Scientific Abstract Presentations: Global Partner E-Posters (Not for CME) Thursday, October 15 Thu, Oct 15 9:30 a.m.-5:00 p.m. CDT

Objective: Acute internal jugular vein thrombosis (IJVT) may compromise venous outflow after head and neck free-flap reconstruction; however, its incidence in the first postoperative week remains incompletely defined. We quantified early IJVT detected on routine contrast-enhanced CT obtained at intensive care unit discharge (postoperative days (POD) 3–7), evaluated laterality relative to the venous anastomosis, and assessed associated clinical outcomes and short-term venous patency. Methods and materials: We performed a retrospective cohort study of patients undergoing head and neck free-flap reconstruction from October 2021 to May 2025 who received routine contrast-enhanced CT at ICU discharge. IJVT on the index CT was classified using prespecified radiologic criteria by independent blinded dual reads with adjudication. Patient, operative, and reconstructive variables were analyzed, and factors associated with IJVT were examined using bias-reduced Firth logistic regression. Flap-related venous events and pulmonary embolism were recorded. Results: Ninety-four patients met inclusion criteria. Follow-up contrast-enhanced CT at approximately postoperative month 3 was available for all IJVT-positive cases (median, 89 days). Early IJVT was identified in 33/94 patients (35.1%), including 28 unilateral and 5 bilateral cases. Thrombosis involved the internal jugular vein ipsilateral to the venous anastomosis in 31/33 cases (93.9%). Rectus abdominis flap reconstruction was independently associated with IJVT (adjusted odds ratio, 2.83; 95% confidence interval, 1.01–7.92; P=0.048). Clinically significant venous compromise was uncommon: two patients developed venous congestion requiring re-exploration, and both flaps were salvaged. No pulmonary embolism occurred. On follow-up CT, recanalization was observed in all IJVT-positive cases. Conclusions: Routine POD 3–7 contrast-enhanced CT revealed frequent early IJVT after head and neck free-flap reconstruction, predominantly ipsilateral to the venous anastomosis. Despite the high radiographic incidence, clinically significant sequelae were rare and all IJVT-positive cases demonstrated recanalization on follow-up imaging, supporting a radiographic–clinical disconnect. The association with rectus abdominis flaps suggests a potential role of local mechanical factors in early venous stasis.

Background : Among various reconstructive options for skin defects after skin cancer excision, the bilobed flap has been widely used. During resection, the range of tissue removal may exceed the expected defect size. So, selecting the appropriate flap design and covering the defects in a specific condition remains challenging. In particular, areas such as the nasal tip or periorbital region, postoperative tissue torsion can easily occur and compromise normal structures. Traditional bilobed flaps have drawbacks such as tissue insufficiency, flap shortening during rotation resulting in excessive tension leading to distortion of the normal anatomical structures postoperatively. In response to these, we present a new bilobed flap design with dual peak.

Methods : We designed the dual peak bilobed flap. The tip of the primary lobe is peaked-shape for lengthening and to minimize waste of the tissue. The vertical height was 10~20% longer than the length between the pivot point and the distal tip of the defect site, and the transverse length was the same to the diameter. The secondary lobe is 10~20% longer or similar to the first lobe, with a similar or slightly narrower width. In that, the shape of two lobe will look like a fish-tale. Then the two lobes were transposed to cover the defect area. Redundant tissue on the tip of the primary lobe can be trimmed. Consequently, the scar lines have sharp peak in the defect and donor site. Also, we set the future scar line of the lobes were along the relaxed skin tension lines (RSTL).

Results: From October 2021 to August 2025, we experienced a total of 39 patients with defects located on the medial canthus (5 patients), upper lip (2 patients), nose (11 patients), cheek (6 patients), scalp (9 patients), temple (3 patients), vulva (1 patient), shoulder (1 patient), and chin (1 patient). No acute postoperative events such as skin flap necrosis occurred. No dog-ear or trapdoor deformities were observed during the follow-up period. Furthermore, no obvious distortion of structures such as the alar rim was noted. All scars were inconspicuous, and patients expressed satisfaction with the aesthetic outcomes.

Conclusions: The new dual peak bilobed flap offers significant advantages over traditional bilobed flaps without notable disadvantages. Particularly useful for oval-shaped defects, it prevents traction deformity by providing adequate tissue on the primary lobe's tip. Moreover, it is beneficial in areas such as the neck or eyelids, where both lobes can be designed transverse to the RSTL. Its application in areas such as the nose and eyelids can prevent traction deformities and create a scar concealing effect. The peaked shape of the primary lobe facilitates lengthening and ensures adequate tissue coverage without tension.

Purpose: Microsurgical skill acquisition requires extensive and repetitive practice; however, the influence of fatigue-related and lifestyle factors on the learning process remains poorly understood. This study prospectively evaluated the microsurgical learning curve while simultaneously assessing the impact of fatigue and habitual factors on the performance.

Methods and Materials: A prospective observational study was conducted using a chicken wing ulnar artery model. A single trainee performed consecutive microvascular end-to-end anastomosis. Fatigue was quantified using the mean sleep duration over the preceding 14 days, working hours and exercise duration within the preceding 24 hours, and the presence of a 32-hour shift on the previous day. Alcohol and caffeine intake within 12 hours prior to each practice session were recorded. Performance outcomes included vessel exposure time, anastomosis time, total operative time, suture pitch range as a quality metric, and the presence of anastomotic leakage. Multiple linear regression and logistic regression analyses were performed and learning plateaus were estimated using segmented regression models.

Experience: A total of 242 microvascular anastomosis were analyzed. All data were prospectively recorded, and only final complete datasets were included in the analysis. Because this was a training-based experimental study, no clinical follow-up was required.

Results: All performance metrics improved with increasing practice. Vessel exposure time plateaued at approximately 120 practices, whereas anastomosis time and total operative time plateaued at approximately 160 practices. Suture pitch range progressively decreased and stabilized at approximately 140 practices, indicating increased suturing uniformity. The probability of anastomotic leakage declined with experience and plateaued at approximately 130 practices. Multivariable analyses demonstrated that increased practice frequency and longer average sleep duration were independently associated with improved performance. In contrast, longer intervals between practice sessions and 32-hour shifts were associated with performance deterioration. Alcohol intake, exercise, and smaller diameter of the vessels showed an unexpected association with reduced leakage rates. Multicollinearity among independent variables was minimal.

Conclusions: Microsurgical performance improves in both efficiency and technical quality with repeated practice; however, fatigue-related and lifestyle factors significantly influence the learning process. These findings suggest that microsurgical training programs may be optimized not only by increasing practice volume but also by incorporating workload management and adequate recovery into training schedules.

References: 1. Selber et al, Tracking the Learning Curve in Microsurgical Skill Acquisition 2. Lascar et al, Training Program and Learning Curve in Experimental Microsurgery during the Residency in Plastic Surgery 3. Legevre et al, Learning curve and influencing factors of performing microsurgical anastomosis: a laboratory prospective study

Background Implant-based breast reconstruction has become the most commonly performed method after mastectomy, with increasing adoption of prepectoral direct-to-implant (DTI) techniques following advances in nipple-sparing mastectomy (NSM). Preservation of the pectoralis major muscle and the use of acellular dermal matrix have been associated with improved aesthetic outcomes and reduced animation deformity compared with subpectoral reconstruction. Despite these advantages, the longitudinal morphological stability of prepectoral DTI reconstruction remains incompletely characterized. Early postoperative appearance may not reflect stable breast contour, as progressive soft-tissue settling, implant–flap interactions, and adjuvant therapies such as radiotherapy can influence breast shape over time. Objective longitudinal evaluation using three-dimensional (3D) imaging is therefore required to clarify time-dependent morphological changes and the influence of radiotherapy.

Methods This prospective observational study was approved by the Institutional Review Board, and written informed consent was obtained. Patients undergoing unilateral NSM followed by prepectoral DTI reconstruction were prospectively enrolled between October 2021 and October 2023 and followed for 12 months. Completion of all scheduled postoperative assessments was required for inclusion. Patients with prior non-oncologic breast surgery or evidence of recurrence were excluded. Breast morphology was assessed preoperatively and at 1, 6, and 12 months postoperatively using standardized 3D photographic imaging. Linear measurements included sternal notch–to-nipple, nipple-to-midline, nipple-to-inframammary fold, sternal notch–to-inframammary fold, and breast width. Breast projection and volume were calculated, and nipple displacement was quantified using three-dimensional coordinate analysis relative to the preoperative position. Repeated-measures ANOVA was performed to evaluate time effects, radiotherapy effects, and time × radiotherapy interactions. Pairwise comparisons using the 12-month time point as the reference assessed differences from earlier postoperative assessments. Changes between 1 and 12 months were further quantified to determine the magnitude of postoperative variation.

Results Sixty-three patients were included (17 received radiotherapy; 46 did not). Repeated-measures ANOVA demonstrated significant time effects across most morphological parameters, whereas radiotherapy did not exert a consistent main effect on overall breast morphology. However, temporal pattern analysis using the 12-month time point as the reference revealed distinct postoperative trajectories between groups. In the no-radiotherapy cohort, most parameters stabilized by 6 months, whereas the radiotherapy group demonstrated additional post-radiotherapy changes with delayed stabilization in selected metrics. Directional analysis showed a general tendency toward superior, medial, and posterior nipple displacement. Medial and posterior shifts were attenuated in the radiotherapy group. Even among parameters demonstrating statistically significant time effects, the mean magnitude of change between 1 and 12 months remained less than 1 cm, supporting overall morphological stability.

Conclusion Although statistically significant temporal changes were observed, postoperative morphological variation was minimal, indicating sustained clinical stability following prepectoral DTI reconstruction. Radiotherapy did not demonstrate a consistent overall effect on breast morphology but was associated with differences in stabilization patterns. These findings support the morphological reliability of the prepectoral approach while emphasizing the importance of anticipating subtle time-dependent changes in postoperative breast contour.

Purpose The umbilicus, serving as the most common site for the insertion of the primary trocar, tends to be intruded by laparoscopically induced keloids, epidermal cysts, and iatrogenic endometriosis. After the complete excision of the lesions, reconstructive neo-umbilicoplasty is required. This article reviews the literature to explore the aesthetic components of a beautiful umbilicus, the existing reconstruction methods, and propose a new reconstruction technique.

Methods and Materials Patients with laparoscopic procedures-induced umbilical lesions who underwent umbilical lesion excision and the new surgical method between December 2022 and December 2025 were enrolled. The neo-umbilicus was reconstructed by a superior-based double triangular transposition flaps. Postoperative aesthetic outcomes were assessed using a 5-point satisfaction scale.

Results During an average follow-up of 7.8 months (ranging from 2-20 months), all 11 patients were highly satisfied with the surgical outcomes. There were no recurrences of lesions, umbilical flattening, stenosis, or flap necrosis. Additionally, the neo-umbilicus maintained normal sensation.

Conclusion The authors present a simple, rapid, and reliable method for reconstructive neo-umbilicoplasty, which avoids complex designs, achieves adequate umbilical depth, provides minimal wound tension to prevent keloid recurrence, and results in an aesthetically pleasing T-shaped (oval to linear with superior hooding) umbilical appearance.

Goals/Purpose: Forehead fat grafting is a common aesthetic procedure. While often successful, it can lead to a spectrum of complications ranging from minor nodularity and oil cysts to significant aesthetic deformities. These include severe contour irregularities from overcorrection or graft malposition in incorrect tissue planes, and long-term volume hypertrophy secondary to weight fluctuations. Surgical removal of these problematic grafts is often necessary, yet presents a significant clinical challenge. Minimally invasive procedures like injection lipolysis, liposuction, or laser-assisted devices often yield incomplete results and carry a high risk of iatrogenic injury to native tissues, leading to further fibrosis and irreversible contour irregularities. We present a systematic surgical approach designed for precise, safe, and effective removal based on pre-operative sonographic findings. Methods/Technique: A retrospective review was conducted on 32 consecutive patients who underwent surgical removal of problematic forehead fat grafts between April 2023 and October 2025. All patients underwent pre-operative high-resolution ultrasound to delineate the precise location and depth of the grafted fat (e.g., subcutaneous, subfascial, intramuscular, subgaleal). Based on these sonographic findings, a tailored surgical plan was executed: 1. Suprafascial Approach: For grafts residing in subcutaneous, subfascial, or intramuscular planes, a transverse hairline incision was used for suprafascial dissection. 2. Endoscopic Subgaleal Approach: For grafts confined to the subgaleal plane, endoscopic dissection was performed via standard scalp incisions. Of the 32 patients, 27 were treated with the endoscopic approach only, while 5 necessitated a combined dual-plane dissection. A critical step in all cases was pre-operative ultrasound-guided hydrodissection, performed immediately before surgery. This technique was used to separate the fat grafts from surrounding native tissues, facilitating safer and more efficient removal while minimizing bleeding. During subgaleal dissection, the branches of the supraorbital nerves (SON) were identified and meticulously preserved. Adjunctive procedures, such as endoscopic brow lifting or forehead reduction, were performed as indicated. Results/Complications: Significant aesthetic improvement in forehead contour was achieved in all 32 patients. Follow-up at 3 months post-operatively showed high patient satisfaction. Complications were minimal; transient sensory disturbances in the supraorbital nerve distribution were noted in a few cases but resolved completely within 3 months. No irreversible nerve injuries were observed. Conclusion: A standardized methodology for the safe and effective removal of problematic forehead fat grafts has been notably absent. Historically, uncertainty regarding the precise injection plane has made pre-operative planning difficult, often limiting surgical goals to incomplete debulking. A uni-planar, subgaleal-only approach, for instance, cannot safely address superficial (e.g., intramuscular or suprafascial) grafts, as this risks iatrogenic injury to the frontalis muscle and supraorbital nerves. Our systematic approach overcomes these limitations. First, pre-operative ultrasound provides precise anatomical mapping, allowing for a strategic surgical plan that respects safe dissection planes based on the graft's specific location. Second, ultrasound-guided hydrodissection creates a distinct avascular plane, which significantly improves the safety, speed, and efficiency of the dissection. We report this combination as a safe, reproducible, and effective method for managing these complex cases.

