Scientific Abstract Presentations: Global Partner E-Posters (Not for CME) Thursday, October 9 Thu, Oct 9 9:30 a.m.-5:00 p.m. CDT

Background The eye is an important component of facial aesthetics and blepharoplasty can play a vital role in facial harmonization and aging process. The key to a successful eyelid surgery is a careful analysis of the face, a carefully conceived surgical plan and meticulous operative technique. Blepharoplasty alone or combined with other cosmetic surgeries such as brow lifting or facial lifting or other facial and skin rejuvenation such as fat grafting represents the best approach in these cases for optimal results [1] . Objectives The purpose of this study was to utilize a database to provide an overview of the upper and lower eyelid blepharoplasty techniques, to analyze the surgical outcomes and complications of blepharoplasty. Material and Methods This retrospective study case-series included patients who underwent upper and lower blepharoplasty in a private clinic in Tirana, from September 2019 to September 2024. Patients were stratified according to data such as age, gender, surgical technique and history of smoking. Type of anesthesia and postoperative and long term complications were reviewed for every patient. Exclusion criteria were any of the following: thyroid eye disease, myasthenia gravis, myotonic dystrophy, pregnancy, blepharoptosis, dry eye syndrome, previous upper eyelid surgery or trauma. Simple descriptive statistics were utilized to report the data of the sample. Data are presented as frequency tables and percentages. Results The study included 287 patients age 28-77 years old. The mean age was 51,69 years old. Female rate was 78% (224) and male 22% (63), with a significantly higher predominance in females undergoing blepharoplasty. According to our study, 155 cases (54%) were upper eyelid blepharoplasty, 44 (15,3%) lower blepharoplasty, and 88 (30,7%) were combined. Local anesthesia with sedation was used in 265 (92,3%) of cases, followed by local anesthesia in 11(3,8 %) and general anesthesia in 10 (3,5%) of cases. All blepharoplasties were performed by the same surgeon. Skin excision was performed in 117 of cases (40.8%), fat pads removal was performed in 158 cases (55%) and only in 12 cases (4.2%) fat removal was accompanied by autologous fat grafting according to their preoperative assessment. None of the patients underwent muscle excision. Patients were followed for an average of 4.2 months (range, 1-12months). Age group that had more complications was 35-49 years old. The most common complication was cyst 14 patients (4,9%). In our study 29,6% had a personal smoking history. There was a statistically higher rate of complications in smokers (p=0,0003). Conclusions We demonstrated that blepharoplasty is a procedure with a high satisfaction among the patients, with a complication rate of 14,6%. It's an excellent surgical procedure, when properly indicated. According to our study smoking history is a risk factor for postoperative complications when performing a blepharoplasty. With appropriate counseling, planning and proper surgical technique, good aesthetic results can be achieved. Nevertheless the goal remain the same, to achieve a youthful and natural look of the periorbital region. References: 1.Jacono AA, Moskowitz B. Transconjunctival versus transcutaneous approach in upper and lower blepharoplasty. Facial Plast Surg. 2001;17:21–8. doi: 10.1055/s-2001-16366.

BACKGROUND: Blepharospasm (BEB) and hemifacial spasms (HFS) are characterized by short or persistent, synchronous, intermittent contractions of the facial muscles, with botulinum toxin type A (BTxA) being the first-line treatment. BEB typically begins in both eyes, whereas HFS is known to progress to the contralateral hemiface in 0.6 to 3% of cases1. However, there is a lack of literature describing the progression of HFS during treatment with BTxA. The objective of this study is to describe the epidemiology and long-term evolution of BEB and HFS cases treated with BTxA. METHODS: We followed 95 facial spasms patients (79 females, mean age 62.19 ± 10.31 years) treated with BTxA from May 2003 to December 2023. The following data were collected: etiology; duration of the disease before treatment; treatment duration; date and number of the corresponding treatment session; affected side; presence of synkinesias; and evolution to cure or bilateral involvement. BTxA was administered to both hemifaces following a previously established institution protocol2,3. We used the Student's t-test and Mann-Whitney test to evaluate the time to progression to the ipsilateral and contralateral hemiface. RESULTS: 1212 applications of BTxA were performed during the study, with an average of 12.8 ± 8.5 sessions per patient. Fifteen patients had BEB and the remaining had HFS. The primary etiology was idiopathic (92%). Our case series revealed: family history (10.5%), synkinesias (15.7%), facial paralysis (10.2%) and nocturnal spasms (30.5%). In 9 out of 15 cases, BEB was bilateral; among the unilateral cases, two resolved after two sessions of BTxA, while one progressed to bilateral involvement. In 55% of HFS cases, the disease started in one eye, with all cases progressing to the ipsilateral hemiface at a mean time of 1.14 ± 1.31 years. In all other patients, the disease began affecting the entire hemiface. Subsequently, in 28 patients (35%), there was progression over a longer time period (10.1 ± 6.74 years, p < 0.01) to the contralateral eye; of these, 10 patients (12.5%) progressed to the entire contralateral hemiface. The time of progression to the contralateral hemiface was shorter in patients receiving treatment with the toxin (3.3 ± 2.3 years) compared to untreated patients (9.0 ± 5.5 years) (p = 0.02). CONCLUSION: This study provides insights into the progression timeline of symptoms that have not been previously described. Treatment with BTxA did not prevent the progression of BEB and HFS. The protocol used may be associated with a more accelerated progression of HFS to the contralateral eye.

REFERENCES: 1. Felício AC, Godeiro-Junior C de O, Borges V, Silva SM de A, Ferraz HB. Bilateral hemifacial spasm: A series of 10 patients with literature review. Parkinsonism Relat Disord. 2008;14(2):154-156. 2. Salles AG, Teixeira NH, Mattos FTB, et al. Protocol for bilateral application of botulinum toxin type A to avoid asymmetry during treatment of hemifacial spasms. Rev Bras Cir Plást. 2015;30:228-234. 3. Salles AG, Toledo PN, Ferreira MC. Botulinum Toxin Injection in Long-Standing Facial Paralysis Patients: Improvement of Facial Symmetry Observed up to 6 Months. Aesth Plast Surg 2009; 33:582–590.

BACKGROUND: Hemifacial spasm (HFS) and blepharospasm (BEB) are among the most prevalent and debilitating craniofacial movement dystonias that originate from the peripheral nervous system. Although botulinum toxin type A (BTxA) is regarded as the standard treatment, myectomy of the periorbital muscles is indicated in cases of refractoriness or disease progression. This study aims to evaluate the efficacy of a combined treatment approach utilizing myectomy and BTxA for the management of severe facial spasms. METHODS: 11 patients (10 females, mean age 65.18 ± 9.06 years) diagnosed with facial dystonias were assessed between January 1996 and December 2023. Five patients had previously received BTxA treatment and were referred for myectomy due to treatment refractoriness. Myectomies followed the technique of Gillium and Anderson1. The remaining six patients commenced BTxA therapy after myectomy. BTxA was administered to both hemifaces in accordance with our institutional protocol to avoid facial asymmetries2,3. In patients diagnosed with BEB, bilateral resection of the orbicularis oculi muscle was performed, while preserving the pre-tarsal portion. Additionally, the corrugator, depressor supercilii, and procerus muscles were excised. In the case of HFS, surgical intervention was conducted on the affected side, and bilaterally in instances of bilateral involvement. RESULTS: Among the patients, three presented with bilateral BEB, while the remainder were diagnosed with HFS. A mean reduction of approximately 19.4 ± 4.05% (range: 13.3 to 24.7%) in the required BTxA dosage for spasmodic control of the periorbital muscles was observed in all five patients who underwent surgical intervention due to treatment refractoriness, all of whom were diagnosed with HFS. Furthermore, in addition to the reduction in the pre-tarsal BTxA dosage, notable alleviation of lower facial and cervical spasms was observed subsequent to periorbital myectomy. For the other six patients who experienced recurrent spasms post-myectomy, the three individuals who began BTxA treatment within one-year post-surgery included one patient (BEB) who achieved complete remission of spasms after two treatment sessions, while the other two (one BEB and one HFS) exhibited a decrease in the BTxA dosage necessary for spasmodic control. Conversely, the remaining three patients (two with BEB and one with HFS), who commenced treatment after one year, required significantly higher doses of BTxA, consistent with the average dosages recorded in our cohort2. No complications related to the myectomy procedure were noted. CONCLUSION: The association of myectomy and BTxA injections is imperative for the effective management of patients with severe facial dystonia. Myectomy yields favorable outcomes when appropriately indicated for cases unresponsive to BTxA treatment, and contributes to a reduction in the necessary BTxA dosage to effectively control facial spasms.

REFERENCES: 1- Gillum WN, Anderson RL. Blepharospasm surgery. An anatomical approach. Arch Ophthalmol. 1981;99(6):1056-1062. 2- Salles AG, Teixeira NH, Mattos FTB, et al. Protocol for bilateral application of botulinum toxin type A to avoid asymmetry during treatment of hemifacial spasms. Rev Bras Cir Plást. 2015;30:228-234. 3- Salles AG, Toledo PN, Ferreira MC. Botulinum Toxin Injection in Long-Standing Facial Paralysis Patients: Improvement of Facial Symmetry Observed up to 6 Months. Aesth Plast Surg. 2009; 33:582–590.

Many young women seek consultation for breast asymmetry and request bilateral breast augmentation. However, during the examination, it is crucial to investigate the presence of any underlying thoracic deformity that may contribute to the asymmetry. In cases where breast asymmetry is associated with a thoracic defect, such as pectus excavatum, breast surgery alone may be insufficient or even ineffective (1).

This case report presents a woman with breast asymmetry and asymmetric pectus excavatum. At the age of 15, she initially underwent breast augmentation with mastopexy using implants of different sizes in an attempt to mask the underlying chest deformity. However, two years later, she underwent a Nuss procedure for pectus excavatum, which resulted in incomplete correction and persistent asymmetry.

By the age of 32, she remained dissatisfied with the outcome due to capsular contracture and persistent breast and chest asymmetry. To achieve a more effective correction, we decided to start over, first removing the contracted implants and prioritizing the correction of the thoracic deformity. This was accomplished using a custom-made silicone sternal implant designed with 3D technology. A chest CT scan allowed for the creation of a virtual replica of the patient's anatomy, enabling the design of a personalized silicone prosthesis with millimeter precision. The implant was positioned within the thoracic defect, placed under the pectoralis major muscle. Six months later, with a restored and more symmetric chest wall, we proceeded with breast augmentation surgery, achieving a more harmonious and natural result.

The use of custom-made 3D silicone implants appears to be a highly promising approach in reconstructive plastic surgery, offering essential support in cases of breast asymmetry associated with thoracic malformations.

(1) Chavoin JP et al. Le sein et les malformations thoraciques: stratégie chirurgicale et implants [Breasts and congenital chest-wall deformities:Surgical strategy with 3D implants]. Ann Chir Plast Esthet. 2022;67(5-6):404-413.doi:10.1016/j.anplas.2022.07.010

Purpose: The anterolateral thigh (ALT) free flap has been widely used in reconstructive surgery due to its consistent vascular anatomy and adaptability. This study highlights its versatility in reconstructing defects across various anatomical regions, emphasizing its functional and structural benefits. The sensate anterolateral thigh flap is typically described as innervated by the lateral cutaneous femoral nerve (1). The motor nerve to the vastus lateralis muscle is commonly encountered in close proximity to the vascular pedicle (2). We have aimed to provide a good sensory or a functional result after reconstruction by means of coaptation of one of these nerves in various reconstructive procedures.

