient character, the simplicity of the procedure, low complication rates, short recovery time, and predictably good results.

Macrostomia is a rare facial cleft, with an incompletely described pathogenesis. This series highlights cases of isolated macrostomia presenting with several distinct phenotypes. We examine phenotypic differences in macrostomia patients, to further elucidate the etiopathogenesis.We performed a retrospective review of macrostomia patients evaluated during a 10-year period. Patient demographics and clinical features are reported.We identified 25 macrostomia patients (13M/12F). Right-sided macrostomia occurred in 15, left-sided macrostomia occurred in 6, and bilateral macrostomia occurred in 4 patients. Of the bilateral cases, 100% existed in isolation of craniofacial microsomia (CFM) or other craniofacial abnormalities. Twelve patients presented with macrostomia in isolation of CFM; in this subgroup, the male-to-female ratio was 1:1. Bilateral macrostomia was present in 33% of patients. Unilateral macrostomia occurred more often on the right (5:2). Phenotypes included simple unilateral or bilateral macrostomia (67%), macrostomia associated with severe diastasis of the cheek musculature (8%), macrostomia associated with lateral facial clefts (17%), and diastasis of cheek musculature without significant macrostomia (8%).Macrostomia seen in isolation of CFM presents in phenotypically distinct forms. It is unlikely that a single mechanism is responsible for this range of phenotypes. We believe that both intrauterine trauma and failure of fusion of the mandibular and maxillary processes secondary to an aberration in FGF8 function are responsible. Additionally, diastasis of facial musculature may result from delayed fusion and subsequent decreased mesodermal penetration of the mandibular and maxillary processes.