Purpose Constriction Ring Syndrome (CRS) is a rare congenital condition caused by fibrous amniotic bands that constrict fetal limbs, leading to deformities, neurovascular compromise, or amputation (1) . While early intervention is ideal, delayed presentations pose unique surgical and functional challenges. We present a study of 20 surgically managed cases, analyzed using Patterson's classification (2), to assess outcomes and propose a practical surgical approach.

Methods and Materials A retrospective analysis was conducted on 20 patients with CRS managed surgically over a 2-year period. Patients were classified according to the Patterson system (Types 1–4) (2). Surgical techniques were then categorized based on our findings which included circumferential release, Z-plasty, staged releases, web-space deepening, and coverage using split-thickness or full-thickness skin grafts. Functional outcomes were evaluated using age-appropriate parameters including grip strength, range of motion, ambulation, and return to daily activities. Postoperative complications and recurrence were recorded.

Results The cohort comprised 20 patients (12 females, 8 males) aged 10 months to 18 years, with 32 affected limbs (22 upper limbs, 10 lower limbs). All Patterson types were represented. Functional improvement was observed in all patients, with significant gains in hand function and ambulation. Late presenters required more extensive reconstructive procedures, including staged releases and web-space reconstruction (3). No recurrence, graft failure, or postoperative neurovascular compromise was observed during follow-up.

Discussion A structured, classification-guided approach facilitates individualized surgical planning and optimizes outcomes in CRS (2). Even in delayed presentations, functional recovery can be achieved with meticulous release and appropriate soft-tissue reconstruction (3). Technical refinements such as staged release and strategic graft selection play a critical role in preventing recurrence and preserving neurovascular integrity (4).

Conclusion CRS management should be guided by clinical severity and anatomical involvement. A classification-based surgical strategy provides predictable functional and aesthetic outcomes, even in late presenters, and supports durable long-term recovery.

References 1. Patterson TJ. Amniotic Band Syndrome: Classification and Management. Plast Reconstr Surg, 1961. 2. Venkataram V et al. Amniotic Band Syndrome: Indian Perspective. IJPS, 2014. 3. Kumar P, Shetty P, Shankhdhar VK. Late Presentation of Amniotic Band Syndrome: Challenges and Surgical Strategies. Indian J Plast Surg. 4. Foulkes GD, Reinker KA. Congenital Constriction Band Syndrome: A Review of 24 Cases. J Pediatr Orthop. 1994;14(5):624–629.

Purpose The Profunda Artery Perforator (PAP) flap has gained popularity as a reliable option for autologous breast reconstruction, particularly in patients with small-to-moderate breast volumes. Despite its advantages, the posteromedial thigh donor site is associated with a relatively high incidence of complications, such as wound dehiscence. This study aimed to retrospectively evaluate donor site complications in our institutional series and to identify independent risk factors, including patient demographics and objective anatomical measurements from preoperative imaging. Methods We conducted a retrospective analysis of 75 consecutive patients (87 flaps) who underwent PAP flap breast reconstruction at our institution between November 2019 and February 2025. Patient characteristics, including age, height, weight, and body mass index (BMI), were recorded. Additionally, we utilized preoperative computed tomography (CT) to measure the medial thigh subcutaneous fat thickness and the posteromedial fat area as potential anatomical risk factors. Donor site complications were defined as wound dehiscence, hematoma, or infection requiring intervention or prolonged care. Statistical Analysis Statistical analyses were performed using GraphPad Prism software (version 10, GraphPad Software, Inc., La Jolla, CA; accessed in March 2025). Multivariate linear regression analysis with nine independent variables was conducted to identify predictors of donor site complications. A P-value of less than 0.05 was considered statistically significant. Results The study included 87 flaps with a mean patient age of 47.1 years (range 31–79) and a mean BMI of 20.4 kg/m². The average weight of the harvested flaps was 285.5 g. Postoperative donor site complications occurred in 18 patients (19 flaps), representing an overall complication rate of 21.8%. The most frequent complication was wound dehiscence (n=16 flaps), followed by hematoma (n=2) and cellulitis (n=1). All complications were successfully managed with conservative treatment, and no patients required surgical revision. Multivariate analysis revealed that younger age (P = 0.009) and thinner medial thigh subcutaneous fat thickness (P = 0.015) were significantly associated with an increased risk of donor site complications. Other factors, such as BMI, flap weight, and thigh circumference, did not show statistical significance. Conclusions Our findings indicate that younger age and limited subcutaneous fat in the medial thigh are critical risk factors for donor site morbidity in PAP flap breast reconstruction. Younger patients may experience higher wound tension due to greater skin elasticity and increased physical activity after surgery. Furthermore, in patients with thin subcutaneous layers, the relative volume of tissue removed may lead to excessive tension during closure. Surgeons should consider these factors during patient selection and intraoperative design-such as limiting flap width or utilizing tension-reducing closure techniques- to minimize donor site complications.

Background: Exosomes have emerged as key mediators in regenerative medicine because of their ability to facilitate intercellular signaling and promote tissue renewal. Exosomes from various origins have demonstrated efficacy in tissue regeneration. Aims: To explore the potential of plasma-derived exosomes (PDEs) in wound healing through in vitro analyses and an in vivo mouse model. Patients/Methods: PDEs were isolated from blood and characterized using a nanoparticle assay. Human dermal fibroblasts (HDFs) were treated with PDEs at different concentrations to assess cell proliferation, migration, and gene expression. For in vivo evaluation, 8-mm full-thickness wounds were created on C57BL/6 mice and treated with either subcutaneous injection or topical smearing of PDEs at low (5 × 109/mL) or high (5 × 1010/mL) concentrations. Wound closure was monitored over an 8-day period, and tissue samples were collected for analysis. Results: PDEs promoted HDF proliferation and migration in vitro, with significantly higher cell migration rates (38.2, 40.2%) compared to controls (17.8%, p < 0.001). Gene expression analysis revealed the upregulation of collagen synthesis markers (COL1A1) and the downregulation of degradation markers (MMP1). Both subcutaneous injection and topical smearing methods accelerated wound healing in vivo, with closure rates of 91.8%–96.5% in treated groups versus 70.9%–72.6% in controls by day 8. Treatment increased the expression of regenerative markers (Fgf1, Fn1) while reducing the levels of inflammatory markers (Il6, Ptgs2). Conclusion: PDEs promote wound healing by enhancing cell proliferation, stimulating collagen synthesis, and modulating inflammatory responses. Both subcutaneous injection and topical smearing were effective.

Introduction: Velopharyngeal insufficiency (VPI) carries a significant psychosocial burden, impacting not just speech but the overall well-being of the pediatric patient. While the pharyngeal flap is the gold standard for functional correction, its impact on the "lived experience" of the child remains under quantified. This study aims to evaluate long-term Quality of Life (QoL) outcomes following pharyngeal flap surgery using the validated VPI Quality of Life (VPIQL) scale and to assess the concordance between patient and parental perceptions.

Methods: A cross-sectional study was conducted on 19 pediatric patients (mean age: 8.1 ± 2.9 years) who underwent pharyngeal flap surgery for VPI. The mean post-operative follow-up period was 3.1 years, ensuring long-term assessment. Both patients and their parents completed the validated VPIQL survey independently. Scores were analyzed for impact severity (Lower Score = Better QoL) and concordance between child and parent reports was tested using independent samples t-test.

Results: The cohort demonstrated low total impact scores, indicating a high quality of life. The mean patient-reported score was 22.68 ± 18.78, and the mean parent-reported score was 26.37 ± 23.28. Crucially, there was no statistically significant difference between patient and parent perceptions (p = 0.59). This strong concordance suggests that the functional improvements observed clinically are accurately reflected in the daily psychosocial reality of both the child and the family.

Conclusion: Pharyngeal flap surgery succeeds beyond anatomical correction; it effectively restores psychosocial normalcy. The statistically significant agreement between patients and parents confirms that the surgery eliminates the "burden of disease" from the family dynamic. These findings advocate for the use of VPIQL as a standard metric to document the holistic success of surgical intervention in VPI.

Purpose NUT carcinoma is an uncommon highly aggressive epithelial malignancy characterized by NUTM1 gene rearrangement, most often arising in midline structures such as the thorax or head and neck (1). Oral cavity involvement is exceedingly rare, particularly in young patients without conventional risk factors. Diagnosis is frequently delayed due to its rarity and nonspecific histology (2). While oncologic management is critical, optimal long-term functional and aesthetic rehabilitation remains underreported. We describe a rare case of oral cavity NUT carcinoma in a young, non-addicted female patient treated with radical oncologic resection followed by a structured multistage reconstructive approach to rebuild form and function.

Methods and Materials A 26-year-old female presented with a chronic ulcer involving the right buccal mucosa. Imaging revealed tumor extension into the gingivobuccal sulcus, retromolar trigone, mandibular ramus, and infratemporal fossa. She underwent wide local excision, right hemi-mandibulectomy, and MRND-III. Primary reconstruction was performed using a left free fibular osteo-cutaneous flap (3). Histopathology demonstrated a poorly differentiated carcinoma, and molecular analysis confirmed WHSC1L1–NUTM1 fusion (2). Adjuvant chemoradiotherapy (60 Gy/30 fractions with concurrent cisplatin) was administered. Two years postoperatively, she presented with right hemifacial hollowing and aesthetic concerns. Secondary reconstruction was undertaken using a free adipofascial anterolateral thigh flap to restore contour. The flap pedicle was anastomosed to transverse cervical vessels due to prior vessel depletion from radiotherapy. Persistent facial asymmetry and oral incompetence were subsequently addressed with a static-dynamic temporalis muscle sling using autologous fascia lata graft, inset to the lateral nasal ala, oral commissure, upper and lower lips, along with lateral canthopexy (4).

Experience A 4 year follow up of a rare case of NUT carcinoma in a young female

Results The fibular flap achieved stable mandibular reconstruction with satisfactory intraoral lining and occlusal alignment (3). The adipofascial ALT flap restored midfacial contour with good symmetry. Following facial reanimation, the patient demonstrated improved resting symmetry, enhanced oral competence, and measurable dynamic excursion during smiling (4). At two-year follow-up, she remained disease-free with no major flap-related complications (1).

Discussion and Conclusion NUT carcinoma of the oral cavity is rare and biologically aggressive, necessitating radical resection (1). However, survivorship in young patients demands reconstruction beyond defect closure. This case illustrates the value of a staged strategy addressing skeletal integrity, soft tissue contour, and functional reanimation. The use of alternative recipient vessels in a radiated field and incorporation of dynamic sling techniques contributed to durable aesthetic and functional outcomes (3,4).

References 1. Chau NG, Ma C, Danga K, et al. An anatomical site and genetic-based prognostic model for patients with NUT midline carcinoma: analysis of 124 patients. J Clin Oncol. 2016;34(24):2912–2917. 2. French CA. NUT carcinoma: clinicopathologic features, pathogenesis, and treatment. Pathol Int. 2018;68(11):583–595. 3. Hanasono MM, Skoracki RJ, Silva AK, Yu P. Adapting the fibula osteocutaneous flap for reconstruction of complex oromandibular defects. Plast Reconstr Surg. 2010;125(2):397–407. 4. Biglioli F, Colombo V, Tarabbia F, Pedrazzoli M, Frigerio A. Masseteric nerve transfer and temporalis muscle transposition for facial reanimation: functional outcomes. Plast Reconstr Surg. 2012;130(3):548–558.