Methods and Materials: A retrospective analysis of 52 patients who underwent ALT-free flap reconstruction from January 2020 to December 2024 was conducted. Indications included reconstruction for oral onco-resection, scalp defects, foot and leg defects, scrotal reconstruction, post-burn contracture release for hand and forearm defects, palatal defects, and hemifacial atrophy (Parry-Romberg syndrome). Functional modifications included lingual nerve coaptation with the lateral cutaneous femoral nerve for neo-tongue sensation after glossectomy and hypoglossal nerve coaptation for motor innervation of the vastus lateralis muscle to prevent atrophy, which acts as a support and filler in oral and maxillary reconstruction. Foot and hand defects were also reconstructed with sensate flaps. The demographic information, pathologic diagnosis, defect location, flap size, flap anatomy, technique of flap harvest, recipient vessels used, and flap's form and functional outcomes were evaluated postoperatively.

Experience and Follow-up: All 52 patients underwent ALT flap reconstruction with follow-ups ranging from 6 to 24 months. Flap success rate, functional restoration, sensory outcomes and complication rates were analyzed.

Results and observations: The ALT flap demonstrated adaptability in terms of thickness, skin paddle size, and incorporation of muscle and nerve components. Functional integration improved outcomes, particularly in oral reconstruction, where motor-innervated vastus lateralis muscle provided structural support and prevented atrophy. The anatomical origin of perforators supplying the flap was noted from the descending branch of lateral circumflex femoral in 86.5% and from the oblique branch in 13.5%. Musculocutaneous perforators accounted for 52.5%, septocutaneous for 31.2%, and musculo-septocutaneous for 28.7%. The overall flap survival rate was 94.2%. Follow-up revealed good functional outcomes, including speech and deglutition in oral reconstruction, and a good sensory outcome in sensate flap for hand and foot reconstruction.

Conclusions: The ALT flap is a highly reliable and customizable option for soft tissue reconstruction across multiple anatomical regions. Its ability to be harvested in various configurations, provide functional restoration, and minimize donor-site morbidity makes it a superior choice in many complex reconstructions with good functional outcomes.

References 1) Ribuffo D, Cigna E, Gargano F, Spalvieri C, Scuderi N. The innervated anterolateral thigh flap: anatomical study and clinical implications. Plast Reconstr Surg. 2005 Feb;115(2):464-70. doi: 10.1097/01.prs.0000149481.73952.f3. PMID: 15692351. 2) Casey WJ III, Rebecca AM, Smith AA, Craft RO, Hayden RE, Buchel EW. Vastus lateralis motor nerve can adversely affect anterolateral thigh flap harvest. Plast Reconstr Surg. 2007;120(1):196–201 17572563

Purpose: The paramedian forehead flap is widely used in orbital reconstruction for defects involving the medial canthus and eyelids. However, its simultaneous bilateral use in complex orbital reconstructions is scarcely reported. This study highlights the novel application of bilateral paramedian forehead flaps in managing a complex orbital defect following oncologic resection.

Methods and Materials: A 56-year-old diabetic female presented two days post-excision of basal cell carcinoma with a full-thickness right orbital defect involving the medial half of the upper eyelid, entire lower eyelid, and medial orbital wall, with the globe in situ. Reconstruction was planned using:

Ipsilateral paramedian forehead flap for resurfacing the medial orbital wall. Contralateral extended paramedian forehead flap combined with buccal mucosal graft for the lower eyelid. Mobilized conjunctiva for inner lining and split-thickness skin graft for outer coverage of the upper eyelid.

The forehead donor areas were resurfaced using split-thickness skin grafts. Three weeks later, the contralateral forehead flap was divided and inset into the donor site of the ipsilateral flap to optimize contour and minimize scarring.

Results: Postoperative recovery was uneventful, with optimal eyelid movement, excellent flap survival, and minimal donor site morbidity. Both forehead flaps demonstrated excellent vascularity, pliability, and conformity to the defect's three-dimensional architecture. The final outcome yielded aesthetic symmetry and functional restoration without any complications.

Discussion: The use of bilateral paramedian forehead flaps in orbital reconstruction is an innovative technique that capitalizes on the flap's proximity, pliability, and excellent vascularity. This method ensures comprehensive coverage of multiple subunits while minimizing donor site morbidity. The technique not only restores anatomical form but also preserves function, particularly in patients with compromised healing due to comorbidities like diabetes. Using flaps from a single anatomical region improves cosmetic outcomes without compromising flap viability or function.

Conclusions: Bilateral paramedian forehead flaps offer a versatile and reliable solution in managing complex orbital defects involving multiple aesthetic subunits. This technique maximizes the reconstructive potential of the forehead flap, delivering optimal functional and aesthetic outcomes with minimal complications.

[Purpose] Although flap complication due to vascular compromise is rare with patent anastomoses, it is devastating to breast reconstruction patients when it results in flap failure, which is reported to occur from 3-5% of free flap reconstructions. Intervention to prevent such complication occur as early as intraoperatively, but how these actions impact postoperatively have not been thoroughly investigated. Moreover, as preliminary studies discuss, the unpredictability of vascular compromise remains a challenge; even when surgeons implement early intraoperative interventions, the fate of the flap may be uncertain. This study evaluates the efficacy of these immediate corrective procedures and how intraoperative microsurgical procedures impact clinical outcomes such as complication and flap survival rate in free flap breast reconstruction.   

[Materials and Methods] A retrospective chart review of patients who underwent free flap breast reconstruction between April 2004 to June 2023 at a single institution was conducted. A cohort of free flaps with vascular compromise that received intraoperative repeat anastomosis was compared with those who did not undergo intraoperative intervention but returned postoperatively for repeat anastomosis. 

[Results]  A total of 3,521 patients with 6,245 flaps were reviewed. Of those, 273 flaps (186 flaps with intraoperative and 87 flaps with postoperative interventions) were included in our study. Demographics, comorbidities, and operative details such as flap types did not differ significantly in two cohorts. Intraoperative re-anastomosis cohort had significantly lower rates of surgical site infection, seroma, and fat necrosis (odds ratio [OR] 0.11, p<0.001; OR 0.30, p= 0.03; OR 0.27, p=0.01, respectively). Flap loss rate due to vascular compromise was also significantly lower in intraoperative group (OR 0.17, p<0.001). The rate of overall flap loss was found to be 0.93%. 

[Conclusion]  Findings from this comprehensive study indicate that proactive intervention in an intraoperative setting when vascular compromise is concerned is ideal as it optimizes clinical outcomes and flap success rate. As a result, highlighting the importance of early interventions for managing vascular compromise promotes refinement of both surgical skills and decision-making among surgeons, ultimately enhancing patient safety in free flap breast reconstruction. 

Introduction: Gigantomastia in juvenile patients is a rare occurrence with very few reports found in the literature. It's pathophysiology has yet to be elucidated, but an end organ abnormal response has been shown in almost all cases. We will present the case of a 12 year old premenarche girl presenting with bilateral gigantomastia and our management of the case. Case report:

A 12 years old, otherwise healthy female patient presented to our facility with immense growth of her breasts occuring over the pas 6 months. She did not have any previous complaints. Her weight was 60 kg and her height 150 cm. The growth had started slowly, but after the visit she was advised to take Vitamin E, which, according to the parents, caused a very rapid overgrowth of the breasts causing serious discomfort and withdrawal from social life. She was premenarche with very little secondary sexual features development.

Upon inspection, a very distressed child was noted. Bilateral severe gigantomastia was obvious. Inflammation of the breasts, enlargement of the superficial venous system and notable kyphosis were seen. Her temperature was subfebrile and her breasts very sore barely allowing us to touch them. Management:

The patient was consulted with the senologist, pediatrician and plastic surgeon. An MRI was performed revealing no giant fibroadenoma or phylloides. A true cut biopsy revealed Pseudoangiomatosis Stromal Hyperplasia, possibly in the terrain of an abnormal en organ response. A thorough explanation was made to the child and the parents and a decision for a bilateral subcutanous mastectomy and recosntruction with bilateral implants was made. In choosing the size of the implants, we decided to go with a smaller size keeping in mind the age and body size.

A wise pattern excision was employed for the resection. The NAC were excised and later used as free grafts. 12 kg of tissue were resected during the surgery. This made up for 20 % of her body weight. She received blood transfusion and albumin during the surgery. She was kept in the ICU overnight. Bilateral 250 cc smooth breast implants were placed under the muscle. The surgery time was 3 hours. Her drains remained in place for 72 hours.

Her postoperative course was uneventful with little loss on her NAC grafts. She was happy from the start and her body temperature returned to normal immediately after the surgery. She returned to school the next month with complete resolve of her symptoms. Discussion:

Juvenile gigantomastia is a very rare occurrence. Tamoxifen has been proposed as a first line management in these cases. Reduction mastoplasty has also been reported. We selected bilateral mastectomy as the case was very severe and the patient premenarch, worrying the parents she could need further surgery after her period. The results were satisfactory and the patient returned to her normal childhood and school after a month.

Author: Dr Doran Kalmin1

1 Monash Health, Melbourne, Australia

Introduction: The appearance of hands is an accurate isolated predicter of a person's age.1 Age related changes in the hand include thinning of the dermis, epidermis and fibrofatty tissue, pigmentation from photodamage and trauma, prominent veins, tactile roughness, intrinsic muscle atrophy and arthritis. Increasingly, procedures targeting the aesthetic appearance of hands makes up a growing proportion of hand surgeons' work with innovative treatments available to address the ageing hand.

Methods: The MEDLINE database was searched to identify relevant studies. Search terms include: "hand rejuvenation" "hand ageing" "fat grafting" "dermal filler" and "lasers". Studies published from 2000 to 2024 were included.

Results 96.7% of patients seeking hand rejuvenation are females. Topical treatments including sodium copper chlorophyllin, alpha-hydroxy acid and retinol that reverse photodamage and add moisture. Results are unpredictable with short longevity. Laser therapies improve deteriorating skin quality and pigmentation, the two most effective are the Q-switched ruby laser and Intensive Pulsed Light (IPL). Dermal fillers and fat grafting improve the appearance of tendons and veins. These have high patient satisfaction rates with low complication rates. Most authors recommend filler and fat be injected in the dorsal superficial lamina layer to prevent damage to sensory nerves and veins.2

Conclusions Hand rejuvenation is a growing area with treatment options generally very safe with rare complications and have high patient satisfaction. The most common methods in the literature which are readily available in Australia include dorsal hand fat grafting, injectable fillers, topical threapies and skin laser treatments.

References 1. Bains RD, Thorpe H, Southern S. Hand aging: patients' opinions. Plast Reconstr Surg. 2006;117(7):2212-8. 2. Conlon CJ, Abu-Ghname A, Davis MJ, Ali K, Winocour SJ, Eisemann ML, et al. Fat Grafting for Hand Rejuvenation. Semin Plast Surg. 2020;34(1):47-52.

The study focuses on breast reshaping surgery in women who have undergone massive weight loss (MWL) following bariatric surgery, evaluating the use of different types of breast implants and their outcomes. Conducted retrospectively from January 2016 to December 2022 at a public hospital, the study included adult female patients who underwent breast reshaping with implants. Exclusion criteria encompassed weight loss through diet/exercise alone, history of breast cancer, poorly managed comorbidities, and significant psychiatric disorders. The surgeries were performed by a consistent surgical team, with implant selection tailored to each patient based on pre-operative assessments of breast ptosis and individual expectations. Data analysis included patient demographics, surgical specifics, and post-operative complications. Among the 56 patients studied, 38 received polyurethane implants and 18 received textured implants. The study found no significant differences between these groups regarding age, initial weight, BMI, weight loss, return to normal activities, patient satisfaction, implant positioning, or complication rates. The overall complication rate was 37.5%, with no significant variation between the two implant types. The study underscores the challenges of achieving optimal results in post-MWL breast reshaping due to unique deformities and higher risks of complications. Despite ongoing debate over ideal implant types, this research indicates no clear superiority between polyurethane and textured implants. Future research directions should explore newer ultra-light implants and compare implant-based techniques with autologous tissue approaches to further refine outcomes in this patient population.