Purpose: While breast reconstruction improves aesthetic outcomes and overall satisfaction, restoration of breast sensibility remains inconsistent (1) and its influence on quality of life (QoL) is underexplored (2). We evaluated postoperative sensory changes and their relationship with patient-reported outcomes using the BREAST-Q Reconstruction Module. Methods: A prospective cohort of 143 patients undergoing immediate (n=102) or delayed (n=41; LD n=27, DIEP n=24) breast reconstruction from February 2024 to January 2026, completed BREAST-Q questionnaires preoperatively and at 12 months. Domains included breast sensation, sensation-related QoL impact, psychosocial, sexual and physical well-being, and breast satisfaction. Paired t-tests assessed pre–post changes. Pearson correlations examined associations between postoperative sensibility and QoL domains. Multivariable ANCOVA models evaluated predictors of postoperative satisfaction and physical well-being. Results: Breast sensibility significantly declined following reconstruction in both immediate (Δ=−13.16, p<0.001, d=−0.77) and delayed groups (Δ=−18.20, p<0.001, d=−1.36), with greater reduction in delayed autologous reconstruction. DIEP patients demonstrated significantly lower postoperative sensory scores compared with LD flaps (p<0.001). Higher postoperative sensory scores were strongly correlated with improved sexual well-being (r=0.53, p<0.001) and moderately correlated with breast satisfaction (r=0.46, p=0.002), indicating that preserved sensibility was associated with improved intimacy and aesthetic perception. On multivariable analysis, radiotherapy exerted a strong independent negative effect on postoperative breast satisfaction (p<0.001; partial η²=0.453), with a significant interaction with baseline satisfaction (partial η²=0.448). Symmetrization independently improved postoperative physical well-being (p<0.001; partial η²=0.201), while baseline physical well-being remained the strongest predictor of postoperative physical outcomes (partial η²=0.693). Radiotherapy was also associated with lower postoperative sensory scores (p=0.004). Conclusions: Breast reconstruction significantly enhances QoL but results in measurable sensory decline, particularly after autologous procedures without neurotization. Importantly, preserved sensibility is strongly associated with sexual well-being and breast satisfaction, underscoring its role as a functional determinant of reconstructive success. Integrating nerve-preserving and neurotization strategies may optimize long-term patient-reported outcomes. 1. Zhang, A.; Huang, H.; Wang, M.L.; Arbuiso, S.; Black, G.G.; Ellison, A.; Otterburn, D.M. Breast Sensation and Quality of Life: Correlating Cutaneous Sensitivity of the Reconstructed Breast and BREAST-Q Scores. Ann. Plast. Surg. 2025, 94, S276–S282. 2. Hwang, Y.-J.; Lee, H.-C.; Park, S.-H.M.; Yoon, E.-S. A Comparative Study of Breast Sensibility and Patient Satisfaction After Breast Reconstruction. Ann. Plast. Surg. 2022, 88, 262–270.

Periorbital infection after blepharoplasty is rare but may result in significant functional sequelae, particularly when diagnosis and management are delayed. Progressive inflammation may lead to cicatricial changes and eyelid malposition.

Case Report: A 56-year-old female underwent bilateral upper and lower blepharoplasty at an external institution. Postoperatively, she developed persistent unilateral periorbital pain, edema, and ecchymosis. Sequential management over four weeks included corticosteroids and multiple systemic antibiotic regimens without clinical resolution. Microbiological cultures were repeatedly negative.

At 28 days postoperatively, she presented with ongoing periorbital inflammation, lagophthalmos, bilateral eyelid cellulitis, and severe left-sided cicatricial ectropion. Conservative management was optimized with modification of antimicrobial therapy and local wound care, resulting in gradual reduction of active inflammation.

Definitive surgical correction was undertaken three months postoperatively following tissue stabilization. Intraoperative findings demonstrated anterior lamellar scarring. Management included scar release, lateral canthotomy with reinsertion to the lateral orbital rim, and full-thickness skin grafting harvested from the contralateral upper eyelid, supported with a Frost suture.

Conclusion: Delayed or refractory periorbital infection after blepharoplasty may culminate in cicatricial eyelid deformity. Timely reassessment, structured management, and staged reconstruction are critical to restoring function and achieving satisfactory outcomes.

Purpose Skeletal muscle ischemic tolerance limits successful limb replantation. Static cold storage (SCS) remains the standard but may result in irreversible muscle injury after prolonged ischemia. Hypothermic machine perfusion (HMP) has emerged as a potential alternative strategy for amputated limb preservation, although the optimal perfusate remains unclear (1). This study aimed to preliminarily assess the effects of multiple perfusates on skeletal muscle preservation under HMP conditions using a rat hindlimb model. Methods Male Sprague–Dawley rats (8–15 weeks old) underwent proximal thigh amputation. Following femoral cannulation and flushing with heparinized saline, HMP was performed for 12 hours at 4°C (10 mL/h). Perfusates included normal saline (NS), lactated Ringer's (LR), histidine–tryptophan–ketoglutarate (HTK), and University of Wisconsin (UW) solution (n = 5 per group). SCS served as control. Limb weight change was measured to assess edema formation. Lactate, lactate dehydrogenase (LDH), and myoglobin levels in each perfusate were quantified. Histological evaluation was performed using hematoxylin–eosin (H&E), cleaved caspase-3 (CC3), and TUNEL staining. Muscle fiber morphology was evaluated using fiber circularity and cross-sectional area. Results UW-perfused limbs exhibited lower post-preservation weight gain, indicating reduced edema. Lactate and LDH levels were lower in UW and HTK compared with NS and LR. Histological analysis showed relatively preserved fiber architecture in the UW group. CC3 positivity averaged 4.1% in UW versus 8.0–11.4% in other groups. TUNEL positivity was 1.0% in UW compared with 5.6% (SCS), 6.5% (NS), 5.5% (LR), and 16.1% (HTK). Although differences between groups did not reach statistical significance, apoptotic markers were directionally lower in the UW group. Morphometric analysis suggested better fiber alignment and reduced interstitial expansion in the UW group. Conclusions In this rat hindlimb model, HMP using UW solution demonstrated favorable trends toward reduced edema and apoptosis, along with better preservation of skeletal muscle morphology, compared with other perfusates. These findings are consistent with previous experimental reports (2). Although this pilot study was not powered to detect statistical differences, the consistent direction of these results suggests that UW may provide a relative advantage for skeletal muscle preservation during HMP. Further investigation incorporating replantation and functional assessment is warranted. References 1. Haug V, Kollar B, Endo Y, et al. Comparison of Acellular Solutions for Ex-situ Perfusion of Amputated Limbs. Mil Med. Dec 30 2020;185(11-12):e2004-e2012. doi:10.1093/milmed/usaa160 2. Rostami S, Xu M, Datta S, Haykal S. Evaluation of Early Markers of Ischemia-reperfusion Injury and Preservation Solutions in a Modified Hindlimb Model of Vascularized Composite Allotransplantation. Transplant Direct. Jan 2022;8(1):e1251. doi:10.1097/txd.0000000000001251

The goal of this study was to analyze the clinical implications of multi-disciplinary treatment of cutaneous melanoma, and to define the critical diagnostic and therapeutic pitfalls influencing the staging of melanoma, the selection of treatments for melanoma, and the outcomes of melanoma treatment. The materials and methods used were a structured, narrative review of the completed data from all relevant publications and current melanoma treatment guidelines published between January 2000 through December 2025. The results of the reviewed articles demonstrated that biopsied excision of the primary site, followed by precise histopathological staging of melanoma represents the foundation upon which effective treatment of melanoma is based. The use of Sentinel Lymph Node (SLN) biopsy is now strongly recommended for all tumors with a Breslow thickness of greater than or equal to 0.8mm, or in tumors with high risk characteristics, as these patients will experience better prognostication and the ability to make informed decisions regarding adjuvant therapy, including the initiation of Systemic Therapy [1, 2]. While there are some indications of no survival benefit when comparing Routine Completion Lymph Node Dissection to Observation after a positive Sentinel Node biopsy, the literature indicates that the use of Tumor Boards and Individualized discussions regarding the treatment of the patient's cancer may provide important benefits in reducing the number of unnecessary surgical procedures and improving the quality of life of patients undergoing treatment [1, 3]. Studies evaluating the effectiveness of implementing multidisciplinary treatment approaches have demonstrated that coordinated care alters treatment plans for a significant percentage of patients and also reduces errors in staging and eliminates unnecessary procedures [4]. Overall, Multi-Disciplinary Melanoma Care improves staging accuracy, provides optimized therapeutic sequences, and reduces unnecessary complications. Early biopsy, correct surgical planning, proper use of Sentinel Node Biopsy, and prompt initiation of Systemic Therapy represent essential clinical pearls; while late diagnosis, incorrect biopsy techniques, and uncoordinated care represent the largest obstacles in providing effective melanoma care.

1. Márquez-Rodas, I.; Muñoz Couselo, E.; Rodríguez Moreno, J.F.; et al. SEOM-GEM clinical guidelines for cutaneous melanoma (2023). Clin. Transl. Oncol. 2024, 26(11), 2841–2855. https://doi.org/10.1007/s12094-024-03497-2

2. Garbe, C.; Amaral, T.; Peris, K.; et al. European consensus-based interdisciplinary guideline for melanoma. Part 2: Treatment-update 2024. Eur. J. Cancer 2025, 215, 115153. https://doi.org/10.1016/j.ejca.2024.115153

3. Leiter, U.; Stadler, R.; Mauch, C.; et al. Final analysis of DeCOG-SLT trial: No survival benefit for complete lymph node dissection in patients with melanoma with positive sentinel node. J. Clin. Oncol. 2019, 37(32), 3000–3008. https://doi.org/10.1200/JCO.18.02306

4. Mott, N.M.; Duncan, Z.N.; Pesavento, C.M.; et al. Implementation of melanoma guidelines in the multidisciplinary setting: A qualitative analysis. Am. J. Surg. 2023, 225(2), 335–340. https://doi.org/10.1016/j.amjsurg.2022.09.039

Background: Tubular breast deformity is a congenital anomaly characterized by breast base constriction, herniation of glandular tissue through an enlarged areola, hypoplasia of lower pole quadrants, and elevated inframammary fold. The condition presents both aesthetic and psychological challenges and requires individualized surgical planning.

Objectives: To review key surgical principles in the correction of tubular breast deformity and present outcomes following tailored reconstructive approaches.

Methods: Patients presenting with tubular breast deformity underwent preoperative clinical assessment including degree of base constriction, lower pole deficiency, asymmetry, and skin envelope characteristics. Surgical correction was individualized and included combinations of: Radial glandular scoring to release constriction Lower pole expansion Periareolar reduction Implant-based augmentation or autologous reshaping Inframammary fold repositioning Results: Adequate release of the constricted base combined with controlled lower pole expansion achieved improved breast contour and symmetry. Periareolar techniques effectively corrected areolar herniation while maintaining acceptable scar quality. Conclusion: Successful correction of tubular breast deformity relies on adherence to fundamental reconstructive principles: release of constriction, redistribution of glandular tissue, lower pole expansion, and appropriate volume augmentation. A tailored, anatomy-driven approach optimizes aesthetic outcomes and patient satisfaction.

Background Necrotizing fasciitis (NF) is a rapidly progressive, life-threatening soft tissue infection requiring immediate surgical intervention. Early differentiation from severe cellulitis remains challenging because initial clinical manifestations often overlap. The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score was developed to facilitate early diagnosis; however, external validations have demonstrated variable sensitivity and limited reliability in clinical practice. We hypothesized that incorporating readily identifiable clinical and hematologic parameters-specifically bullae formation and band-form neutrophilia-would enhance diagnostic performance. This study aimed to develop and validate a modified LRINEC (m-LRINEC) score integrating these additional predictors. Methods We performed a retrospective cohort study at National Taiwan University Hospital. Patients diagnosed with NF between 2007 and 2017 were identified using ICD-9/10 codes and confirmed by operative and/or histopathological findings. Severe cellulitis controls were selected based on standardized skin and soft tissue infection severity criteria and systemic inflammatory response syndrome (SIRS) criteria. These patients constituted the derivation cohort. An independent cohort (2018–2022) served for external validation. Clinical characteristics and laboratory data were extracted from medical records. Variables significant in univariate analysis were entered into stepwise multivariable logistic regression to construct the m-LRINEC model. Diagnostic performance was assessed using area under the receiver operating characteristic curves (AUROC). Results The derivation cohort included 103 patients with NF and 152 with severe cellulitis. Multivariable analysis identified three independent predictors of NF: baseline LRINEC score, bullae formation, and band-form neutrophilia. The m-LRINEC score was calculated as: LRINEC score + 4 points for bullae + 7 points for band forms. Compared with the original LRINEC score, the m-LRINEC demonstrated significantly improved discrimination, with AUROC values of 0.805 versus 0.635 in the derivation cohort and 0.954 versus 0.867 in the validation cohort. In monomicrobial NF, Klebsiella pneumoniae and Staphylococcus aureus were the most frequently isolated pathogens. Conclusion Incorporation of bullae formation and band-form neutrophilia substantially improves the diagnostic accuracy of the LRINEC score. The m-LRINEC provides a simple, clinically applicable tool to facilitate earlier recognition of necrotizing fasciitis and expedite surgical decision-making in high-risk patients.

Keywords: necrotizing fasciitis, cellulitis, risk factors, scoring system, LRINEC

DiGeorge syndrome is a complex genetic condition associated with craniofacial and systemic abnormalities. Facial paralysis is uncommon in this population, and reports of facial reanimation are limited. We present a 6-year-old girl with DiGeorge syndrome and incomplete left congenital facial paralysis who underwent staged facial reanimation. The first stage consisted of two cross-facial nerve grafts, followed 18 months later by free gracilis muscle transfer for smile reconstruction and anterior belly of digastric transposition for lower lip reanimation. Intraoperatively, the gracilis demonstrated a bipennate morphology with a thickened central tendon and an atypical vascular pedicle penetrating the adductor longus muscle. Variant facial vessel anatomy was also encountered, increasing surgical complexity and requiring intraoperative modification of flap inset. At 8 months postoperatively, stable facial symmetry and dynamic smile restoration were achieved without major complications. This case highlights the importance of anticipating anatomical variations when performing microsurgical facial reanimation in syndromic pediatric patients.

Background Wide excision remains essential for local control of sacral chordoma but frequently results in large composite defects involving bone, muscle, and soft tissue. Reconstruction is particularly challenging when adjuvant radiation therapy is required, as protection of adjacent organs such as the rectum becomes critical. Conventional musculofascial free flap reconstruction restores volume but may lead to donor-site morbidity, functional impairment, prolonged operative time, and delayed rehabilitation. A less invasive reconstructive strategy that simultaneously restores structural volume and protects internal organs is desirable. We present the clinical application of a customized TissueDerm® spacer as a regenerative reconstruction material and internal organ protector following sacral chordoma excision.

Methods A 65-year-old female with sacral chordoma underwent wide tumor excision at the S2–3 level performed by the neurosurgical team. Preoperative MRI evaluation and multidisciplinary discussion established the need for spacer placement to protect adjacent internal organs, particularly the rectum, during subsequent carbon-ion radiotherapy. The anticipated defect, estimated as 7 × 9.5 × 5 cm in collaboration with the neurosurgical team, enabled pre-fabrication of a customized spacer. The spacer was assembled intraoperatively and inserted following tumor resection. TissueDerm consists of animal-derived collagen promoting tissue ingrowth reinforced with a biodegradable polycaprolactone mesh for temporary structural support. Primary closure was achieved without musculofascial flap transfer.

Results The spacer effectively separated the rectum from the radiation field while maintaining structural volume and preventing contour depression. Reconstruction required less than one hour of additional operative time. The patient initiated ambulation on postoperative day 7 and was discharged on postoperative day 26 without complications. One-month postoperative computed tomography demonstrated a seroma measuring less than 50 cc without evidence of structural collapse or volume loss. Carbon-ion radiotherapy was successfully initiated 59 days after surgery.

Conclusion Customized TissueDerm spacer placement following sacral chordoma excision enabled simultaneous internal organ protection and stable reconstruction without donor-site morbidity. By separating adjacent organs from the radiation field when adjuvant radiotherapy is required, it may help reduce radiation-related injury while maintaining structural volume. The biodegradable scaffold allows progressive tissue integration, eliminating the need for secondary removal surgery. This spacer-based approach introduces a reconstructive strategy that simultaneously addresses structural restoration and radiation protection, potentially expanding reconstructive options for complex oncologic defects.

Purpose: Facial aging is characterized by soft tissue atrophy, subcutaneous fat redistribution, and dermal laxity, most pronounced in the lower face and submental region. High intensity focused ultrasound (HIFU) is the benchmark non-invasive lifting modality, whereas microwave-energy-based devices (MEBD) have recently emerged, targeting adipose tissue and dermis. While MEBD has been validated in body contouring, evidence for facial efficacy and safety remains limited. This study aimed to compare the efficacy and safety of MEBD and HIFU for facial rejuvenation in an East Asian population, emphasizing temporal improvement patterns, tolerability, and adverse events. Materials and Methods: We retrospectively analyzed 171 patients (MEBD: n = 89; HIFU: n = 82) treated at a single institution. MEBD used 7 mm and 3 mm handpieces for subcutaneous lipolysis and 13 dermal tightening, guided by fat compartment mapping. HIFU applied 600 shots at 3.0 mm and 4.5 mm depths targeting dermis and SMAS. Outcomes included blinded evaluator GAIS, Cutometer elasticity, FACE-Q satisfaction, pain, and adverse events, assessed at baseline, 1 month, and 3 months. Results: MEBD showed greater early improvements in GAIS, Cutometer parameters (R2, R5), and FACE-Q scores at 1 month, with lower pain (2.3 vs. 4.7, p < 0.001) and fewer adverse events. By 3 months, HIFU surpassed MEBD in sustained GAIS, FACE-Q, and elasticity gains. Both modalities were safe, with only mild, transient effects. Conclusions: MEBD demonstrated rapid onset, superior tolerability, and lower complication rates, while HIFU provided stronger long-term lifting and elasticity improvements. These findings support complementary clinical roles and a compartment-based rationale for facial MEBD.

Reconstruction of the plantar weight-bearing area remains challenging for plastic surgeons, especially when combined with extensive soft tissue loss. We report the case of a 52-year-old female with an extensive degloving injury to her left foot during a traffic accident. Definite reconstruction surgery was performed after a series of debridement surgeries and wound management. We used flow-through double-free flaps combining an anterolateral thigh fasciocutaneous flap with a medial plantar artery perforator flap to reconstruct the defect, including the weight-bearing heel area. Intraoperatively, indocyanine green angiography was performed before flap division and after vessel anastomosis. Another defat surgery was performed four months after the injury, resulting in a satisfactory aesthetic outcome, and allowing the patient to walk without assistance. We believe that the combination of an anterolateral thigh flow-through free flap and a medial plantar artery perforator flap may be a reliable option for composite foot reconstruction with the aid of intraoperative indocyanine green angiography.

Background Cutaneous melanoma remains the most lethal form of skin cancer, with unpredictable clinical behaviour, early metastatic spread, and variable responses to systemic therapy (1). Despite advances in targeted and immunotherapies, reliable biomarkers for risk stratification, disease monitoring, and treatment selection remain limited (2). Current prognostic assessment relies largely on clinicopathological features such as Breslow thickness (BT), ulceration and lymph node status. These however are poor indicators of disease, with thin melanomas with a BT <1mm, accounting for approximately 25% of melanoma-related deaths (3). Improved molecular markers that reflect tumour biology and microenvironmental activity are urgently needed to guide personalised management. Tumour progression is driven not only by intrinsic genetic alterations but also by dynamic signalling between melanoma cells and the tumour microenvironment (TME), including immune cells, fibroblasts, and vascular endothelium (4). Extracellular vesicles (EVs)-nano-sized, membrane-bound particles released by all cell types-have emerged as key mediators of this intercellular communication. EVs carry proteins and nucleic acids that actively influence angiogenesis, immune modulation, and metastatic dissemination. As EV cargo mirrors tumour state, EV-associated proteins represent an attractive and minimally invasive source of clinically actionable biomarkers (4). Leucine-rich alpha-2 glycoprotein 1 (LRG1) has been identified within EVs and is linked to angiogenesis, immune regulation, and poor outcomes across several malignancies (5). However, its relevance in melanoma, particularly as an EV-associated signalling molecule, remains poorly characterised. This study aims to characterise melanoma-derived EVs and evaluate the role of LRG1-mediated EV signalling in TME interactions, with the goal of identifying novel biomarker and therapeutic opportunities.

Materials and Methods Melanoma and cancer-associated fibroblast cell lines with confirmed LRG1 expression were cultured under EV-depleted conditions prior to EV isolation. Vesicles were isolated and characterised using standardised methodologies. EV-associated LRG1 was quantified using ELISA, mass spectrometry, and proteomic profiling.

Results Preliminary analyses demonstrate higher LRG1 expression in primary tumour–derived cell lines compared with metastatic counterparts, indicating stage-dependent variation and a potential role in early tumour-microenvironment interactions. Ongoing studies are quantifying EV-associated LRG1 and evaluating its functional significance within this context.

Conclusions LRG1 may represent a novel EV-associated biomarker and mediator of melanoma progression. Defining its role could support improved prognostication, patient stratification, and development of targeted therapeutic strategies.

References 1. Cancer research UK: What is melanoma skin cancer? 2025 [Available from: https://www.cancerresearchuk.org/about-cancer/melanoma/about. 2. Andrews MC, Li G, Graf RP, et al. Predictive Impact of Tumor Mutational Burden on Real-World Outcomes of First-Line Immune Checkpoint Inhibition in Metastatic Melanoma. JCO Precision Oncology 2024(8):e2300640. doi: 10.1200/po.23.00640 3. Landow SM, Gjelsvik A, Weinstock MA. Mortality burden and prognosis of thin melanomas overall and by subcategory of thickness, SEER registry data, 1992-2013. Journal of the American Academy of Dermatology 2017;76(2):258-63. 4. Hood JL. Natural melanoma-derived extracellular vesicles. Seminars in cancer biology 2019;59:251-65. doi: 10.1016/j.semcancer.2019.06.020 5. Camilli C, Hoeh AE, De Rossi G, et al. LRG1: an emerging player in disease pathogenesis. JOURNAL OF BIOMEDICAL SCIENCE 2022;29(1) doi: 10.1186/s12929-022-00790-6

Purpose Polyacrylamide hydrogel (PAAG) was predominantly used in China, Russia, and Eastern Europe in the late 90s as a permanent soft-tissue filler until accumulating reports of adverse outcomes led to progressive regulatory restrictions. Breast-related adverse events are well described (1); however, lower extremity involvement remains rarely described in the literature. We present a very late manifestation of bilateral calf complications due to PAAG occurring more than two decades after injection and analyze the radiologic–surgical correlation. Additionally, we propose a management framework to optimize patient safety and operative planning. The prolonged appearance of complication observed in this case not only exceeds that typically reported in breast PAAG literature (2) but also underscores the importance of long-term surveillance in patients treated with permanent fillers.

Methods A female patient presented in our Institution with progressive pain, soft-tissue destruction with spontaneous exposure of PAAG through the skin over 25 years after cosmetic PAAG calf augmentation performed abroad. Magnetic resonance imaging (MRI) was obtained to assess the extent of foreign material distribution as well as fascial and intramuscular extension. Management consisted of staged radical debridement, negative-pressure wound therapy, and delayed split-thickness skin graft reconstruction. Excised specimens underwent histopathologic analysis. A focused review of contemporary literature was conducted to contextualize lower extremity presentations relative to more frequently described breast complications.

Results MRI demonstrated extensive inter- and intramuscular fluid collections and a foreign body with fascial spread in both calves, enabling precise preoperative mapping. Intraoperatively, opaque and yellowish gel deposits were identified within fibrotic cavities extending beyond subcutaneous planes, closely mirroring imaging findings. Surgical management was complex because of the inflammation, adhesions, and compartmental involvement, as well as the impossibility of removing the foreign body completely in a single surgical procedure. Histopathology confirmed a chronic granulomatous foreign-body reaction without evidence of active bacterial proliferation. Sequential debridement and negative-pressure therapy allowed wound stabilization prior to definitive reconstruction with a skin graft.

Conclusion Extremely delayed PAAG-related complications can involve deep muscular and fascial planes of the lower extremity decades after injection. MRI-based mapping is critical for safe surgical planning and complete material removal. We propose a structured algorithm incorporating advanced imaging, staged radical excision, negative-pressure therapy, and delayed reconstruction to minimize morbidity. Long-term surveillance should be considered in patients previously treated with permanent fillers to mitigate late complications and enhance patient safety in contemporary reconstructive practice.

References 1. Yang Y, Li S, He J, et al. Clinicopathological Analysis of 90 Cases of Polyacrylamide Hydrogel Injection for Breast Augmentation Including 2 Cases Followed by Breast Cancer. Breast Care (Basel). 2020;15(1):38-43. doi:10.1159/000499832 2. DeLuca M, Shapiro A, Banayan E, et al. Complications 18 years after polyacrylamide hydrogel augmentation mammoplasty: a case report and histopathological analysis. J Surg Case Rep. 2021;2021(6):rjab276. Published 2021 Jun 22. doi:10.1093/jscr/rjab276

Purpose: The reconstruction of all three competences of the oral cavity (competence), sphincter function, and aesthetics after oncologic removal of total lower lip defects represents a great challenge in the field of reconstruction, since here, all three competences of the oral cavity (competence), sphincter function, and aesthetics have to be restored without making any compromises concerning the oncologic safety. While free tissue transfer is often used for the treatment of near-total or total lip loss, there are excellent regional procedures to achieve functional preservation with reduced morbidity at the donor site. In this report, we want to illustrate an exemplary case of the combination of Bernard-Burow and Karapandzic methods for the reconstruction of a full-thickness 100% defect of the lower lip, and of subsequent two-stage neck management.

Methods and Materials: A 75-year-old man was referred to our clinic with a large keratinizing squamous cell carcinoma of the lower lip. A wide excision with an oncologic margin was performed, resulting in a full-thickness defect of 100% of the lower lip. Immediate reconstruction of the lip defect was achieved by means of bilateral Bernard – Burow advancement flaps and Karapandzic rotational neurovascular flaps to ensure the continuity of the orbicularis oris muscle and the labial innervation. Histologically, a complete oncologic resection (R0 resection) was confirmed. The patient underwent no elective neck dissection during the first operation. Six months later, clinical progression of the tumor indicated a lymph node metastasis of the right neck (level Ib) (pN1). Thus, a selective neck dissection was performed. Because of a cutaneous infiltration in the cervical region, a pectoralis major myocutaneous flap was required to cover the wound. No postoperative radiotherapy was administered.

Experience: Since the neck surgery, the follow-up of the patient has been six months, and since the primary lip reconstruction, twelve months. Oral competence, speech articulation, ability to eat, and sphincter integrity were evaluated. Symmetry of the commissure, lower facial balance, and aesthetically relevant parameters, such as the integration of the scar into the skin, were also evaluated.

Results: The primary reconstruction provided complete oral competence with the preservation of the dynamic sphincter function. The patient could feed independently, and only had slightly impaired speech articulation; no functional impairments occurred. There was no clinically significant microstomia with the indication for correction. The symmetry of the commissure and the lower facial balance were preserved. The cervical reconstruction with a pectoralis major flap was done uneventfully. Since then, the patient has been free from the disease. The presented case shows that even total lower lip defects can be reconstructed using regional neurovascular techniques with the aim to preserve the function in conformity with the generally established principles of lip reconstruction (1-3). The preservation of the continuity of the orbicularis oris muscle is essential to maintain competent and articulate functions (2,4). Free flap reconstruction may not be necessary if adjacent tissues and vascular pedicles are available for safe advancing and rotating them (3,5).