Introduction Salivary fistulas are postoperative complications with a wide incidence ranging from 2% to 30% in facial surgeries(1). Reported risk factors include radiotherapy, chemotherapy, primary tumor stage, malnutrition and surgery duration(2). In a surgical bed contaminated with bacteria and saliva, surgical reinterventions and flap failures can result in large tissue defects, increasing morbidity and mortality (1). This case focuses on a postoperative salivary fistula as a complication following facial reconstruction after resection of a skin carcinoma, highlighting its conservative management, the incorporation of nutritional guidelines to reduce saliva production and the outcomes achieved. Materials and Methods A 52-year-old male patient with a high-grade squamous cell carcinoma (SCC) of the right cheek region, with a one-year evolution. A full-thickness surgical resection was performed, including the oral mucosa, with clear margins. Reconstruction was subsequently carried out using a Dufourmentel flap. On the eighth postoperative day, a cutaneous salivary fistula was diagnosed (amylase 15,000 U/mL). Conservative management was initiated, starting with antisialogogue therapy using paratropine at a dose of 4 drops every 4 hours, in combination with a soft diet with reduced intake and the elimination of saliva-stimulating foods such as citrus, spicy, and acidic items. Intake, visual exposure, and olfactory stimulation from these foods were also restricted. Additionally, physiotherapy guidelines were implemented to improve drainage and minimize pressure on the fistula. Results The patient was discharged on the sixteenth day postoperative. The salivary fistula completely resolved after 8 weeks of interdisciplinary management, preserving facial symmetry and normal regional function, with no recurrence or complications over a 9-month follow-up period. Discussion Antisialogogues how paratropine reduces saliva production, facilitating spontaneous resolution (1). Somatostatin and octreotide promote the closure of pharyngocutaneous fistulas(3). Negative pressure therapy with a continuous suction system reduces saliva accumulation and infection risk (4). Botulinum toxin shortens fistula closure time(1). Surgery or interventional procedures are reserved for refractory cases(1). Conclusion This case underscores the importance of an interdisciplinary conservative management approach for postoperative salivary fistulas. The incorporation of nutritional guidelines serves as a valuable adjunct to reducing saliva production and promoting healing. Additionally, it reaffirms the versatility of the Dufourmentel flap in oncologic facial reconstructions. Prospective studies could help establish standardized protocols for this complication. References: Belcastro A, Reed W. The Management of Salivary Fistulas. Semin Plast Surg. 2022 Dec 3;37(1):4-8. doi: 10.1055. Bozikov K, Arnez ZM. Factors predicting free flap complications in head and neck reconstruction. J Plast Reconstr Aesthet Surg. 2006;59:737–42. doi: 10.1016. Cohen J, Reed W, Foster MW. Octreotide may improve pharyngocutaneous fistula healing through downregulation of cystatins: A pilot study. Laryngoscope Investig Otolaryngol. 2022 Nov 28;8(1):113-119. doi: 10.1002. Chang HP, Hong JW, Lee WJ. Incorporating a continuous suction system as a preventive measure against fistula-related complications in head and neck reconstructive surgery. Arch Plast Surg. 2018 Sep;45(5):449-457. doi: 10.5999.

Introduction: Atypical fibroxanthoma (AFX) is a rare mesenchymal-derived dermal neoplasm with intermediate malignancy. Its histogenesis remains unknown. It predominantly affects elderly individuals, with solar exposure being the primary risk factor. The prognosis is excellent following complete resection of the lesion (1). We present the case of a 30 year old male patient with HIV who developed a large tumor in the scapular region. Histology and immunohistochemistry were consistent with an AFX (Atypical Fibroxanthoma). The coverage defect following the excision of the lesion posed a therapeutic challenge due to its size. It was resolved using a meshed split-thickness skin graft. Accurate diagnostic orientation is crucial for guiding appropriate treatment and determining the most viable reconstruction approach. Surgical treatment is typically definitive. Metastasis is uncommon(2). Materials and Methods: A retrospective analysis was conducted on the clinical case of a 31-year-old male patient with HIV undergoing treatment and a history of smoking. He presented with a 15 x 15 cm nodular mass in the left scapular region, characterized by firm consistency, lack of deep plane adherence, irregular borders, and a tendency to bleed, with a 3-year progression. Given the significant coverage defect and the complexity of the affected area, a partial-thickness mesh skin graft obtained from the anterior side of the leg was used for coverage. Immunohistochemical profiling was consistent with AFX. Discussion: Research has explored the utility of LN-2 (a 35 kDa protein expressed in B lymphocytes) to distinguish AFX and achieve a definitive diagnosis (3). The clinical presentation in our patient was atypical, as he was young and the affected area (scapular region) was not sun-exposed. The definitive diagnosis was achieved through histopathology and immunostaining, without the use of LN-2, which is less Accessible (4). Large tumors often leave significant coverage defects, posing reconstruction challenges. Partial-thickness skin grafts are effective for covering extensive areas, providing good aesthetic and functional outcomes, and are reproducible (5). Conclusion: AFX is a rare tumor with intermediate malignant potential, generally exhibiting an excellent prognosis post-resection. However, patients should be monitored every 6 months due to the risk of recurrence, metastasis, and the development of additional skin tumors.

References:

1. Romera E, Minaudo C, Vigovich. Vista de Fibroxantoma atípico y sarcoma pleomórfico dérmico: distintos grados de malignidad de una misma entidad [Internet].2023 [citado el 13 de febrero de 2025]. Disponible en: https://dermatolarg.org.ar/index.php/dermatolarg/article/view/2451/1361
2. Kolb L, Schmieder GJ. Atypical fibroxanthoma. En: StatPearls. Treasure Island (FL): StatPearls Publishing; 2025. [citado el 13 de febrero de 2025]. Disponible en: https://www.ncbi.nlm.nih.gov/books/NBK459342/
3. De la Fuente EG, Sols M, Pinedo F, Álvarez-Fernández JG, Vicente FJ, Naz E, et al. Fibroxantoma atípico. Estudio clinicopatológico de 10 casos. Actas Dermosifiliogr [Internet]. 2005 [citado el 13 de febrero de 2025];96(3):153–8. Disponible en: https://www.actasdermo.org/es-fibroxantoma-atipico-estudio-clinicopatologico-10-articulo-13073612
4. McClure E, Michael J, Ayushi P, et al. Atypical Fibroxanthoma: Outcomes from a Large Single Institution Series .2023 [citado el 13 de febrero de 2025]. Disponible en: http://file:///C:/Users/medico/Downloads/10.1177_10732748231155699.pdf
5. Iñigo C, Castillo J, Manuel L. Atypical fibroxanthoma.2017 [citado el 13 de febrero de 2025]. Disponible en: http://file:///C:/Users/medico/Downloads/1130-0558-maxi-39-04-00250.pdf

SCALP AVULSION RECONSTRUCTION SECONDARY TO DOG BITE: A CASE REPORT Eva Peron Hospital, San Martin, Province of Buenos Aires, Argentina.

Introduction Dog bite injuries significantly impact public health and the physical integrity of the population due to their frequency, severity, and sequelae. Dogs are responsible for 80-90% of bites (1) resulting in various types of injuries in different locations. This case report aims to highlight the resources available in a public hospital for the treatment of extensive dog bite injuries. Materials and Methods A 22-year-old male patient with cognitive delay was referred from a rural hospital with multiple dog bites, presenting with over 50% scalp avulsion and exposure of the cranial vault. A combination of perforations of the external table of calvaria and skin grafting was performed. Cranial reconstruction facilitated the generation of granulation tissue over the exposed periosteum. Complete coverage was achieved using multiple partial-thickness skin grafts obtained from inner thigh with the electric dermatome available in our institution. Results The reconstruction of complex scalp injuries requires the utilization of surgical techniques that allow the coverage of the primary defect to prevent infection and heat loss, as to obtain an acceptable aesthetic and functional outcome (2). Discussion We have various procedures available, ranging from primary closure of the defect, secondary intention healing, skin grafts, local, regional, and free flaps, tissue expansion and micro-surgical re-implantation (3). In this case, a combination of perforations of the external table of calvaria and partial skin grafting was chosen, which is an effective therapeutic approach for scalp reconstruction when local flaps are not feasible (4). Conclusions Dog bites are distressing, traumatic, and can sometimes result in disfiguring injuries. This case review evaluates that, although it may not be the final or definitive treatment for the case resolution, partial skin grafts have the advantage of rapid healing, less pain, and better scar formation, making them an important tool for reconstructing such injuries with favorable and satisfactory aesthetic-functional outcomes (5).

References 1. Mendoza J.M., Chi J.J. Reconstruction of animal bite injuries to the head and neck. current opinion in Otolaryngology & Head and neck. Surgery. 2019;27(5):407–412. doi: 10.1097/MOO.0000000000000564. 2. Desai S.C., Sand J.P., Sharon J.D., Branham G., Nussenbaum B. Scalp reconstruction: an algorithmic approach and systematic review. JAMA facial plastic surgery. 2015;17(1):56–66. doi: 10.1001/jamafacial.2014.889. 3. Wechselberger G., Pumberger P., Schwaiger K., Wimbauer J., Köninger F., Russe E., Heinrich K. Microsurgical scalp replantation: lessons learned and technical considerations. Plast. Reconstr. Surg. Glob. Open. 2022;10(3) 4. Schlottmann F., Bucan V., Vogt P.M., Krezdorn N. A short history of skin grafting in burns: from the gold standard of autologous skin grafting to the possibilities of allogeneic skin grafting with immunomodulatory approaches. Medicina. 2021;57(3):225. 5. Shahdadi H, Shahrahmani F, Rezayi S, Hashemian M. Successful partial-thickness skin grafting in a pediatric scalp avulsion after dog bite: A case report. Int J Surg Case Rep. 2024 Dec;125:110506. doi: 10.1016/j.ijscr.2024.110506. Epub 2024 Oct 23. PMID: 39461134; PMCID: PMC11542003.

Background The management of complex wounds, particularly those involving exposed bone, tendons, metalware, or irradiated tissue, remains a challenge in reconstructive surgery. NovoSorb® Biodegradable Temporising Matrix (BTM) offers an alternative approach to conventional grafts and flaps, facilitating vascularisation and graftable neo-dermis formation. However, its efficacy in complex wounds remains unclear.

Purpose The aim of this systematic review and meta-analysis was to evaluate the efficacy and limitations of BTM in complex wound management.

Methods A systematic search of EMBASE, OVID, SCOPUS, and PubMed was conducted to identify human studies reporting BTM use in wounds with exposed bone (with or without periosteal stripping), exposed tendons (denuded or non-denuded paratenon), metal implants, fractures, or radiotherapy exposure. Two independent reviewers screened and selected studies. Data on patient demographics, wound characteristics, treatment outcomes, and complication rates were extracted and analyzed. Multivariate logistic regression was performed to assess factors influencing complications and treatment success.