Conclusion: The combined Bernard-Burow and Karapandzic reconstruction presents a successful functional and aesthetic reconstruction of full-thickness 100% lower lip oncologic resections. The preservation of the neurovascular structures and the continuity of the muscles can prevent the use of free tissue transfers in the primary stage without any compromise on the oncologic security. The staged cervical management remains important in the event of lymphatic spread of the tumor.

References: 1. Russo R, Pentangelo P, Ceccaroni A, Losco L, Alfano C. Lower lip reconstruction after skin cancer excision: a tailored algorithm for elderly patients. J Clin Med. 2024;13(2):554. doi:10.3390/jcm13020554 2. Sumarroca A, Delgado F, Larrain C, et al. Lower lip reconstruction with the Karapandzic flap or the Colmenero flap: results and analysis. Acta Otorrinolaringol (Engl Ed). 2025;76(2):83-90. doi:10.1016/j.otorri.2025.01.005 3. Shaikh AI, Khan AH, Tated S, Khubchandani N. Functional and aesthetic outcomes of different methods of reconstruction of full-thickness lip defects. GMS Interdiscip Plast Reconstr Surg DGPW. 2022;11:Doc02. doi:10.3205/iprs000167 4. Brougham ND, Adams BM. A modification of the Webster-Bernard lip reconstruction. Plast Reconstr Surg Glob Open. 2020;8(4):e2762. doi:10.1097/GOX.0000000000002762 5. Li P, Liu F, Lin Z, et al. Functional and esthetic reconstruction of composite lower lip defects with a motor-innervated chimeric facial artery buccinator myomucosal-submental island flap. J Stomatol Oral Maxillofac Surg. 2024;125(3S):101861. doi:10.1016/j.jormas.2024.101861

Purpose: In Asian rhinoplasty, increasing nasal height alone often fails to correct underlying skeletal imbalance caused by limited midfacial projection and a short, blunt anterior nasal spine (ANS), resulting in insufficient nasal base support and columellar instability. Traditional cartilage-based columellar augmentation may improve projection but can introduce excessive stiffness, impaired upper lip mobility, and unnatural animation. This study evaluates the anatomical rationale and quantitative outcomes of soft tissue–based columellar base reconstruction using the Fusion Sling–SOON composite flap. Methods and Materials: From January 2023 to December 2025, a prospectively collected clinical cohort of 214 consecutive Asian rhinoplasty patients (182 female, 32 male; mean age 28.4 years) underwent columellar base reconstruction using the Fusion Sling–SOON technique. Primary cases comprised 187 patients (87%) and revision cases 27 patients (13%). Exclusion criteria included cleft deformity, prior orthognathic surgery, and upper-lip neuromuscular dysfunction. The technique combines a nondistensible perichondrium-like Fusion Sling with vascularized SOON tissue to create an 8–10 mm composite flap positioned anterior to the membranous septum. Three graded fixation strategies were employed: caudal septal hinge (mild), mid-level septal extension graft (moderate), and superior septal extension graft (large). A representative subgroup of 63 patients underwent standardized three-dimensional Vectra photogrammetry preoperatively and at 6–12 months postoperatively (mean follow-up 9.2 months). Primary endpoints were nasolabial angle and columellar projection. Statistical analysis used paired t-tests with p<0.05 considered significant. Results: Among the 63 quantitatively analyzed patients, mean nasolabial angle increased from 93.4°±4.2° to 101.0°±3.8° (mean change +7.6°, 95% CI 6.8–8.4; p<0.001). Mean columellar projection increased by 1.9±0.6 mm (95% CI 1.7–2.1; p<0.001). Stratified augmentation demonstrated predictable increases (mild +3.2°, moderate +7.8°, large +12.4°). Across all 214 patients, there were no major complications, no flap necrosis, no infections, and no revision surgeries related to the columellar base. Upper lip mobility was preserved in all cases. No patient developed persistent stiffness or frozen smile deformity. Mean Rhinoplasty Outcomes Evaluation score improved significantly (p<0.001). Conclusion: Soft tissue–based columellar base reconstruction using the Fusion Sling–SOON composite flap produces statistically significant improvement in nasolabial angle and columellar projection while preserving physiologic upper-lip mobility. By addressing midfacial skeletal imbalance and limited ANS support, this technique offers a reliable and motion-preserving alternative to cartilage-only columellar augmentation in Asian rhinoplasty.

Background: Aesthetic surgery represents a major sector of direct patient payments in the United States. Evidence on geographic pricing patterns and their socioeconomic determinants remains limited. This study maps advertised prices for common procedures and evaluates their relationship with state-level economic indicators and purchasing power. Methods: Advertised mean prices for six common procedures were analysed across 100 US metropolitan areas (600 city–procedure observations). Provider qualifications were validated in a random 10% subset (75% ABPS-certified). Descriptive statistics and coefficients of variation (CV) quantified dispersion. State-level prices were correlated with per capita personal income and GDP. Nominal prices were adjusted for cost of living using Regional Price Parities (RPP) to derive real economic costs. Results: Mean advertised prices ranged from 6,234 USD (liposuction) to 14,639 USD (facelift), with facelifts showing the greatest dispersion (CV 38.8%). State-level analysis (n = 33) revealed a substantial association between per capita personal income and prices (r = 0.529, p = 0.0016). RPP adjustment shifted rankings: New York remained most expensive, but Michigan and Kentucky became the second- and third-costliest in real terms, surpassing California. The affordability gap was marked, with price-to-income ratios approaching 20% in Kentucky and falling to 10-11% in wealthier states. Conclusions: Aesthetic surgery pricing in the US shows pronounced geographic stratification. After accounting for regional purchasing power, the real economic burden is often greater in lower-income states, indicating that regional wealth and purchasing power fundamentally shape access in the patient-facing aesthetic surgery market.

Background The Italy-Kenya relationship in healthcare dates back over 100 years, with the first rural dispensaries founded by Italian missionaries in the early 1900s. Plastic surgery has always been very active in low and middle-income countries, particularly in the treatment of burns and post-traumatic sequelae, congenital malformations, and acute trauma.

Materials and methods We compiled data on surgical cases, lectures, cultural exchanges, and conference activities organized over the past 14 years at a level V hospital founded in the 1960s by an Italian diocese in rural Kenya.

Results Over the past 14 years, more than 30 missions led by plastic surgeons and residents have taken place, performing over 1,500 procedures and offering the full range of reconstructive techniques, from standard procedures to microsurgical reconstruction. In addition to the traditional indications of burn injuries, trauma, and congenital malformations, autologous breast reconstruction following mastectomy and morpho-functional body contouring surgery have recently been added. Research and experimental activities, including the creation of a spirulina greenhouse for dietary supplementation, have complemented clinical care. Education and staff training have also always played a leading role, with the creation of a wound care course for local staff, masterclasses, over 50 lectures for students and residents, and long-term exchanges of residents and healthcare personnel.

Conclusion The experience gained over more than a decade has demonstrated how relations between two countries can evolve into excellent opportunities, not merely for one-way healthcare assistance, but rather for mutual professional growth and learning, and serve as a blueprint for surgeons or associations interested in launching similar projects.

BACKGROUND 　Alopecia is a multifactorial disorder caused by disruption of hair follicle structures and dysregulation of the hair cycle, involving genetic and hormonal factors, reduced scalp blood flow, and perifollicular inflammation. Although pharmacological treatments such as finasteride and minoxidil are widely used, their long-term use is often limited by insufficient efficacy or adverse effects. Therefore, alternative therapeutic strategies are required. 　We have developed an ex vivo expansion method for peripheral blood mononuclear cells, generating a cell population with enhanced angiogenic, anti-inflammatory, and anti-fibrotic properties (MNC-QQ). Given accumulating evidence that paracrine factors, including cytokines and extracellular vesicles, mediate many regenerative effects, we further optimized this platform to produce a conditioned medium–oriented product (RC01). This study systematically evaluated the hair regenerative potential of ex vivo expanded peripheral blood mononuclear cells and their conditioned medium through preclinical and early clinical studies.

METHODS 　Peripheral blood mononuclear cells were cultured for one week to generate two products: MNC-QQ cells for direct cell therapy and RC01, an optimized derivative developed for conditioned medium production. For clinical studies, products were prepared from each patient's own peripheral blood, whereas preclinical experiments used cells obtained from healthy volunteer donors. Preclinical evaluation of cell therapy: 　To assess hair follicle–forming capacity, BALB/c nude mice with full-thickness dorsal wounds received local injections of MNC-QQ cells or phosphate-buffered saline (PBS). Hair follicle regeneration was evaluated histologically. Preclinical evaluation of conditioned medium: 　RC01-conditioned medium (RC01-CM) was tested using a C57BL/6 depilation-induced alopecia model with daily subcutaneous injections for seven days. Hair regrowth and hair cycle progression were quantified. In vitro, human dermal papilla cells and keratinocytes were treated with RC01-CM to assess proliferation. ex vivo hair follicle models were used to evaluate follicular growth. Clinical studies: 　Five male patients with androgenic alopecia received subcutaneous autologous MNC-QQ cell injections and were followed for six months. Separately, three patients received three monthly subcutaneous RC01-CM injections with three months of follow-up. Safety and efficacy were assessed by adverse events, hair count, hair density, hair shaft diameter, and patient-reported outcomes.

RESULTS 　In the wound-healing model, control animals developed scar tissue lacking hair follicles, whereas MNC-QQ–treated mice demonstrated de novo hair follicle formation. In the alopecia mouse model, RC01-CM significantly accelerated hair regrowth and increased anagen-phase follicles compared with saline and minoxidil groups. RC01-CM also promoted dermal papilla cell proliferation in vitro and enhanced follicular growth in ex vivo hair follicle models. 　Clinically, no treatment-related adverse events were observed. MNC-QQ cell therapy significantly improved hair count, density, shaft diameter, and patient-reported quality of life. RC01-CM injections similarly demonstrated favorable safety with early signs of hair growth promotion.

CONCLUSION 　Both peripheral blood–derived cell therapy and its conditioned medium promoted hair regeneration across preclinical and early clinical settings with favorable safety profiles. These minimally invasive, autologous, and scalable regenerative approaches represent promising therapeutic options for alopecia and warrant further controlled clinical trials.

Background: Lipoabdominoplasty combines liposuction with selective flap undermining to improve contour while preserving perfusion. Despite technical refinements, seroma remains the most common postoperative complication. Because tissue dissection and hemostasis are largely energy-dependent steps, reducing collateral thermal injury may plausibly decrease postoperative exudation and seroma formation.

Methods: In this single-center, randomized pilot study, 22 consecutive female patients undergoing standardized lipoabdominoplasty were allocated 1:1 to dissection/hemostasis with helium–plasma radiofrequency energy versus conventional monopolar electrocautery. The surgical technique, perioperative management, and follow-up schedule were standardized and performed by a single experienced surgeon. The primary endpoints were clinically relevant seroma (defined as a fluid collection >2 cm requiring aspiration, assessed clinically and with routine ultrasound through 3 months) and postoperative bleeding estimated by cumulative drain output over 48 hours. Secondary endpoints included operative time, postoperative pain (VAS) during hospitalization, and patient-reported outcomes (BODY-Q) at baseline and 3 months. An exploratory descriptive safety assessment was performed in patients receiving GLP-1 receptor agonists.

Results: Baseline demographics, comorbidities, and intraoperative parameters were comparable between groups. No major complications occurred. One seroma was observed in the electrocautery group (9%) and none in the helium–plasma group (0%). Mean 48-hour drain output was numerically lower with helium–plasma energy (95 ± 43 mL) than with electrocautery (118 ± 56 mL). Postoperative pain scores were similar between groups (median VAS ≈ 3/10). BODY-Q domains improved substantially from baseline to 3 months in both groups, with no clear between-group differences. No safety signal emerged in the GLP-1 subgroup.

Conclusions: In this randomized pilot cohort, helium–plasma radiofrequency energy was feasible and showed a favorable trend toward reduced seroma and drain output compared with conventional electrocautery, with similar pain and patient-reported recovery at 3 months. Larger, adequately powered studies with longer follow-up are needed to confirm clinical benefit.

Breast ptosis is commonly classified by nipple–areola complex (NAC) descent alone [1], which may overlook key factors such as skin quality and vertical skin excess (VSE), potentially leading to suboptimal surgical technique selection [2]. We retrospectively evaluated the impact of a three-parameter classification (NAC position, skin quality, and VSE) on mastopexy planning in 65 consecutive patients. Methods: Sixty-five patients (mean age 43.1 ± 9.2 years; BMI 24.5 ± 3.2 kg/m²) undergoing mastopexy were included. NAC position was classified using Regnault grades [1]; VSE was measured according to Tebbetts [3] and categorized as Level – (<3 cm), Level 0 (3–4 cm), or Level + (>4 cm); skin quality was assessed using clinical parameters of elasticity, firmness, and visible damage, consistent with concepts of skin quality discussed in the literature [4], and categorized as Type A (preserved), Type B (moderately compromised), or Type C (severely compromised). Surgical techniques performed were recorded (periareolar, vertical, or inverted-T mastopexy). Inter-rater reliability for skin quality and VSE assessment was evaluated between two independent plastic surgeons using Cohen's kappa. Retrospectively, each patient's data were applied to the classification to determine the recommended technique. Results: Among 65 patients, 45 (69%) had severe ptosis (Grade III), 15 (23%) moderate (Grade II), and 5 (8%) mild (Grade I). Skin quality distribution was Type A 20%, Type B 42%, Type C 38%; VSE ranged 2.0–6.5 cm (mean 3.9 ± 1.2). Clinically, 48 patients (74%) underwent inverted-T mastopexy, 12 (18%) vertical, and 5 (8%) periareolar. Retrospective application of the classification suggested that 12 patients with severe ptosis but preserved skin quality or moderate VSE could have undergone less invasive techniques, reducing operative invasiveness without compromising outcomes. Inter-rater reliability was excellent (κ = 0.80–0.86). The classification highlighted heterogeneity within identical NAC grades, supporting personalized surgical planning. Conclusion: The multidimensional classification integrating NAC position, skin quality, and VSE enables individualized mastopexy planning. It identifies patients suitable for less invasive procedures even among severe ptosis cases and supports objective surgical decision-making. Prospective validation is warranted to assess its impact on aesthetic outcomes, complications, and long-term ptosis recurrence. References

[1] Regnault P. Breast ptosis. Definition and treatment. Clin Plast Surg. 1976 Apr;3(2):193-203. PMID: 1261176. [2] See MH, Yip KC, Teh MS, Teoh LY, Lai LL, Wong LK, Hisham Shunmugam R, Ong TA, Ng KH. Classification and assessment techniques of breast ptosis: A systematic review. J Plast Reconstr Aesthet Surg. 2023 Aug;83:380-395. doi: 10.1016/j.bjps.2023.04.003. Epub. [3] Tebbetts JB. A process for quantifying aesthetic and functional breast surgery: I. Quantifying optimal nipple position and vertical and horizontal skin excess for mastopexy and breast reduction. Plast Reconstr Surg. 2013 Jul;132(1):65-73. doi: 10.1097/. [4] Goldie K, Kerscher M, Fabi SG, Hirano C, Landau M, Lim TS, Woolery-Lloyd H, Mariwalla K, Park JY, Yutskovskaya Y. Skin Quality - A Holistic 360° View: Consensus Results. Clin Cosmet Investig Dermatol. 2021 Jun 14;14:643-654. doi: 10.2147/CCID.S309374.

Introduction Multidrug-resistant (MDR) Pseudomonas aeruginosa wound infections remain difficult to manage because biofilm formation limits antibiotic penetration and promotes persistent infection. In addition, increasing antimicrobial resistance narrows effective topical treatment options and raises concern for further resistance selection with repeated antibiotic exposure. We evaluated the in vivo antibacterial, anti-biofilm, and wound-healing efficacy of bacteria-targeting Au/ZnO-Con A nanoparticles activated by white light in a murine skin infection model and explored their translational potential as a non-antibiotic local therapy. Methods A splinted 5-mm full-thickness dorsal skin wound was created in male C57BL/6NTac mice and inoculated with MDR P. aeruginosa. After 24 hours, bacterial colonization/biofilm formation was confirmed using fluorescence imaging (MolecuLight i:X), and mice were randomized into four groups (n=6/group): PBS, topical tobramycin ointment, Au/ZnO-Con A (100 µL; 4×10^8 particles/mL), or Au/ZnO-Con A plus white-light irradiation (20 minutes immediately after nanoparticle treatment). Treatments were administered on days 1 and 5. Serial wound photographs and caliper-based measurements were obtained on days 0, 1, 3, 5, and 8 to assess wound healing progression. On day 8, residual bacterial burden was quantified by culture (CFU/mL) from wound swabs. Histologic evaluation with H&E staining was performed for morphometric assessment of granulation tissue formation and re-epithelialization. Results Biofilm-associated fluorescence was detected in all wounds after the initial 24-hour inoculation period, confirming successful establishment of the infected wound model. Compared with PBS, both the Au/ZnO-Con A plus white-light group and the tobramycin group demonstrated improved wound healing, with smaller wound areas over time and earlier separation from controls after treatment initiation. On day 8, quantitative cultures showed complete bacterial clearance (0 CFU/mL) in the Au/ZnO-Con A plus white-light and tobramycin groups, whereas persistent bacterial growth remained in the PBS and Au/ZnO-Con A (no light) groups. Fluorescence imaging demonstrated progressive reduction of biofilm-associated cyan fluorescence in the Au/ZnO-Con A plus white-light and tobramycin groups, while PBS showed increasing fluorescence over time. Histologic morphometric analysis showed significantly increased granulation tissue formation in the Au/ZnO-Con A plus white-light group compared with PBS, with improved re-epithelialization observed in treatment groups versus PBS. Au/ZnO-Con A without light did not achieve antibacterial or wound-healing effects comparable to the light-activated nanoparticle or tobramycin groups, supporting a light-dependent therapeutic mechanism. Conclusions White light-activated Au/ZnO-Con A nanoparticles produced potent in vivo antibacterial and anti-biofilm effects against MDR P. aeruginosa while improving wound healing, with efficacy comparable to topical tobramycin in this model. Clinically, this approach is notable because it combines localized bacterial targeting with externally controllable activation, offering a potential antibiotic-sparing strategy for biofilm-prone wounds. If optimized, this platform may be useful as an adjunct or alternative in settings where resistance, recurrent infection, or concern for prolonged topical antibiotic exposure limits current management. Further work is needed to define dose optimization, light-delivery protocols, safety, and reproducibility in clinically relevant wound conditions.

Skin grafting is a standard surgical treatment for severe burns and traumatic skin defects; however, in cases of extensive burns, the availability of donor skin is often limited. Although cultured epidermal autografts are clinically available, they lack dermis and skin appendages such as hair follicles and sweat glands and therefore remain inferior to autologous skin grafts. Despite advances in stem cell biology and tissue engineering, the generation of complete human skin with both a robust epidermal barrier and skin appendages has not yet been achieved. We previously established a developmental niche–based strategy using p63 knockout (KO) mouse embryos (1). The transcription factor p63 is essential for epidermal and appendage development, and its genetic ablation results in a single-layered immature epithelium lacking appendages. Injection of mouse pluripotent stem cells into p63 KO embryos enabled donor-derived cells to exploit the host developmental environment to generate epidermis and functional appendages, including hair follicles. The resulting skin could be transplanted as a graft, maintaining hair growth and cycling without immunosuppression. We further showed that human immortalized keratinocytes injected into post-implantation p63 KO embryos formed human epidermis–like structures. However, because immortalized keratinocytes exhibit altered signaling responses and reduced niche dependency, primary human keratinocytes were used for physiological evaluation. The purpose of this study was to determine whether xenogeneic primary human keratinocytes can undergo physiological epidermal stratification within the post-implantation p63 knockout embryonic niche. Primary human keratinocytes were maintained on 3T3-J2 feeder cells in modified Green's medium and characterized prior to transplantation. In culture, cells expressed basal markers KRT5/14 and p63, while lacking expression of differentiation markers KRT1/10. Cells were injected as a single-cell suspension into p63 KO mouse embryos via in utero delivery at Embryonic day (E) 13.5 (n = 23). Twelve embryos developed to E 18.5, and all surviving embryos (12/12) demonstrated GFP-positive human cell engraftment. In embryos exhibiting robust engraftment, engrafted primary keratinocytes formed organized sheet-like epidermal structures and underwent stepwise stratification within the embryonic in vivo environment. Immunohistochemical analysis demonstrated the establishment of distinct epidermal layers: a basal layer positive for KRT5/14 and p63, suprabasal layers expressing KRT1/10, and upper layers positive for involucrin and loricrin, consistent with terminal differentiation. These findings demonstrate that the p63 KO embryonic niche provides instructive developmental cues that enable xenogeneic epidermal stratification of primary human keratinocytes within a dermal microenvironment, establishing a robust in vivo platform for human epidermal integration and future appendage regeneration.

(1) Nagano, H. et al. Skin graft with dermis and appendages generated in vivo by cell competition. Nat Commun 15, 3366 (2024).

Introduction The inframammary fold (IMF) represents an essential anatomical landmark for the aesthetic and functional definition of the breast. Its integrity provides inferior support, determines nipple projection, and contributes decisively to thoracic symmetry. Recreation of the IMF poses a technical challenge, requiring stable fixation, appropriate curvature, and minimal morbidity (1). Various methods have been proposed for IMF recreation, which can be classified into four main categories: use of local tissues, suture suspension, external devices, and acellular dermal matrices (2). In this article, we describe the technique originally utilized by Handel and Jensen since 1988, which employs local tissues (adipofascial flap) for IMF recreation (3). However, in this clinical case, it was adapted from its original description for implant- or expander-based breast reconstruction to use solely autologous local tissues.

Clinical Case A 52-year-old woman sustained high-energy motor vehicle trauma with seatbelt-related right thoracic injury: multiple rib fractures, pectoralis major disinsertion, medial IMF loss with inferior pole deficit, and nipple-areola complex displacement. Reconstructive committee planned secondary breast reconstruction with pectoralis repositioning, volume symmetrization, and IMF recreation.

Surgical Technique Under general anesthesia, a lateral IMF incision was performed, followed by subglandular dissection and pectoralis muscle mobilization; the pectoralis muscle flap was then advanced and fixated. An inferior skin flap was dissected in a deep plane above the thoracoabdominal fascia to mobilize it to the neofold position. An adipofascial flap incorporating Scarpa's fascia was created. The adipofascial flap was anchored to the thoracic wall, forming the neo-IMF. Finally, the breast gland was mobilized and positioned to fill the inferior pole. In a second-stage procedure, lipotransfer was performed for right breast symmetrization.

Results The patient exhibited favorable evolution without complications. The neo-IMF demonstrated adequate definition and symmetry with the contralateral breast from the first follow-up visit. Subsequent lipotransfer achieved mammary symmetrization. The patient reported high satisfaction with the aesthetic outcome and improvement in body image.

Conclusions Although multiple techniques exist for its reconstruction, they must be selected and tailored to each case. In this instance, the patient's adipofascial flap and autologous breast gland mobilization were utilized instead of implants or expanders. This modification of the Handel and Jensen technique demonstrates an innovative and effective adaptation for managing post-traumatic breast defects. This approach not only preserved native tissue, minimizing complications associated with prostheses or expanders, but also achieved satisfactory aesthetic and functional reconstruction with appropriate IMF restoration and breast symmetry. These findings underscore the value of customizing established techniques to the clinical context, promoting safe and accessible reconstructive options in acute trauma settings, particularly in resource-limited environments.

References 1. Nava M, Quattrone P, Riggio E. Focus on the breast fascial system: a new approach for inframammary fold reconstruction. Plast Reconstr Surg. 1998;102(4):1034-1045. 2. Kraft CT, Rendon JL, Koutz CA, et al. Inframammary fold reconstruction in the previously reconstructed breast: a comprehensive review. Plast Reconstr Surg. 2019;143(4):1019-1029. 3. Handel N, Jensen JA. An improved technique for creation of the inframammary fold in silicone implant breast reconstruction. Plast Reconstr Surg. 1992;89(3):558-562.

Summary Background: The deep inferior epigastric perforator flap (DIEP) is the gold standard for autologous breast reconstruction. The procedure and peri-operative period is associated with the risk of severe post-operative complications, like venous thromboembolic events (VTE) and lung embolism. Whether the intraabdominal pressure (IAP) increases after closure of the abdominal defect, thereby potentially affecting the venous backflow and the risk of VTE, is currently not known. Aim: The primary aim is to test if closure of the abdominal donor site increases the IAP in women undergoing secondary DIEP flap breast reconstruction. Materials and method: By an Unometer, we measured the intravesical pressure as a surrogate marker for the IAP, at baseline, immediate after- and 24 hours after abdominal skin closure, for 13 patients. Results: The mean IAP increased from 6.1 mmHg (95% CI 4.6-7.7) at baseline to 9.0 mmHg (95% CI 8.0-10.0) immediate after skin closure (mean diff. 2.9 (95% CI 1.0-4.8) (p=0.007)) and further up to 11.7 mmHg (95% CI 9.0-14.5) 24 hours after closure (mean diff. 5.3 (95% CI 1.4-9.1) (p=0.012). We found that IAP varies among the patients, regardless of the tightness of abdominal closure or rectus plication (n=3). Isolated no patients showed abnormal levels of IAP (>12 mmHg) immediate after closure, while 8 out of 12 patients (67%) show IAP above the normal range after 24 hours. One patient developed a non-fatal lung embolism. Conclusion: The mean IAP increases significantly over the post-operative period after DIEP flap reconstruction, although abnormal IAP values are only seen 24 hours after closure of the skin.

Objective: Evaluate whether brief low-temperature plasma (LTP) applied to mouse adipose stem cells (mASC) and/or decellularized Wharton's jelly (dWJ) enhances performance toward a tissue-engineered dressing for wound healing.

Materials and Methods: mASC received LTP (1 kV, 20 kHz, 15.6 mm, 1 min); dWJ received LTP (1 kV, 20 kHz, 1 mm, 15 min). mASC (1.25 × 10^4 cells/cm^2) were seeded onto dWJ under four conditions: (1) dWJ + cell (no LTP), (2) dWJ + cell/LTP (cells pretreated), (3) dWJ/LTP + cell (scaffold pretreated), and (4) dWJ/LTP + cell/LTP (both pretreated). Proliferation was quantified by CCK-8 (OD450–630) on Days 1–3. dWJ wettability was assessed by contact angle before and after LTP. A mouse back wound model was established, and materials from four groups were applied. The wounds were monitored for two weeks. Changes in wound area were measured, and histological examinations of the tissue were performed and compared.