Findings A total of 34 studies comprising 208 patients met the inclusion criteria. The median age was 58.5 years, with trauma (28.4%), malignancy (19.7%), and burns (16.8%) being the most common wound etiology. The lower extremity was the most commonly reported anatomical site (49.0%). Radiotherapy-exposed wounds had the highest complication rate (60.0%, p = 0.022). Exposed bone with periosteal stripping (33.3%) and exposed tendon with denuded paratenon (38.9%) led to higher complication rates than exposed bone with intact periosteum (20.9%, p = 0.295) and exposed tendon with intact paratenon (18.6%, p = 0.110) respectively, though not statistically significant. Across all cases, wounds with exposed bone with periosteal stripping and exposed tendon with denuded paratenon had significantly higher complication rates than non-denuded cases (40.0% vs. 21.8%, p = 0.011). Age was a significant risk factor for complications, with an odds ratio of 1.015 (p = 0.039), indicating that each additional year increased the likelihood of complications by 1.52%. Median BTM integration time was longer in complicated cases (45.0 days vs. 38.5 days, p = 0.097), suggesting a potential association between delayed integration and adverse outcomes.

Conclusions Increased complication rates in wounds with exposed bone with periosteal stripping, exposed tendon with denuded paratenon and irradiated wounds highlight the need for careful patient selection and clinical judgment. While BTM generally achieves good success rates, increased patient age and wound complexity adversely influence outcomes.

Background Australia has the highest incidence of Non Melanoma Skin Cancer in the world. Squamous Cell Carcinoma is the second most common tumour of the scalp and can present with advanced disease. We present our surgical experience of free flap reconstruction for scalp defects in a tertiary plastic surgery centre.

Methods Over a 10 year period, 2014 to 2024, we identified 324 patients who underwent major scalp reconstruction; of these we found 76 free flaps were performed.

Results The majority of patients were male (91%) with median age 72 years (range 35 to 89 years). Reconstruction was performed primarily for SCC (56 cases) followed by Pleomorphic dermal sarcoma (9), Osteoradionecrosis (7), Basal cell carcinoma (1), Burns (2) and Dermatofibrosarcoma Protuberans(1). The measured defect size ranged from 88x85cm to 220x120cm. The majority of reconstructions utilised Latissimus Dorsi (90%), Anterolateral thigh (9%) and Omentum (1%) flaps. The superficial temporal vessels were the predominant recipient vessels (82%). Mean ischemic time was 64 minutes. Pathological tumour clearance was achieved peripherally in 98% and deep in 84% of cases. Further cranium resection was conducted in the form of burring (34%), outer table resection (10%) and full thickness craniectomy (45%). Microsurgical outcomes noted flap survival in 97%. Complications included haematoma (6 cases) and infection (3 cases).

Conclusions
Our experience highlights the largest series of free flap reconstruction for the scalp. The patient cohort represent high-risk factors presenting with pathologically advanced tumours. We advocate a multidisciplinary approach and share our experience and lessons learned.

Free flap monitoring is crucial for early detection of vascular compromise as early intervention can save a compromised flap. Traditional clinical methods, such as tissue color assessment and capillary refill time, are less reliable in dark-skinned individuals so invasive procedures such as a pin prick test need to be performed at regular intervals. Thermal imaging offers a non-invasive, objective method for assessing perfusion in these patients Thermal imaging is a non-invasive, contactless technique that utilizes infrared technology to detect temperature variations in tissues, Studies have demonstrated its efficacy in early detection of vascular compromise, with temperature differences (ΔT) between the flap and adjacent skin serving as critical indicators. For instance, compromised flaps exhibit a higher ΔT compared to viable ones, and this difference is evident even before clinical signs manifest. However, factors such as ambient and patient temperature can influence accuracy. Despite these limitations, thermal imaging remains a promising tool for enhancing postoperative free flap monitoring across diverse patient populations and authors will present some cases of monitoring of free flaps using a handheld FLIR camera in dark-skinned individuals who had complex reconstructions with free tissue transfer. References:

1. Nelson Z, O'Neill L, Fisher AH, et al. Postoperative Detection of Free Flap Congestion in a Fitzpatrick Skin Type VI Patient using the FLIR Thermal Imaging Camera: A Case Report and Literature Review. Case Reports Plast Surg Hand Surg. 2022;9(1):1-5.
2. Singla P, Dixit PK, Kala PC, et al. Free Flap Monitoring Using Infrared Thermography: An Objective Adjunct to Clinical Monitoring. Indian J Plast Surg. 2023;56(2):178-184.
3. Chava S, Chava V, Reddy LV, et al. An Experimental and Clinical Study of Flap Monitoring with Infrared Thermal Imaging. Bioengineering. 2023;11(7):688.

ABSTRACT: Introduction The prevention of peritendinous adhesions after tendon repair is a significant challenge in hand surgery. The search for the "holy grail" to reduce postoperative peritendinous adhesions is ongoing. Our study is a prospective, double-blind, randomized case-control study using MatriDerm as an adhesion barrier after primary repair of the flexor digitorum profundus (FDP) tendon of the human hand in zone II. To our best knowledge, MatriDerm sheets had never been clinically used for this purpose before. Material and methods Between September 2021 and April 2024, we evaluated 40 patients with isolated FDP injuries. All tendons were repaired using a core and circumferential suture. MatriDerm is a single-layer dermal matrix composed of collagen and elastin (Skin and Health Care AG, Billerbeck, Germany) that has been previously proven effective in similar cases. Randomization was double-blinded into two groups of 20 patients. In the first group the repaired site was wrapped in MatriDerm, while in the second, the site was repaired without MatriDerm. Clinical and functional results were evaluated using the total active movement (TAM), ultrasound, and visual analog pain scale (VAS). The MatriDerm group showed a mean TAM of 82.1%, whereas that of the control group was 66.11%. According to the Mann-Whitney- U test, the MatriDerm group showed significantly higher values than the control group with a medium effect size (exact p=0.014, p<0.05, Pearson's r =0.36). Adhesion formation on ultrasound and pain scores were similar between the control and MatriDerm groups. Conclusion Our prospective, double-blind, randomized clinical study showed significantly better TAM outcomes in repaired tendons wrapped in MatriDerm. The promising results of this novel MatriDerm application in zone II flexor tendon repair must withstand testing in wider, adequately powered clinical trials in the future. Study Type: Prospective, Double-blind, Randomized, Clinical Study Keywords: Adhesion Barrier, Adhesion Formation, MatriDerm, Tendon, Gliding

Medical School University of Zagreb, Croatia University Hospital DUBRAVA, Department of Plastic Surgery, National Hand Trauma Center Corresponding Author: zlatkovlajcic@yahoo.com

Introduction: Breast cancer-related lymphedema affects 21.9% of patients. The role of breast reconstruction in lymphedema prevention remains unclear. This review aimed to assess the relative risk of breast cancer-related lymphedema after breast reconstruction compared to mastectomy and breast-conserving surgery, which has thus far been inconclusively assessed. Methods: We conducted a systematic review and meta-analysis following PRISMA guidelines. PubMed, EMBASE, Cochrane Central, and grey literature searches identified studies reporting lymphedema outcomes after mastectomy, breast-conserving surgery, and breast reconstruction. We calculated incidence rate ratios using random-effects models. Subgroup analyses compared reconstruction timing (immediate vs. delayed), types (autologous vs. implant-based), and immediate implant stages (one-stage vs. two-stage). Results: Twenty-three studies with 15,670 patients were included in the qualitative analysis, and 14 were included in the meta-analysis. Patients with breast reconstruction had a significantly lower risk of lymphedema than those without reconstruction (IRR = 0.58, 95% CI: 0.38–0.87, p < 0.001). However, this effect was less pronounced when only studies with baseline lymphedema measurements were included. We found no significant differences between autologous and implant-based reconstructions, immediate and delayed reconstruction, or one- and two-stage implant reconstruction. Conclusion: Breast reconstruction does not increase the risk for breast cancer-related lymphedema, and the risk of lymphedema is similar across different types of breast reconstruction. Breast reconstruction may reduce the risk of breast cancer-related lymphedema compared to mastectomy alone. The lack of baseline lymphedema measurements in most studies and studies with follow-up less than 4 years limits the strength of these findings.

Aim: The objective of this study is to present a complex case of surgical and hematological treatment in a 31-year-old female patient diagnosed with peripheral T-cell non-Hodgkin lymphoma with panniculitis-like features, associated with a soft tissue defect following a gluteal abscess and complicated by Pseudomonas aeruginosa infection, a rare pathology with no standardized therapeutic protocol. Method: The patient was initially treated for a left gluteal abscess, which subsequently led to a significant soft tissue defect. Following multiple biopsies, she was diagnosed with peripheral T-cell non-Hodgkin lymphoma with panniculitis-like features and alpha/beta receptors. An initial attempt was made to close the defect using two local rotational flaps. After this, during specific hematological treatment (CHOEP21 regimen), serial debridements and negative pressure wound therapy (VAC) were performed. The evolution of the patient's condition was marked by wound dehiscence and infection with multidrug-resistant Pseudomonas aeruginosa, a condition that was exacerbated by immunosuppressive therapy. Concurrently, an Integra® double-layer dermal regeneration template graft was applied, followed by negative pressure therapy and local dressings (Hyalo 4 Regen sponge). Between CHOEP21 chemotherapy cycles, advanced wound management techniques were employed to optimize skin closure. Results/Discussion: Despite challenges related to immunosuppression and infection, the combined surgical and hematological treatment led to complete disease remission and closure of the gluteal defect. The split-thickness skin grafts applied were partially rejected; however, the use of negative pressure therapy and the Integra® dermal regeneration template facilitated complete tissue regeneration. The application of Integra® dermal regeneration template in combination with VAC therapy was found to be essential in promoting tissue regeneration in an oncologic patient with complex wounds. Furthermore, complete remission of non-Hodgkin lymphoma was observed following six cycles of chemotherapy. Conclusions: A multidisciplinary approach that combines specialized hematological therapy, negative pressure wound therapy, and the Integra® dermal regeneration template has demonstrated effectiveness in managing a complex soft tissue defect within a rare oncological context that lacks a standardized treatment protocol. This strategy may serve as a therapeutic model for similar cases and underscores the essential collaboration among surgical, hematological, and dermatological specialties.

Introduction: Brachial plexus injuries (BPI) in pediatric patients can lead to significant functional impairment, particularly affecting shoulder mobility and strength. Traditional nerve repair techniques often yield suboptimal results, necessitating innovative approaches to optimize recovery. Supercharged nerve transfer has emerged as a promising solution, enhancing axonal regeneration and functional restoration. This case report presents the successful management of a pediatric patient with partial axillary nerve injury using supercharged nerve transfer. Aims & Objectives: 1. To describe the clinical presentation and surgical management of a pediatric patient with partial axillary nerve injury. 2. To evaluate the effectiveness of supercharged nerve transfer in improving shoulder mobility and function. 3. To highlight the role of early surgical intervention in optimizing recovery. Case Report: A 5-year-old girl presented with an inability to abduct her left shoulder and flex her left elbow following a fall 1.5 months prior. Initial treatment involved physiotherapy and nerve stimulation, leading to partial elbow flexion recovery but limited shoulder abduction. After five months with no further improvement, surgical intervention was planned. Intraoperative findings confirmed an excitable posterior division of the axillary nerve, and a supercharged end-to-side nerve transfer using the nerve to the medial head of the triceps was performed. Methodology: Preoperative assessment included electromyography (EMG) and nerve conduction velocity (NCV) studies, confirming partial axillary nerve dysfunction. Postoperatively, structured physiotherapy was initiated at three weeks, with functional evaluations conducted at two months, six months, and one year post-surgery. Results: Two months postoperatively, the patient demonstrated a full range of motion in shoulder abduction. At the one-year follow-up, sustained functional recovery was observed, with no complications. EMG studies confirmed enhanced reinnervation, reinforcing the efficacy of the supercharging technique. Discussion: Supercharged nerve transfer offers a novel approach to augmenting axonal regeneration in cases of partial axillary nerve injury. This technique provides an additional motor input to facilitate faster and more efficient recovery. In pediatric patients, early intervention is critical due to their heightened regenerative potential. Compared to conventional nerve grafting, supercharging nerve transfer minimizes donor site morbidity while accelerating functional recovery. This case underscores the importance of postoperative rehabilitation and structured physiotherapy in maximizing surgical outcomes. Further studies are needed to establish standardized protocols and long-term efficacy of this technique in pediatric populations. Conclusion: Supercharged nerve transfer represents a promising surgical approach for enhancing recovery in cases of partial axillary nerve injury. This case highlights its potential to accelerate nerve regeneration and restore function in pediatric patients. Early intervention and structured rehabilitation are key factors in achieving optimal outcomes. References: 1. Isaacs, J. (2022). Reverse End-to-Side (Supercharging) Nerve Transfer: Conceptualization, Validation, and Translation. In Hand (Vol. 17, Issue 6, pp. 1017–1023). SAGE Publications Inc 2. Viterbo F, Trindade JC, Hoshino K, et al. Latero-terminal neurorrhaphy without removal of the epineural sheath. Experimental study in rats. Rev Paul Med. 1992;110(6):267-275.

Introduction Soft tissue reconstruction in hand surgery demands an optimal balance between durability, pliability, and sensory restoration. The medial plantar artery (MPA) flap has emerged as a promising reconstructive option, offering thin, sensate tissue with minimal donor site morbidity. This study presents two cases where the sensate MPA flap was successfully utilized for hand defect reconstruction, focusing on surgical technique, sensory outcomes, and functional recovery. Aims and Objectives The primary aim of this study is to evaluate the functional and sensory outcomes of the sensate MPA flap in hand reconstruction. Specific objectives include: 1. Assessing flap viability and sensory restoration using two-point discrimination. 2. Evaluating postoperative functional improvement, including grip strength and dexterity. 3. Analyzing donor site morbidity and patient-reported outcomes. Methodology This case series includes two patients who underwent MPA flap reconstruction for hand defects. Both cases involved careful flap elevation with preservation of the medial plantar cutaneous nerve for sensory restoration. Postoperative follow-up included assessments of: • Flap survival and complications • Sensory recovery (evaluated via two-point discrimination) • Functional improvement (measured by grip strength and dexterity tests) • Patient-reported satisfaction regarding aesthetics and function Case Presentations Case 1: A 25 year-old male presented with a 3-month-old post-traumatic left-hand palmar contracture with an inability to extend the fingers. Following release, a sensate MPA flap was harvested, with neurorrhaphy of the medial plantar cutaneous nerve to the recipient digital nerve. Flap survival was 100%, and sensory recovery (two-point discrimination of 30 mm) was observed at six months. Grip strength improved significantly over six months. Case 2: A 13 year-old boy with a 11 year old post-burn contracture required soft tissue coverage following contracture release. The sensate MPA flap was used with microsurgical neurorrhaphy. At two months, the patient demonstrated protective sensation and improved dexterity, with no donor site complications. Discussion Traditional reconstructive options, such as groin or radial forearm flaps, offer durable coverage but often lack sensibility. The MPA flap, when harvested with the medial plantar cutaneous nerve, presents an opportunity for sensory reinnervation. Our case series highlights the clinical advantages of this technique: • Functional restoration: Both patients demonstrated meaningful grip strength and dexterity improvements. • Sensory recovery: Two-point discrimination improved over time, supporting the potential for reinnervation. • Minimal donor site morbidity: Both patients had well-concealed scars and preserved foot function. However, challenges include meticulous flap dissection and the need for precise neurorrhaphy to optimize sensory return. While limited to two cases, these findings suggest that the sensate MPA flap is a valuable option for complex hand reconstructions. Conclusion The sensate medial plantar artery flap is a reliable and functionally superior option for hand reconstruction, providing both durable coverage and meaningful sensory recovery. These two cases demonstrate its clinical feasibility, with favorable postoperative outcomes. References 1. Padovano, William M. MD, MPHS; Hill, Elspeth J. R. MBChB, MRes, PhD; Felder, John M. III, MD. Reconstruction of Severe Palm Injury with Sensate Medial Plantar Artery Flap and Nerve Grafting. Plastic and Reconstructive Surgery - Global Open 8(7):p e2944, July 2020. | DOI: 10.1097/GOX.0000000000002944

ABSTRACT Background

The deviated nose represents a complex aesthetic and functional problem. Thus, correcting the deformed nose with long-term functional and aesthetic success remains a major challenge for rhinoplasty surgeons.

Methods

A prospective study was held in Terna Medical College and Hospital, Navi Mumbai from July 2021 until August 2023 to evaluate the functional outcome of septorhinoplasty subjectively in cases of deviated nasal septum in the Indian population. A total of 25 patients were enrolled and completed the study. Detailed history, symptoms, and all measurements were taken preoperatively and evaluated immediately on the day and 3 months postoperatively. Septorhinoplasty was performed in all patients, ranging in age from 18 to 33 years. The majority had a history of trauma with 14 being male and 11 being females. A deviated nose was the most common external nose abnormality followed by crooked and saddle nose. Almost all patients presented with variable degrees of congestion, nasal blockages, breathing troubles, and problems with the aesthetic look of the nose.

Results

Out of 25, 9 patients crooked noses, 7 patients had hump deformity, and 9 patients had saddle noses with all had associated with deviated nose and tip deformity. Septorhinoplasty done with the use of nasal, ear, and rib cartilage depends on nasal deformity. Subjective assessment using the Nasal Obstruction Symptoms Evaluation (NOSE) scale was done on all patients postoperatively. There was significant improvement was observed in all of the parameters in the NOSE scale post-septorhinoplasty (p < 0.05). Furthermore, there was a significant improvement in the aesthetic look of the nose.

Conclusion

Functional Septorhinoplasty improves the nasal airflow and quality of life of patients with nasal obstruction as well as gives a good aesthetic straight nose.

REFERENCE

1. Stewart MG, Smith TL. Weaver EM et al. Outcomes after nasal septoplasty: results from the Nasal Obstruction Effectiveness (NOSE) study. Otolatyngol Head Neck Surg: 2004; 130(3):283-90.
2. Matthew K. Lee, MD and Sam P. Most, MD A Comprehensive Quality-of-Life Instrument for Aesthetic and Functional Rhinoplasty: The RHINO Scale Plast Reconstr Surg Glob Open. 2016 Feb; 4(2): e611.
3. André RF, Vuyk HD. Reconstruction of dorsal and/or caudal nasal septum deformities with septal battens or by septal replacement: an overview and comparison of techniques. Laryngoscope 2006; 116:1668–1673.
4. FD Zahedi, S Husain, BS Gendeh. Functional outcome evaluation of septorhinoplasty for nasal obstruction Indian Journal of Otolaryngology and Head & Neck Surgery 68, 218-223
5. Lee JW, Baker SR. Correction of caudal septal deviation and deformity using nasal septal bone graft. Facial Plast Surg 2013; 15:96–100.

ABSTRACT Background. Clavicular reconstruction poses several challenges to the reconstructive surgeons, especially when a long bone defect (>6cm) needs to be addressed. The rarity of the condition with the related scarce number of reported cases contributes to the lack of standardization. The aim of this paper is to contribute to the existing literature by presenting a European multicentre case series on the use of free fibula flap for clavicle reconstruction and reporting on the outcomes in a uniform manner. At the same time, the objective is to apply orthoplastic concepts to suggest technical tips in order to maximise the success of the procedure. Methods. Adult patients affected by clavicular bone loss due to trauma, infection, or oncological resections, were included. Surgical outcomes were measured in terms of bone healing and functional recovery through pre-operative and post-operative Disability of Arm, Shoulder, and Hand (DASH) and Constant-Murley score. Complication rates were recorded. Patients were followed-up with radiographs obtained at 1,3,6,9 and 12 months. Results. Nine patients with a mean age of 44.4 ±16.4yo were included. The mean clavicular bone defect was 8.5±2.8 cm. The etiologies of defect were sarcoma excision (5/9) fracture-related infection (2/9), osteoradionecrosis (1/9) and chronic sclerosing osteomyelitis of Garré (1/9). The average follow-up was 32.8±13.1 months A successful bone union was achieved in all cases after 180±20 days. Significant improvements in both the DASH and Constant-Murley score were recorded. Six patients regained full range of motion. No flap complications were reported. In two cases an additional procedure was performed due to exposed metalwork and poor cosmesis. Orthoplastic principles were applied, such as dual plate fixation in a 90° configuration and use of minifragment plates. Conclusions. This study supports the fibular flap's efficacy in reconstructing critical-sized clavicular defects and emphasizes technical strategies to reach the stability of the final construct and optimize the functional outcome.

Introduction: Immediate prepectoral breast reconstruction has emerged as a prominent technique for patients undergoing mastectomy, particularly for those desiring improved aesthetic outcomes and fewer complications. Unlike the traditional subpectoral placement of breast implants, the prepectoral approach involves positioning the implant above the pectoralis muscle, offering benefits such as a more natural appearance and a reduction in postoperative pain and muscle-related issues. Despite these advantages, the procedure is not without challenges. The development of seromas remains one of the most common complications. Seromas not only delay wound healing but also increase the risk of infection, necessitating additional interventions, and potentially compromising the aesthetic results. The aim of this study was to evaluate the combined effect of incisional negative pressure wound therapy (iNPWT) for seven days postoperatively, alongside a structured ultrasound-based protocol for the early detection and management of seromas, in patients undergoing immediate prepectoral breast reconstruction. We hypothesized that the addition of iNPWT to the conventional ultrasound monitoring protocol would significantly reduce the incidence of clinically significant seromas, enhance wound healing and reduce the overall complication rate. Methods: This research was designed as a mixed observational study. A total of 100 patients were enrolled, with a focus on those undergoing immediate prepectoral breast reconstruction following mastectomy for breast cancer. Patients were divided into two groups: the case group, which received both iNPWT and the ultrasound-based protocol, and the control group, which only received the ultrasound protocol. Statistical analyses were performed using R and SPSS software. Descriptive statistics were used to summarize demographic data, while inferential tests (such as chi-square and t-tests) were employed to assess differences between the groups. A p-value of less than 0.05 was considered statistically significant. Results: Preliminary findings from this study suggest that the use of iNPWT, in conjunction with the ultrasound protocol, resulted in a marked reduction in the incidence of clinically significant seromas. In addition, the time to seroma diagnosis was significantly shorter in the iNPWT group, owing to the frequent monitoring facilitated by the ultrasound protocol. This early detection enabled more timely interventions, preventing the development of larger, more problematic seromas. Furthermore, patients in the iNPWT group demonstrated faster overall recovery times, with fewer instances of wound dehiscence and lower rates of infection. While the benefits of iNPWT were evident in reducing seroma-related complications, it also contributed to improved wound adhesion and minimized the need for secondary interventions. This finding is particularly important in the context of prepectoral reconstruction, where maintaining implant positioning and optimizing cosmetic results are paramount. Conclusion: The integration of incisional negative pressure wound therapy (iNPWT) and structured ultrasound monitoring represents a promising strategy to reduce seroma-related complications in immediate prepectoral breast reconstruction. The preliminary data from this study suggest that the combined approach offers significant advantages in terms of reducing seroma incidence, accelerating wound healing, and improving overall patient outcomes.

Background

Breast reconstruction after mastectomy plays a crucial role in restoring patients' physical appearance and psychological well-being. Immediate prosthetic breast reconstruction (IPBR) has gained popularity, with the prepectoral approach offering advantages such as reduced postoperative pain, improved aesthetic outcomes, and quicker recovery. Among the options for implant coverage, two main techniques are widely used: (1) implants fully covered with acellular dermal matrices (ADM) and (2) polyurethane (PU)-coated implants without ADM. While both methods aim to minimize complications and maximize aesthetic results, comparative long-term data are limited. This study compares early, intermediate, and long-term outcomes of these two reconstructive approaches.