Results: All groups exhibited continuous growth over three days. Dual pretreatment achieved the highest proliferation (fold vs Day 0: Day 1, 2.66 ± 1.18; Day 2, 3.25 ± 0.95; Day 3, 3.58 ± 0.28). Cell-only pretreatment ranked next (2.38 ± 1.61; 2.66 ± 1.45; 2.88 ± 0.09), followed by scaffold-only (1.63 ± 0.48; 2.07 ± 0.26; 2.48 ± 0.28), all exceeding no LTP (1.39 ± 0.09; 1.82 ± 0.08; 2.42 ± 0.85). LTP changed the dWJ contact angle, indicating modified surface properties.

Conclusions: Brief LTP enhances mASC proliferation on dWJ, with dual pretreatment providing the greatest benefit and cell pretreatment contributing more than scaffold pretreatment. LTP-induced surface modifications of dWJ may support improved cell performance. Optimizing LTP dose, exposure distance, and timing could further advance dWJ-based, cell-laden dressings for reconstructive applications

Background: Lymphatic complications following medial thighplasty are underreported yet clinically relevant, particularly in post-bariatric patients. The medial thigh contains a thin dermato-adipose layer and a superficial three-dimensional lymphatic network converging toward the femoral triangle along the great saphenous vein. Disruption of this system may result in lymphocele or secondary lymphedema. We evaluated whether an anatomy-based, supra-fascial dissection combined with water-assisted liposuction (WAL) reduces lymphatic morbidity. Additionally, we analyzed secondary lymphatic complications referred from external institutions. Methods: A retrospective analysis was performed of all medial thighplasties with water assisted liposuction (WAL) technique at our institution between 2016 and 2026. Of 260 extremity contouring procedures, 116 patients underwent medial thighplasty with WAL (Body-jet® system). Demographics, bariatric history, BMI, weight loss, and postoperative lymphatic complications were recorded. A separate cohort included patients referred for lymphatic complications following thighplasty performed at external institutions. High-resolution MRI with 3D reconstruction was used to identify injury patterns and guide surgical planning. Microsurgical lymphovenous anastomosis (LVA), clipping, or combined approaches were performed when indicated. Results: Among 116 patients (110 female, 6 male; mean age 48 years; mean BMI 28; mean weight loss 58 kg), all procedures were performed using WAL. One patient (0.86%) developed a postoperative lymphocele, successfully treated at our center. A total of 51 external patients were referred with lymphatic complications, 8 of whom had undergone medial thighplasty externally. In this subgroup (mean age 58 years; mean BMI 28), prior liposuction technique was non-WAL in four cases and unknown in one. MRI with 3D reconstruction demonstrated reproducible injury patterns at the vertical convergence point ("Seki point") and within the saphenous triangle. All thighplasty-associated lymphatic complications were successfully managed with LVA, clipping, or a combined microsurgical approach. Conclusions: Anatomy-guided, supra-fascial medial thighplasty combined with WAL demonstrates a very low lymphatic complication rate. Precise knowledge of lymphatic convergence zones is essential to minimize morbidity. In cases of secondary lymphatic injury, advanced imaging and microsurgical expertise allow reliable functional restoration. These findings support an anatomy-driven approach as a safety standard in post-bariatric thigh contouring.

Purpose: The anterolateral thigh (ALT) flap is one of the most versatile flaps in reconstructive surgery, but its variable perforator anatomy can make flap harvest technically challenging. Suprafascial dissection allows the harvest of thin, pliable flaps but requires accurate identification and preservation of perforators. Previous studies have demonstrated significant anatomical variability of ALT perforators across populations (1,2). This study aimed to evaluate the intraoperative vascular anatomy of the suprafascial ALT flap using a lateral approach.

Methods and Materials: A prospective observational study was conducted in patients undergoing suprafascial ALT flap harvest using the lateral approach between June 2022 and January 2024. Preoperative handheld Doppler was used to localize cutaneous perforators. Intraoperative assessment included perforator location, number, type, and vascular origin. Perforators were categorized as musculocutaneous, septocutaneous, or musculoseptocutaneous and classified according to Yu's ABC system (1). The origin of perforators from branches of the lateral circumflex femoral artery was recorded (3,4).

Experience: Twenty-seven patients underwent suprafascial ALT flap harvest, with 39 perforators identified intraoperatively.

Results: Of the 39 perforators, 51.3% were musculocutaneous, 25.6% septocutaneous, and 23.1% musculoseptocutaneous. Most perforators (87.2%) originated from the descending branch of the lateral circumflex femoral artery, consistent with prior anatomical studies (3). According to Yu's classification, 59% were Type B, 30.75% Type A, and 10.25% Type C (1). Preoperative Doppler localization was accurate in 84.6% of cases. Flap-related complications were more commonly associated with musculocutaneous perforators. These findings are consistent with previously reported variability in large ALT flap series (5).

Conclusions: The suprafascial ALT flap demonstrates considerable variability in perforator anatomy. The lateral approach facilitates reliable identification and preservation of perforators during dissection. Improved understanding of perforator patterns enables precise suprafascial harvest and supports the design of thin, pliable flaps tailored to reconstructive requirements.

References

1. Yu P. Characteristics of the anterolateral thigh flap in a Western population and its application in head and neck reconstruction. Head Neck. 2004;26:759–769.

2. SeethaRaman SS, Yadav PS, Shankhdhar VK, Dushyant J, Prashant P. Anthropomorphic and perforator analysis of anterolateral thigh flap in Indian population. Indian J Plast Surg. 2013;46:59.

3. Choi SW, Park JY, Hur MS, et al. An anatomic assessment on perforators of the lateral circumflex femoral artery for anterolateral thigh flap. J Craniofac Surg. 2007;18:866–871.

4. Wong CH, Wei FC, Fu B, Chen YA, Lin JY. Alternative vascular pedicle of the anterolateral thigh flap: the oblique branch of the lateral circumflex femoral artery. Plast Reconstr Surg. 2009;123:571–577.

5. Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg. 2002;109:2219–2226.

Purpose – Medial canthal reconstruction after oncologic resection is uniquely challenging due to thin periocular skin, the native concavity of the region, and proximity to the eyelid margin and lacrimal drainage system. Technique selection must be tailored to the defect to minimize functional and aesthetic complications. We present a practical, defect-based approach illustrated by two cases reconstructed with local flaps, emphasizing functional preservation and aesthetic contour restoration. Methods and Materials – Two consecutive patients underwent medial canthal reconstruction after oncologic excision for basal cell carcinoma. Defects were assessed by depth, eyelid margin involvement, and suspected lacrimal drainage disruption, which guided technique selection. Because both defects required stable coverage with restoration of medial canthal concavity and minimization of webbing, reconstruction was performed using local/locoregional flaps selected according to defect geometry and adjacent tissue availability, including glabellar-based and other local flap designs (1,2). Functional assessment at follow-up focused on eyelid competence (complete closure, lagophthalmos, exposure symptoms) and lacrimal function (epiphora and need for targeted evaluation). Experience – Case 1: Male who presented with medial canthal basal cell carcinoma measuring approximately 2 cm in diameter; after excision, reconstruction was performed using a local flap. Follow-up was 3 months. Case 2: Male with basal cell carcinoma approximately 3 × 2 cm with eyelid margin involvement; reconstruction was performed using a locoregional flap after excision and margin management. Follow-up was 3 months. Results – Both reconstructions healed without flap loss. At final follow-up, eyelid closure was complete in both cases with no exposure symptoms. Medial canthal contour and concavity were restored with acceptable scar placement and minimal webbing. Neither case showed epiphora, and no revision procedures were necessary. Conclusions – In medial canthal reconstruction after oncologic resection, a defect-based strategy centered on depth, eyelid margin status, and lacrimal risk supports reliable technique selection. Local and locoregional flaps provide stable coverage for complex or contour-critical defects and can preserve eyelid function while achieving satisfactory aesthetic integration (1-3). 1. Bhandari PS. Reconstruction of medial canthal defects by local/loco-regional flaps. J Craniofac Surg. 2022. 2. Cespedes RAD, Evangelio LO. Utility of the glabellar flap in the reconstruction of medial canthal tumors after Mohs surgery. Turk J Ophthalmol. 2021. 3. Ekin MA, Ugurlu SK. Effect of eyelid involvement in the reconstruction of medial canthal defects. Facial Plast Surg. 2019. doi:10.1055/s-0039-1694722

Transfeminine individuals undergoing orchiectomy face an increased risk of early osteopenia and osteoporosis. Here, we investigated whether melatonin enhances estradiol (E2)-mediated skeletal protection after androgen deprivation using an orchiectomy plus E2 mouse model designed to mimic gender-affirming hormone therapy (GAHT). Bone architecture was assessed by micro-computed tomography (micro-CT) and histology. Enriched LEPR⁺ bone marrow stromal cells (MSCs) were analyzed for cell viability and osteogenic mineralization. In parallel, publicly available single-cell RNA-seq datasets were reanalyzed to characterize sex-steroid and melatonin receptor expression across bone marrow stromal populations. Orchiectomy caused marked trabecular bone loss, which high-dose E2 only partially rescued and failed to restore the LEPR⁺ progenitor pool. Single-cell analyses identified Lepr⁺ MSCs as a stromal subset enriched for Ar/Esr1, with further upregulation during fracture repair. These progenitors also expressed Mtnr1a/Mtnr1b, supporting coordinated sex-steroid and circadian regulation of skeletal progenitor function. Orchiectomy reduced pineal expression of melatonin synthesis enzymes (Tph1/Ddc), and this deficit was only partially corrected by E2 treatment. Functionally, combined E2-melatonin treatment significantly improved LEPR⁺ MSC viability and mineralization in vitro. In vivo, co-treatment increased trabecular number, bone volume fraction, and connectivity density beyond E2 alone. Together, these findings suggest that E2 maintains mineralization capacity but is insufficient to replenish skeletal progenitor reserves, whereas melatonin provides complementary progenitor support. Therefore, E2-melatonin co-therapy represents a mechanism-based and low-risk strategy to mitigate GAHT-associated bone loss and warrants clinical evaluation.

Introduction: The umbilical scar is a frequent concern in patients undergoing abdominoplasty.Treatment of the umbilical scar is extremely important in abdominoplasties, with the umbilicus being the main aesthetic unit of the abdominal wall15. The objective of this study is to report the experience with the neo-omphaloplasty technique after anchor abdominoplasty in post-gastroplasty patients using bilateral skin flaps sutured to the aponeurosis and to each other to determine the umbilication (1). Concern about the umbilicus began to develop in (1956), with the work of Andrews who reconstructed it, and Vernon (1957), who performed its transposition, using circular incisions2,3. The objective of this study is to report the experience with the neo-omphaloplasty technique after anchor abdominoplasty in post-gastroplasty patients using bilateral skin flaps sutured to the aponeurosis and to each other to determine the umbilication. Methods: From January 2021 to December 2025, 22 abdominoplasties were performed using the neo-omphaloplasty technique in female patients aged between 32 and 67 years. The patients underwent abdominoplasty with the anchor technique. All patients underwent neo-omphaloplasty with flaps that were defatted and sutured to the aponeurosis with 4.0 monocryl. The ends of the flaps were joined with interrupted sutures to form the umbilication. Results: The evaluation of the umbilicus submitted to this type of procedure has confirmed results with a high level of aesthetic quality, due to its natural characteristics, the absence of scars, the ease of execution, and the low rate of complications. Regarding the umbilical scar, we had one case of dermatitis due to intertrigo that required a new approach to reconstruct the neoumbilicus. There were no cases of necrosis, stenosis, or dehiscence in the suture lines of the neoumbilicus in this reported series. Conclusion: Neo-omphaloplasty using skin flaps proved to be an easy-to-perform umbilical reconstruction method, providing a natural-looking aesthetic result and a lower incidence of complications. References: 1.Abdominoplasties: scarless and fat-free neo-omphaloplasty. Joseph Alexander Abreu 2. Seung-Jun O, Thaller SR. Refinements in abdominoplasty. Clin Plast Surg. 2002;29(1):95-109. 3. Ribeiro L, Muzy S, Accorsi A. Omphaloplasty. Ann Plast Surg. 1991;27(5):457-75. 4. Cortes JES, Oliveira DP, Sperly A. Anchor abdominoplasties in formerly obese patients. Rev Bras Cir Plast. 2009;24(1); 57 5. Cavalcanti ELF. Neoumbilicoplasty as an option for umbilical reconstruction in post-gastroplasty anchor abdominoplasties. Rev Bras Cir Plast. 2010;25(3): 509-18

Introduction: Proximal phalanx fractures are a common yet challenging injury, frequently managed surgically. Evidence supports conservative management, however patient-focused outcomes remain unknown.

Aim: To investigate patient-focused outcomes of conservative management of proximal phalanx fracture and quantify the healthcare resources required to deliver care.

Methods: Adults with single extra-articular proximal phalanx fractures were recruited at their initial presentation to the plastic surgery outpatient clinic. Closed reduction was performed in cases of unacceptable fracture alignment. Conservative management included a hand-based orthosis in maximal MCP joint flexion and hand therapy. Outcomes collected at 4,8 and 12 weeks included Hand function (MHQ, RTW), Pain (NPRS), Quality of Life (EQ5D3L), satisfaction, range of motion (TAM), adverse events and healthcare usage.