Methods

A retrospective analysis was conducted on 97 patients (135 breasts) who underwent immediate prepectoral breast reconstruction following nipple-sparing mastectomy (NSM), skin-sparing mastectomy (SSM), or skin-reducing mastectomy (SRM) between April 2018 and March 2021. Patients were categorized into two groups: Group A received PU-coated implants, and Group B received textured implants with total ADM coverage. Primary endpoints included complication rates (seroma, infection, hematoma, rippling, capsular contracture) and aesthetic outcomes, assessed at multiple postoperative intervals up to five years. Statistical analysis involved chi-square tests for categorical variables and logistic regression models adjusted for age, BMI, mastectomy volume, and implant volume.

Results

Patient Demographics:The median age was 47.8 years, with a median BMI of 23.3 kg/m². There were no significant demographic differences between groups. Bilateral reconstructions were more common in the ADM group.

Short-Term Complications (≤4 weeks):

Seroma: PU group had significantly lower rates (2.9%) compared to the ADM group (33.8%, p<0.001).

Infections: Occurred in 1.4% of PU patients versus 6.2% in ADM patients (p=0.195).

Hematomas and Red Breast Syndrome: Low incidence in both groups, with no significant differences.

Medium-Term Complications (4 weeks to 1 year):

Persistent seromas occurred only in the ADM group.

Infection rates remained higher in the ADM group beyond the first month postoperatively.

Long-Term Complications (>1 year):

Capsular Contracture: At five years, the PU group demonstrated significantly lower contracture rates (24.3%) compared to the ADM group (47.7%, p<0.001).

Rippling and Step-Off Deformity: Similar rates were observed between groups, with no significant correlations with implant volume or flap thickness.

BIA-ALCL: No cases were recorded in either group during the follow-up period.

Aesthetic Outcomes:Aesthetic assessments favored the ADM group in terms of breast symmetry and contour. However, the PU group had fewer reoperations and lower complication-related morbidity. Patient satisfaction remained high in both groups.

Discussion

PU-coated implants provide a safer profile with fewer early postoperative complications and a lower long-term risk of capsular contracture. The adhesive properties of the polyurethane coating promote better implant stabilization, reducing micro-movement-induced inflammation. ADM-based reconstructions, while offering improved contour and aesthetic outcomes, present higher complication rates and a greater likelihood of requiring secondary procedures.

Conclusions

Selecting between PU-coated implants and ADM-covered implants should be individualized, weighing patient anatomy, aesthetic preferences, and potential complication risks. PU implants are advantageous for patients prioritizing lower complication rates, while ADM-based reconstruction may suit those seeking optimal aesthetic results despite higher risks.

G. H. Pontes et al., "Long-term Insights: Histopathological Assessment of Polyurethane Implant Capsules Over 24 Years," Aesthet Surg J, vol. 44, no. 9, pp. 915–924, Sep. 2024, doi: 10.1093/asj/sjae057. S. Pompei, F. Arelli, L. Labardi, F. Marcasciano, D. Evangelidou, and G. Ferrante, "Polyurethane Implants in 2-Stage Breast Reconstruction: 9-Year Clinical Experience," Aesthet Surg J, vol. 37, no. 2, pp. 171–176, Feb. 2017, doi: 10.1093/asj/sjw183. M. Salgarello, D. Pagliara, L. Barone Adesi, G. Visconti, J. B. Wild, and P. Matey, "Direct to Implant Breast Reconstruction With Prepectoral Micropolyurethane Foam-Coated Implant: Analysis of Patient Satisfaction," Clin Breast Cancer, vol. 21, no. 4, pp. e454–e461, Aug. 2021, doi: 10.1016/j.clbc.2021.01.015. G. Franceschini et al., "Immediate prosthetic breast reconstruction after nipple-sparing mastectomy: Traditional subpectoral technique versus direct-to-implant prepectoral reconstruction without acellular dermal matrix," J Pers Med, vol. 11, no. 2, pp. 1–12, Mar. 2021, doi: 10.3390/jpm11020153. G. Berna, S. J. Cawthorn, G. Papaccio, and N. Balestrieri, "Evaluation of a novel breast reco

INTRODUCTION HIV-associated lipodystrophy is a complication of prolonged antiretroviral therapy, characterized by abnormal fat redistribution (1,2,3). This study evaluates the impact of plastic surgery interventions on health-related quality of life (QoL) in HIV-positive patients using the Visual Index of Health (VIH) protocol. MATERIALS AND METHODS A retrospective analysis was conducted on 264 HIV-positive patients presenting with lipohypertrophy who underwent surgical intervention from November 2016 to July 2024. Surgical interventions consisted of district-specific liposuction (UAL and SAL) and contextual lipofilling of areas requiring volumization. Liposuction was performed using ultrasonic-assisted techniques to precisely target fat deposits in the dorsocervical region, abdomen, and flanks . Harvested adipose tissue was purified and immediately re-injected into areas of volume depletion, including the face, buttocks, and extremities, to restore symmetry and enhance aesthetic outcomes. Postoperative care included compression garments, routine follow-ups at 1, 3, and 6 months, and continuous monitoring of surgical outcomes. Demographic data, therapy details, and clinical outcomes were collected. The VIH protocol evaluated HRQoL across five macro areas: self-care, mobility and social life, usual life, discomfort, and anxiety/depression. Statistical analyses included subgroup comparisons by sex, age, and CD4 count. Scores ranged from 1 to 5, with higher scores indicating better function or less discomfort. Statistical analysis was performed using paired t- tests, with significance set at p<0.05. RESULTS Of 264 patients, 65% were male, with a mean age of 42 years. All patients completed the 6-month follow-up. Significant improvements were observed across all domains. In the self-care domain, mean scores increased from 3.5 (±0.6) pre-surgery to 4.2 (±0.5) post-surgery, with a mean difference of +0.7 (±0.2) (p=0.004). Mobility and social life scores improved from 3.6 (±0.5) to 4.4 (±0.4), with a mean difference of +0.8 (±0.3) (p=0.003). Usual life activities scores increased from 3.4 (±0.7) to 4.3 (±0.6), with a mean difference of +0.9 (±0.4) (p=0.002). Discomfort scores improved from 3.2 (±0.5) to 4.0 (±0.4), with a mean difference of +0.8 (±0.3) (p=0.004). Anxiety/depression scores increased from 2.9 (±0.6) to 3.8 (±0.5), with a mean difference of +0.9 (±0.3) (p=0.001). No major complications were reported. The greatest improvements were seen in anxiety/depression and discomfort scores (mean change: 0.7 ± 0.2; p < 0.005). Female patients experienced greater HRQoL benefits compared to males. Patients with higher baseline CD4 counts showed more substantial improvements. CONCLUSIONS Plastic surgery significantly enhances the health-related quality of life of HIV-positive patients, as demonstrated by the VIH protocol. Integrating surgical interventions into holistic HIV care frameworks is vital for effectively addressing both physical and psychological dimensions (4,5). REFERENCES

1.Guaraldi G, Murri R, Orlando G, et al. Lipodystrophy and quality of life of HIV-infected persons. AIDS Rev. 2008;10(3):152-61. PMID: 18820717. 2.Moyle GJ, Lysakova L, Brown S, et al. A randomized open-label study of immediate versus delayed polylactic acid injections for the cosmetic management of facial lipoatrophy in persons with HIV infection. HIV Med. 2004;5(2):82-7. doi:10.1111/j.1468-1293.2004.00200.x. 3.Guaraldi G, Baraboutis IG. Evolving perspectives on HIV-associated lipodistrophy syndrome: moving from lipodystrophy to non-infectious HIV co-morbidities. J Antimicrob Chemother. 2009;64(3):437-40. doi:10.1093/jac/dkp240. 4.Hultman CS, McPhail LE, Donaldson JH, Wohl DA. Surgical management of HIV-associated lipodystrophy: role of ultrasonic-assisted liposuction and suction-assisted lipectomy in the treatment of lipohypertrophy. Ann Plast Surg. 2007;58(3):255-263. 5.Duracinsky M, Leclercq P, Herrmann S, Christen MO, Dolivo M, Goujard C, Chassany O. Safety of poly-L-lactic acid (New-Fill®) in the treatment of facial lipoatrophy: a large observational study among HIV-positive patients. BMC Infect Dis. 2014 Sep 1;14:474. doi: 10.1186/1471-2334-14-474. PMID: 25178390; PMCID: PMC4160543.

Background: Although closed-suction drains are routinely used in breast reconstruction, research on the safety and efficacy of early drain removal remains limited. We aimed to evaluate the effect of early drain removal on local wound complications following breast reconstruction. Methods: This retrospective cohort study, conducted at a single institution, included patients who underwent breast reconstruction with tissue expanders (TE), breast implants, or autologous tissue between January 2019 and August 2024. Patients were classified into two groups based on drain removal criteria: the volume-based group, where drains were removed when output fell below 30 mL/24 h, and the early-removal group, where drains were removed within 4 d postoperatively. The incidence of local wound complications of breasts, including seroma, surgical site infection (SSI), and implant removal, within the first postoperative year was compared between groups. Results: The study included 241 patients and 265 breast reconstructions: 134 in the volume-based group and 131 in the early-removal group. Seroma incidence did not differ significantly between groups. SSI incidence was significantly lower in the early-removal group (15.7% vs. 6.9%, p=0.032). Subgroup analysis showed that the reduction in SSI incidence was observed only in TE or implant-based reconstructions, not autologous reconstructions. Multivariable logistic regression identified early drain removal as a significant protective factor against SSI (OR, 0.304; p=0.011). Conclusions: Early drain removal in breast reconstruction did not increase seroma incidence and significantly decreased SSI incidence in TE or implant-based reconstructions. Drain removal within 4 d postoperatively appears safe and beneficial in breast reconstruction.

Purpose: Probiotics are well known to have beneficial effects in modulating immune responses against microbial infection and in protecting the host. Previously, we have reported that topical administration of heat-killed Lactobacillus plantarum (L. plantarum) promotes wound healing. In this study, we analyzed the changes in cell accumulation at the wound site induced by L. plantarum administration in order to elucidate the detailed mechanism. In addition, we analyzed the signaling pathway using CARD9KO mice and reporter cells. Method: A full-thickness skin defect wounds were created on the dorsal skin of wild-type (WT) mice (C57BL/6), and L. plantarum or distilled water (vehicle control) was immediately injected into the wound. Wound closure rate, pathological findings, and cytokines, chemokines, and growth factors in the homogenate supernatant were analyzed daily after wound creation. In addition, the number and fractionation of leukocytes accumulated in the wound were analyzed by flow cytometry. We also performed the same analysis using WT and CARD9KO mice. In addition, L. plantarum stimulation experiments using Dectin-1, Dectin-2, and Mincle reporter cells were performed to search for receptors upstream of CARD9. Results: Flow cytometric analysis showed that L. plantarum induced neutrophils in the early phase of the treatment, followed by persistent macrophages in the mid- to late phase of the treatment. In addition, the M2/M1 ratio was significantly increased in the L. plantarum group at 10 days after wound preparation. Furthermore, analysis of wound closure rates in WT and CARD9KO mice showed that L. plantarum treatment in CARD9KO mice lost its wound-healing promoting effect. The GFP activity of each reporter cell was not observed in the L. plantarum-stimulated experiments using Dectin-1, Dectin-2, and Mincle reporter cells. Conclusions: These results indicate that L. plantarum induces the differentiation of M2 macrophages. It is also possible that CARD9 is involved in the mechanism of wound healing promotion by L. plantarum, and that signaling is mediated through receptors other than Dectin-1, Dectin-2, and Mincle. The results of this study are expected to lead to the development of novel wound healing agents using heat-killed probiotics.

Background: In cases of mandibulectomy involving the condyle, reconstruction of the temporomandibular joint is necessary to preserve masticatory function. We have been reconstructing the mandibular condyle using a free peroneal flap and a Suture Anchor, and we report on the medium-term results of this. Method: After harvesting the free fibula osteocutaneous flap, the tip of the fibula corresponding to the mandibular condyle is rounded, and the suture anchor (Mitek Suture anchor system®) is inserted into the lateral and posterior surface of the fibula and fixed with sutures, and the fibula is suspended by attaching it to the capsule of the articular capsule. From April 2020 to January 2023, we investigated the masticatory function, diet, postoperative complications, and the shape and position of the reconstructed fibula in 11 cases in which the mandibular condyle was reconstructed using the aforementioned method. Results: We examined 8 cases in which follow-up was possible for more than 6 months. The underlying diseases were: 4 cases of carcinoma of the gingiva, 2 cases of osteosarcoma, 1 case of ameloblastoma, and 1 case of radiation-induced osteonecrosis of the jaw. The mandibular defects were classified as follows according to the Brown classification: 2 cases were classified as Ic, 5 cases were classified as IIc, and 1 case was classified as IVc. According to the Eichner classification of occlusal support, 6 cases were classified as B2, 1 case was classified as B3, and 1 case was classified as B4. The fibula flaps survived in all cases, and postoperative radiation therapy was administered to 2 cases of carcinoma of the gingiva. At 6 months post-operatively, the Functional Oral Intake Scale (FOIS) was level 6 in one case and level 7 in seven cases, and in many cases, normal food intake was possible. The average score on the Hirose Conversation Classification was 9.8, and there were no cases of pain in the temporomandibular joint. On CT scans taken more than 6 months after surgery, anterior dislocation of the temporomandibular joint was observed in three cases. Discussion: Various methods have been reported for the mandibular condyle reconstruction, including the use of a plate with condylar prosthesis, autologous cartilage grafting, and insertion of vascularized bone. In this study, the patients' eating function was relatively good at 6 months post-surgery, and it was thought that they had achieved stable occlusion. In the future, we plan to continue to monitor the patient's progress and evaluate the function of the temporomandibular joint, including not only rotational but also gliding movements, before and after surgery, and to continue to investigate the long-term results of this method.

Purpose: Recently, increasing attention has been attracted to cell-conditioned media for their therapeutic potential, largely owing to their rich content of growth factors and exosomes. We have previously established a novel type of cells named MNC-QQ cells which is from a serum free quantity and quality control culture (QQc) of peripheral blood mononuclear cells (MNCs) that increases the vasculogenic and tissue regeneration ability of MNCs. In our previous study we confirmed that the conditioned medium derived from MNCQQ cells (QQ-Sup) also contains a rich composition of growth factors, cytokines, and exosomes, including numerous angiogenesis-related factors. While QQ-Sup is expected to promote vascular regeneration and tissue repair, the precise therapeutic efficacy and underlying mechanisms remain unclear. Therefore, the purpose of this study is to evaluate the angiogenic effects of QQ-Sup on ischemic tissues both in vitro and in vivo and to elucidate the molecular mechanisms underlying its pro-angiogenic and tissue regenerative properties.

Methods: QQ-Sup was collected from MNCQQ cultures and analyzed for its angiogenic potential. Human umbilical vein endothelial cells (HUVECs) were cultured with QQ-Sup to assess its effects on cell proliferation, migration, and tube formation through MTT assays, wound healing assays, and tube formation assays, respectively. To identify key factors, ELISA was performed to quantify the levels of angiogenesis related factors in the QQ-Sup. Functional blockade experiments using inhibitors against target factors were conducted to validate their roles in mediating angiogenic responses. Additionally, a murine hindlimb ischemia model was established, where QQ-Sup was administered intravenously. The development of ischemia-related ulcers or necrosis was observed and blood flow recovery was monitored using laser Doppler perfusion imaging at regular intervals.

Results: To evaluate the pro-angiogenic potential of QQ-Sup, we first assessed its effects on HUVECs. QQ-Sup treatment significantly enhanced HUVEC proliferation (0.46 ± 0.09 vs. 0.84 ± 0.10/24h; p < 0.01), migration (29.21% ± 3.87% vs. 96.1% ± 3.21%/18h; p < 0.001), and tube formation (16.17 ± 3.16 vs. 22.29 ± 2.25/5h; p < 0.01) compared to controls, indicating a strong capacity to promote key cellular processes involved in angiogenesis. Next, to identify the molecular mediators responsible for these effects, we conducted ELISA, which revealed elevated levels of two key undisclosed angiogenic factors (X and Y) in QQ-Sup. To test if these factors play a pivotal role in QQ-Sup-mediated angiogenesis, we performed neutralization assays using specific inhibitors targeting these factors. As expected, the angiogenic activities, including endothelial cell proliferation, migration, and tube formation were markedly reduced upon inhibition of these factors. Building upon these in vitro findings, we next explored the potential therapeutic effects of QQ-Sup in vivo using a murine hindlimb ischemia model. The preliminary observations indicated that QQ-Sup-treated mice exhibited favorable outcomes, notably the absence of severe ulcerations, which is often a hallmark of advanced ischemic damage.

Conclusion: This study indicated that QQ-Sup might promote angiogenesis and accelerates wound healing through the paracrine actions of key factors X and Y. This approach offers promising prospects for treating ischemic conditions, chronic wounds, and other vascular-related disorders in regenerative medicine.

INTRODUCTION: Reconstruction of complex head and neck defects after multiple failed flaps presents a significant challenge, particularly when dealing with radiation-induced tissue damage and limited recipient vessels. When in need for additional skin and no apparent suitable flap left to use, skin expansion may be a useful option. While traditional tissue expanders are well-established, they carry risks associated with prolonged implant placement (1,2). Intraoperative tissue expansion (ITE) offers a viable alternative (3).

METHODS: We present a case of a 68-year-old female with squamous cell carcinoma of the floor of mouth diagnosed in 2022. After initial segmental mandibulectomy, pelviglossectomy, bilateral neck dissection and immediate free fibular osteoseptocutaneous flap reconstruction, the patient developed necrotizing fasciitis. Salvage reconstruction with pectoral and supraclavicular flap enabled the patient to perform radiotherapy but one month later she developed exposure of the mandibular reconstruction plate. Following failed salvage procedures including a second free fibular flap, supraclavicular and pectoral flaps, the patient still presented with soft tissue retraction and insufficient soft tissue coverage for mandibular reconstruction. A staged approach using intraoperative tissue expansion with Foley catheter balloons was implemented.

RESULTS: A staged tissue expansion implant approach was deemed too risky given the patient's history of multiple infections. Instead, through sequential intraoperative tissue expansion procedures, we successfully achieved adequate soft tissue coverage for mandibular plate reconstruction placement and lower lip repositioning. No immediate or delayed complications were observed. The patient maintained stable soft tissue coverage at 3-month follow-up, with improved speech, oral competence and enabled tracheostomy decannulation.

CONCLUSION: Intraoperative tissue expansion may serve as a useful salvage technique in complex head and neck reconstruction. This approach provides immediate results with reduced complication rates compared to traditional expansion methods, making it an important addition to the reconstructive surgeon's armamentarium for challenging cases with very limited options.

References 1. NEUMANN CG. The expansion of an area of skin by progressive distention of a subcutaneous balloon; use of the method for securing skin for subtotal reconstruction of the ear. Plast Reconstr Surg (1946). 1957;19(2):124-130. doi:10.1097/00006534-195702000-00004 2. Radovan C. Tissue expansion in soft-tissue reconstruction. Plast Reconstr Surg. 1984;74(4):482-492. doi:10.1097/00006534-198410000-00005 3. Johnson TM, Brown MD, Sullivan MJ, Swanson NA. Immediate intraoperative tissue expansion. J Am Acad Dermatol. 1990;22(2 Pt 1):283-287. doi:10.1016/0190-9622(90)70038-j

Background: Advances in surgical procedures improved the safety profile of aesthetic surgery. Several side effects have been described for facelift surgeries, and nerve injuries are one of the most feared due to their impact on quality of life. The main objective of this work is to evaluate the rate and type of nerve injury during facelift procedures through a systematic review. Methods: PubMed®, EMBASE® and Web of Science® databases were searched for articles on nerve injury rates after facelift surgeries using controlled and non-controlled terms to establish search queries. Three investigators independently assessed the eligibility of publications, first based on the title and abstract and then based on the full text. The DerSimonian-Laird random effects model was used for proportion estimation through a meta-analysis. Results: A total of 67 eligible publications with a total of 15404 patients and 15441 procedures were included in the analysis according to the eligibility criteria. The overall estimated pooled motor and sensory nerve damage rate was 0.66% (95% confidence interval [95%CI]: [0.5% ; 0.9%], Z = 6.07, p < .001) and 0.39% (95%CI: [0.2% ; 0.6%], Z = 4.16, p < .001), respectively. For permanent neuronal damage, the estimated pooled rates were 0.047% (95%CI: ]0.0% ; 0.1%], Z = 2.69, p = .007) and 0.045% (95%CI:]0.0% ; 0.1%], Z = 2.63, p =.009), respectively, for motor and sensory nerve damage. Conclusions: The recognition of nerve damage as a serious complication of facelift surgery is increasing, although the estimated pooled rate is less than 1%.

Background: Previous studies demonstrated the effectiveness and safety of tranexamic acid (TXA) in several surgical specialties. Recent publications suggested that TXA may also be beneficial in plastic surgery, including breast procedures. Objective: The aim of this study is to evaluate the impact of TXA in reduction mammaplasty by assessing several intraoperative and postoperative outcomes and the safety of its administration.

Methods: A systematic search was conducted according to PRISMA (Preferred Reporting Items for Systematic reviews andMeta-Analysis) guidelines on several online databases. Studies evaluating the outcomes of TXA administration in patients undergoing reduction mammaplasty, regardless of TXA dose and administration route were eligible for inclusion. Only studies with a control group were included. Risk-of-bias assessment was conducted using Cochrane and MINORS (Methodological Index for Non-Randomized Studies) tools.

Results: Our systematic review included 7 studies: 3 randomized controlled trials and 4 retrospective cohorts involving 1234 female patients (2232 breasts), 741 of whom received TXA (60%). Four studies used topical TXA, 2 used intravenous (IV) TXA, one used locally infiltrated TXA, and another combined locally infiltrated TXAwith IV TXA. Four studies demonstrated benefits from TXA administration, whereas 3 studies did not. Topical TXA used just before wound closure resulted in a 42% reduction in drain fluid output and a 10-times reduction in major hematoma. The administration of IV TXA during induction resulted in a 12- times reduction in major and minor hematoma. The combined use of IVand locally infiltrated TXA reduced intraoperative blood loss. No adverse effects were reported.

Conclusions: There is scientific evidence suggesting TXA may be effective and safe in reduction mammaplasty.

Background: The hand is a part of the human body with unique characteristics that combine functionality and aesthetics with great social and emotional significance. It plays a crucial role in daily activities, serves as a "work tool" and is essential for leisure and sports. Emotionally and socially, the hand is involved in actions such as shaking or holding hands, physical displays of affection such as hugging and touching, and is also a symbol of beauty and youth, often adorned with jewelry. However, as we age, noticeable changes occur, known as "tell-tale signs". These include skin discoloration, roughness, wrinkles and a loss of tissue volume (protruding veins, prominent tendons and bones, and deeper and wider spaces between the fingers). These changes often contrast with the appearance of the face and reveal a person's true age. To combat these signs of aging, volume restoration techniques are used with fillers such as hyaluronic acid, poly-L-lactic acid, calcium hydroxyapatite and autologous fat (lipofilling). Methods: This study presents two clinical cases of patients who underwent lipofilling of the hand and had fat harvested from different areas of the body. In the first case, fat was harvested from the abdomen, thighs and back. In the second case, the fat was taken mainly from the front of the abdomen and the flanks as part of an abdominoplasty. Both procedures were performed under general anesthesia. The areas to be liposuctioned were infiltrated with a solution of saline, adrenaline and tranexamic acid. After liposuction, the fat was decanted and then used for lipofilling of the back of the hand. Discussion: Fat grafting or lipofilling is a widely used technique in plastic surgery to restore volume and correct deformities. It is used in aesthetic surgery of the breast, buttocks, calves and reconstructive surgery of the face, breast, hands and body. This technique, also known as lipoinjection, fat grafting, liposculpture and autologous fat transfer, offers several advantages over hyaluronic acid fillers, including longer durability and longevity, a lower risk of allergic reactions and a lower risk of infection. It can also be combined with other procedures and performed under general or local anesthesia. Conclusion: Lipofilling is a safe, quick and effective technique for restoring volume to aging hands. It can be combined with other techniques and offers long-lasting results with high patient satisfaction. This study highlights the benefits of lipofilling as a reliable option for hand rejuvenation and illustrates its potential to improve both functional and esthetic outcomes in patients with aging hands.

Introduction: The Deep Inferior Epigastric Perforator (DIEP) flap is widely recognized as the gold standard in autologous breast reconstruction, typically used as a free flap. However, its applications extend beyond breast reconstruction, particularly for locoregional defects, due to its standardized harvesting technique and favorable donor site morbidity. This study aims to demonstrate that the pedicled DIEP flap can be an effective solution for large vulvar and perineal defects.

Patients and Methods: A retrospective analysis was conducted on patients who underwent reconstruction of vulvar and/or perineal defects using a pedicled DIEP flap. All procedures were performed at ULS São João.

Discussion: We present three cases of successful vulvar and perineal reconstructions with the pedicled DIEP flap. • Case 1: A 64-year-old female with vulvar carcinoma underwent radical vulvectomy and abdominoperineal resection. A pedicled DIEP flap was used for defect reconstruction with a favorable aesthetic result. • Case 2: A 72-year-old female with recurrent vulvar carcinoma required radical vulvectomy, distal colpectomy, and abdominoperineal resection. A fenestrated pedicled DIEP flap was used to reconstruct the defect, as well as both the vagina and the urethral meatus. • Case 3: A 34-year-old woman sustained severe perineal trauma due to a dog bite, resulting in avulsion of the labia minora and majora on the left side, along with tissue loss at the root of the ipsilateral thigh. A pedicled DIEP flap was successfully utilized for reconstruction.

Conclusion: The pedicled DIEP flap has proven to be an effective and reliable option for the reconstruction of various locoregional defects, providing excellent aesthetic results while minimizing donor-site morbidity. It should be considered a valuable addition to traditional locoregional flaps for the reconstruction of large vulvar and perineal defects.

References: (1) Muneuchi, Gan, et al. "Deep inferior epigastric perforator (DIEP) flap for vulvar reconstruction after radical vulvectomy: a less invasive and simple procedure utilizing an abdominal incision wound." Annals of plastic surgery 55.4 (2005): 427-429. (2) Cheng, Angela, and Michel Saint-Cyr. "Split and thinned pedicle deep inferior epigastric perforator (DIEP) flap for vulvar reconstruction." Journal of reconstructive microsurgery 29.04 (2013): 277-282. (3) Bodin, Frédéric, et al. "Extended vulvar immediate reconstruction using the bilateral transverse pedicled DIEP flap." Journal of Plastic, Reconstructive & Aesthetic Surgery 68.5 (2015): 745-747. (4) Huang, Jung-Ju, et al. "Pedicle perforator flaps for vulvar reconstruction-new generation of less invasive vulvar reconstruction with favorable results." Gynecologic oncology 137.1 (2015): 66-72. (5) Bachleitner, K., et al. "The Pedicled Deep Inferior Epigastric Perforator (DIEP) Flap for Vulva Reconstruction." Austin J Clin Case Rep 8.2 (2021): 1196.

Introduction: Vascular malformations are structural and morphological anomalies of blood and lymphatic vessels, which can be classified as capillary, venous, lymphatic, and arteriovenous lesions. These malformations can vary in size and severity, with some growing to giant proportions, severely affecting the patient's quality of life. This report presents two cases of patients with giant vascular malformations who underwent surgical treatment, highlighting the challenges and outcomes associated with their management.

Patients and Methods: A retrospective analysis was conducted on patients with giant vascular malformations who underwent surgical intervention at our center between January 2023 and December 2024.

Discussion: Case 1: A 54-year-old male presented with a giant vascular malformation involving his face and scalp. The patient underwent resection of the malformation, followed by reconstruction of the defect using artificial dermis and hair follicle transplantation. Postoperative recovery was satisfactory, and the patient showed significant improvement in both function and appearance. Case 2: A 52-year-old female presented with a giant pubic mass that significantly impaired her mobility and caused severe personal hygiene issues. She also had similar lesions on her lower limb. The pubic mass was surgically resected, revealing a lymphatic malformation. The patient's postoperative recovery was uneventful, and her quality of life significantly improved after the procedure.

Conclusion:
Giant vascular malformations are rare and often require complex surgical procedures. Proper preoperative planning and experienced surgical teams are essential to achieve good outcomes and improve patients' quality of life.

Introduction Occult carcinoma (OBC) in contralateral breast specimens remains an underdiagnosed entity in breast cancer patients undergoing symmetrization surgery. While the primary goal of symmetrization is aesthetic and functional balance following oncologic surgery, studies indicate a higher incidence of occult malignancies in cancer patients than previously recognized. The challenge lies in preoperative imaging limitations, insufficient histological analysis, and the absence of standardized protocols for sentinel lymph node (SLN) mapping in the contralateral breast. This study aims to analyze the incidence of occult carcinoma in symmetrization specimens and discuss implications for surgical management. Materials and Methods This retrospective study included 117 patients treated between 2020 and 2023 at our institution, undergoing unilateral or bilateral breast surgery. Among them:  76 patients underwent unilateral surgery (oncoplastic breast-conserving surgery or mastectomy with symmetrization).  41 patients underwent contralateral breast surgery, including prophylactic mastectomy or symmetrization. All excised tissue was histopathologically examined, and sentinel lymph node biopsy (SLNB) was selectively performed based on clinical indications. The results were compared with previous large-scale studies, including a multicentric study (T. Sorin et al., 2015) of 2718 patients by T. Sorin et al. in 2015. [1] Discussion The analysis revealed occult carcinoma in 5 out of 41 contralateral breast surgeries (12.2%), confirming that a subset of patients harbors undiagnosed malignancies. The most significant case (Patient #5) demonstrated a paradoxical finding: a positive SLNB in the contralateral "healthy" breast while the initially diagnosed cancerous breast had a negative SLNB. This highlights the limitations of current diagnostic tools and challenges in disease staging. Key findings from our data and literature review:  Higher occult carcinoma incidence in patients with a previous breast cancer diagnosis (3.8%) compared to those without (0.6%).  Histological analysis revealed LCIS, IDC, and ILC cases, most of which were not detected by preoperative imaging.  MRI is superior to mammography and ultrasound for detecting ductal carcinoma in situ (DCIS), but limitations persist.  SLNB in the contralateral breast is rarely performed in current practice, yet our findings suggest it may be warranted in selected patients.

Conclusion Occult carcinoma remains underestimated in breast cancer patients undergoing symmetrization surgery. Our findings support enhanced preoperative screening, better intraoperative assessment, and standardized pathological evaluation. The paradoxical case of the last patient underscores the necessity of reconsidering SLNB strategies for the contralateral breast, particularly in high-risk patients. Better screening and techniques, improved communication between surgeons, radiologists, and pathologists could optimize detection and treatment, reducing unnecessary radical interventions. Future guidelines should address contralateral breast evaluation in oncologic surgery to improve patient outcomes

1. Sorin T, Fyad JP, Delay E, Rouanet P, Rimareix F, Houpeau JL, Classe JM, Garrido I, Tunon De Lara C, Dauplat J, Bendavid C, Houvenaeghel G, Clough KB, Sarfati I, Leymarie N, Trudel M, Salleron J, Guillemin F, Oldrini G, Brix M, Dolivet G, Simon E, Verhaeghe JL, Marchal F. Occult cancer in specimens of reduction mammaplasty aimed at symmetrization. A multicentric study of 2718 patients. Breast. 2015 Jun;24(3):272-7. doi: 10.1016/j.breast.2015.02.033. Epub 2015 Mar 11. PMID: 25771081.

1. Purpose

Latissimus dorsi (LD) flap is frequently used to cover soft tissue defects after mastectomy. While harvesting, the area surrounding thoracodorsal nerve is dissected and accompanied radiotherapy may cause aberrant nervous connections within the brachial plexus. We present a case of shoulder dystonia following immediate breast reconstruction with latissimus dorsi flap.

2. Methods

A 46-year-old female diagnosed with left breast cancer underwent total mastectomy and immediate LD flap with implant reconstruction in another institution. After concurrent chemoradiotherapy, patient developed focal dystonia in her left shoulder and transection of the proximal trunk of thoracodorsal nerve was performed, although without significant improvement. When referred, patient showed repetitive involuntary movement, first initiated by jerky elevation of her left shoulder, then posterior descent and mild abduction.

3. Results

We discovered an aberrant connection between lower subscapular nerve and thoracodorsal nerve. En bloc resection of the proximal portion of previously denervated thoracodorsal nerve was done. Movement partially resolved and patient could identify the origin of remnant movement; pectoralis major. In the second operation with intraoperative nerve stimulation, we re-enacted the symptom by stimulating lateral pectoral nerve. Along with denervation, pectoralis major muscle was resected totally at the clavicular part and partially at the sternocostal part. Patient now reports significant improvements in shoulder dystonia and subjective symptoms including sleep disturbance.

4. Conclusions

Present case shows an unexpected nervous stimulation challenging to apprehend with normal anatomy. Thus, branches originated from brachial plexus should be comprehensively evaluated in cases of shoulder dystonia after LD flap breast reconstruction.

Background
Breast cancer related lymphoedema (BCRL) affects up to 58% of breast cancer patients who undergo nodal dissection, chemotherapy and radiotherapy as part of their cancer treatment. The risk of developing BCRL varies between individuals, and this is likely due to underlying anatomical variations of the lymphatic pathway and other patient or treatment related factors. BRCL leads to reduced quality of life and increased risk of cellulitis. The bioimpedance spectroscopy (BIS) technology is a simple and non-invasive screening tool that can be used to enable early diagnosis of subclinical lymphoedema and allow early intervention.

Materials and methods
A prospective single centre study was conducted on patients diagnosed with breast cancer who are scheduled to commence taxane based chemotherapy or undergo axillary clearance surgery. Patients received a baseline BIS measurement, and had follow up at 12 months up to 10 years post-surgery. The aim of our study is to review the incidence of lymphoedema beyond the routine surveillance program and correlate the findings with the physical symptoms and quality of life survey.

Results
Total of 30 patients are enrolled in this study to analyse their BIS reading and determine if they developed lymphoedema.

Conclusions
This study aims to identify the long-term incidence of BCRL with up to 10 years follow up. Early identification with screening can help to facilitate timely intervention and therefore reduce the progression and severity of lymphoedema. This can enhance patient outcomes by preventing complications and improving overall quality of life.