Results: Thirty individuals consented to participate. Two participants (2/30, 7%) were withdrawn after losing fracture position. Data was analysed for twenty-eight participants (16 female, 57%;12 male, 43%) with median age 40.5 years (35.5 IQR). Significant improvement was seen in all outcomes over 12 weeks. A significant difference in hand function between the affected and unaffected hand was reported at 12 weeks. Normal hand use for work resumed 3 weeks after injury (median, 7 IQR), and 10 weeks for sport (median, 7 IQR). Pain resolved by 8 weeks (1/10 = no pain median, 1 IQR). Total active range of motion was 241, or 92% of the unaffected hand (median, 18 IQR). Half (14/28, 50%) required fracture reduction. Other healthcare usage included: 1 X-ray (median, 1 IQR) after commencing treatment and 5 appointments (median, 11 IQR). All participants (100%) were satisfied with their treatment.

Conclusions: Conservative management of extra-articular proximal phalanx fractures demonstrated good patient-focused outcomes, with high levels of satisfaction, without the need for surgery.

Background: Soft tissue defects of the distal third of the leg and ankle pose reconstructive challenges owing to thin soft tissue, superficial tendons and limited local options. The distally based peroneus brevis muscle flap is a versatile alternative but large case series evaluating its outcomes are limited. (1) We report our institutional experience with 100 consecutive distally based peroneus brevis flaps for distal leg and ankle reconstruction.

Methods: A retrospective review was performed of patients who underwent reconstruction with a distally based peroneus brevis flap at our institution between 2015 and 2024. Demographic data, defect etiology and size, flap dimensions, operative details, adjunctive procedures, follow up duration, flap survival, complications (partial/total loss, infection, donor site morbidity), reoperation rates and functional outcomes were recorded.

Results: One hundred distally based peroneus brevis flaps were performed in 100 patients (mean age 40.5 year). Mean defect width was 4 cm or lesser. Flap survival was achieved in 96 % cases. Graft loss was the commonest complication. There were no significant functional deficits attributable to peroneus brevis harvest when peroneus longus function was preserved. Median follow up was 1 year and 5 months, during which satisfactory contour due to auto thinning and durable coverage were observed.

Conclusion: The peroneus brevis muscle flap is a reliable, versatile option for reconstruction of small to moderate sized distal leg and around ankle defects, providing high rates of flap survival, low donor site morbidity and acceptable functional and aesthetic outcomes. (2,3) It is particularly useful where microsurgical reconstruction is impractical. (4) Careful patient selection and attention to flap design mitigate complications. These findings support broader adoption of the flap as a primary reconstructive option in appropriately selected patients.(5)

References : 1. Mégevand V, Scampa M, Suva D, Kalbermatten DF, Oranges CM. Versatility of the Peroneus Brevis Muscle Flap for Distal Leg, Ankle, and Foot Defects: A Comprehensive Review. JPRAS Open. 2024 Sep;41:230–9 2. Bajantri B, Bharathi R, Ramkumar S, Latheef L, Dhane S, Sabapathy SR. Experience with peroneus brevis muscle flaps for reconstruction of distal leg and ankle defects. Indian J Plast Surg. 2013 Jan;46(1):48–54. 3. Sahu S, Gohil AJ, Patil S, Lamba S, Paul K, Gupta AK. Distally based peroneus brevis muscle flap: A single centre experience. Chin J Traumatol. 2019 Apr;22(2):108–12. 4. Halverson S, Fadell N, Boyer M, Brogan D. Limitations of Computed Tomography Angiography in Preoperative Planning of Peroneus Brevis Rotational Flap. Plast Reconstr Surg Glob Open. 2023 Jan;11(1):e4774. 5. Cho EH, Shammas RL, Carney MJ, Weissler JM, Bauder AR, Glener AD, et al. Muscle versus Fasciocutaneous Free Flaps in Lower Extremity Traumatic Reconstruction: A Multicenter Outcomes Analysis. Plast Reconstr Surg. 2018 Jan;141(1):191–9.

Background: Reconstructing lower limb defects is often challenging due to limited soft tissue mobility and the exposure of critical structures. Perforator-based flaps offer reliable solutions with minimal donor site morbidity. However, ensuring adequate tissue perfusion remains a critical factor for success. This study evaluates the efficacy of Infrared Thermography as a non-invasive tool for preoperative mapping and postoperative monitoring of perforator flaps.

Materials and Methods: A prospective observational study was conducted on 82 patients undergoing lower limb reconstruction with fascio-cutaneous perforator flaps (V-Y advancement, Keystone, and Propeller flaps). Perforator mapping was performed preoperatively using Infrared Thermography, validated with Doppler ultrasonography, and confirmed intraoperatively. Postoperative viability was assessed via thermal imaging on days 1 and 7, analyzing absolute temperatures and gradients relative to surrounding skin. Statistical correlations were made between outcomes and anatomical, thermal, and systemic factors (e.g., diabetes, smoking, and CRP levels).

Results: IRT demonstrated a high sensitivity (97.9%) and positive predictive value (95.2%) for identifying perforators. Minor complications (9 cases) occurred exclusively in patients with diabetes mellitus (p < 0.05) and were significantly associated with preoperative hyperglycemia. Regarding postoperative monitoring, at the first time threshold, flaps which developed complications were on average 0,5°C colder than flaps with favorable evolution. By postoperative day 7, complicated flaps exhibited significantly lower temperatures (1,1°C) and higher temperature gradients (1,21°C) compared to uneventful flaps (p < 0.05).

Conclusions: IRT is a reliable, cost-effective, and non-invasive modality that enhances surgical planning and early complication detection. When integrated with D-US, IRT-guided planning and monitoring provides a robust solution for ensuring flap viability in lower limb reconstruction.

References: 1. Papadopoulos O.N., Tsakoniatis N.J. Lower limb soft tissue reconstruction using microsurgical techniques. Acta Orthop. Scand. 1995;66((Suppl. 264)):35–37. doi: 10.3109/17453679509157163. 2. Innocenti M., Dell'Acqua I., Famiglietti M., Vignini L., Menichini G., Ghezzi S. Free perforator flaps vs propeller flaps in lower limb reconstruction: A cost/effectiveness analysis on a series of 179 cases. Injury. 2019;50((Suppl. 5)):S11–S16. doi: 10.1016/j.injury.2019.10.039.

Background: Pelvic floor dysfunctions, congenital anomalies, and acquired defects of the female genital, urethral, and anal tract are complex conditions requiring multidisciplinary management. Plastic surgery increasingly contributes to integrating functional restoration with aesthetic refinement. This review synthesizes contemporary evidence on reconstructive techniques, prosthetic materials, and cosmetic procedures, focusing on functional and patient-reported outcomes.

Methods: A structured search of PubMed, Embase, and the Cochrane Library was conducted for studies published between January 2005 and April 2025 (last search: 30 April 2025). Eligible studies included randomized controlled trials, prospective and retrospective cohort studies, and case series published in English. Women aged ≥18 years with a minimum follow-up of 12 months were included. Primary outcomes were anatomical restoration, continence, sexual function, and quality of life. Secondary outcomes included complication rates, donor-site morbidity, recurrence, and patient satisfaction. Study quality and level of evidence were critically assessed.

Results: A total of 842 records were identified. After screening, 176 full-text articles were evaluated and 73 studies met inclusion criteria, encompassing 3,964 patients. Flap-based reconstruction (gluteus maximus, vertical rectus abdominis myocutaneous [VRAM], gracilis, and anterolateral thigh [ALT] flaps) demonstrated high reliability and durable outcomes, particularly in oncologic or irradiated defects. Prosthetic meshes improved short-term anatomical correction but were associated with increased long-term complications, including mesh exposure and chronic pelvic pain, prompting a progressive shift toward autologous tissue reconstruction in recent studies. Cosmetic procedures (labiaplasty, vaginoplasty, perineoplasty) reported overall satisfaction rates between 82–93%, although outcome reporting remained heterogeneous. Integrated reconstructive–aesthetic approaches were consistently associated with improvements in continence, sexual function, quality of life, and body image.

Conclusions: Plastic surgical management of female genital and perineal defects provides significant functional and psychosocial benefits. Autologous reconstruction remains central in complex cases. Future prospective multicenter studies with standardized outcome measures are essential to further optimize personalized, patient-centered care.

References 1. Parums, D.V. Editorial: Review Articles, Systematic Reviews, Meta-Analysis, and the Updated Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 Guidelines. Med. Sci. Monit. 2021, 27, e934475. [CrossRef] [PubMed] 2. Higgins, J.P.T.; Thomas, J.; Chandler, J.; Cumpston, M.; Li, T.; Page, M.J.; Welch, V.A. Cochrane Handbook for Systematic Reviews of Interventions, Version 6.4; Cochrane: London, UK, 2024. 3. Wells, G.A.; Shea, B.; O'Connell, D.; Peterson, J.; Welch, V.; Losos, M.; Tugwell, P. The Newcastle–Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-Analyses; Ottawa Hospital Research Institute: Ottawa, ON, Canada, 2013. 4. Chen, Q.; Dong, R.; Zeng, A.; Teng, Y.; Liu, Z.; Zhu, L.; Long, F.; Si, L.; Yu, N.; Wang, X. The Reconstructive Strategy for Pelvic Oncological Surgery with Various Types of MS-VRAM Flaps. J. Plast. Reconstr. Aesthet. Surg. 2022, 75, 2090–2097. [CrossRef] [PubMed] 5. PelvEx Collaborative. A Review of Functional and Surgical Outcomes of Gynaecological Reconstruction in the Context of Pelvic Exenteration. Surg. Oncol. 2024, 52, 101996. [CrossRef]

Background Minimally invasive treatments for facial laxity, including thread lifting and high-intensity focused ultrasound (HIFU), are increasingly used in Asia, yet objective evaluation standards remain limited.1-2 Because facial soft tissue position differs between upright and supine postures, assessments performed in the supine position may not reflect real-world facial appearance in daily life.3-5 This study quantified posture-dependent facial soft tissue displacement in Japanese participants and compared displacement among individuals with prior HIFU, prior thread lift, and no prior laxity treatment. Methods Standardized frontal and lateral facial photographs were retrospectively analyzed from 138 Japanese volunteers (February–May 2024) after excluding cases with inadequate image quality or inconsistent head positioning. Participants with prior surgeries expected to cause substantial facial scarring were excluded. Images were acquired in seated and supine positions under controlled conditions (fixed camera distance, standardized focal length, and alignment of key facial landmarks). Using ImageJ, vertical distances from ocular reference points to the mandibular border were measured and normalized by stable facial reference lengths to minimize scaling effects. The absolute seated–supine difference was defined as a proxy for soft tissue mobility (greater difference indicating greater laxity). Groups were categorized as untreated (n=84), prior HIFU (n=24; approximately 400 shots to the face; ≥2 sessions), and prior thread lift (n=52; absorbable threads; ≥3 threads per side). Group comparisons were performed using t-tests (p<0.05). Subgroup analyses were conducted by BMI category. Results Posture change produced substantial soft tissue displacement across the cohort. Mean seated–supine shifts in the untreated group were 20.8% (frontal) and 41.4% (lateral). The HIFU group showed similar shifts (20.7% frontal; 38.2% lateral) with no significant difference versus untreated (frontal p=0.48; lateral p=0.17). In contrast, the thread lift group demonstrated reduced shifts (14.1% frontal; 33.4% lateral) with significant differences versus untreated (frontal p=0.0092; lateral p=0.02). In BMI-stratified analyses, thread lifting significantly reduced mobility in underweight and normal-weight participants, while no significant reduction was observed in the overweight subgroup. Conclusion In Japanese participants, facial soft tissue position changes markedly between seated and supine postures, supporting upright assessment to better approximate real-life appearance. Prior thread lifting, but not prior HIFU alone, was associated with significantly reduced posture-dependent soft tissue mobility, particularly in underweight and normal-weight individuals. These findings suggest that thread lifting may provide greater stabilization against gravitational shift and that higher-BMI patients may require tailored strategies and/or combination approaches for optimal laxity management.

References 1 Ayatollahi A, Gholami J, Saberi M, et al. Systematic review and meta-analysis of safety and efficacy of high-intensity focused ultrasound (HIFU) for face and neck rejuvenation. Lasers Med Sci. 2020;35:1007–1024. PubMed 2 Halepas S, Chen XJ, Ferneini EM. Thread-Lift Sutures: Anatomy, Technique, and Review of Current Literature. J Oral Maxillofac Surg. 2020;78:813–820. PubMed 3 Ozsoy U, Sekerci R, Ogut E. Effect of sitting, standing, and supine body positions on facial soft tissue: detailed 3D analysis. Int J Oral Maxillofac Surg. 2015;44:1309–1316. PubMed 4 Hsu C, Gruber RP, Dosanjh A. Prediction of face-lift outcomes using the preoperative supine test. Aesthetic Plast Surg. 2009;33:828–831. PubMed 5 Yamaguchi Y, Yamauchi K, Suzuki H, et al. Volumetric comparison of maxillofacial soft tissue morphology: computed tomography in the supine position versus three-dimensional optical scanning in the sitting position. Oral Surg Oral Med Oral Pathol Oral Radiol. 2018;125:351–357. PubMed

Background Nipple-sparing mastectomy (NSM) has gained widespread acceptance because of its oncologic safety and favorable aesthetic outcomes. However, mastectomy flap necrosis remains a clinically significant complication, particularly in prepectoral direct-to-implant (DTI) breast reconstruction, in which the implant is positioned directly beneath the mastectomy flap without muscular coverage. In this setting, even limited ischemic compromise may result in delayed wound healing, infection, or implant exposure, potentially jeopardizing reconstructive success. Although multiple factors have been proposed as predictors of flap necrosis, clinically relevant thresholds have not been clearly established, especially in homogeneous cohorts undergoing prepectoral DTI reconstruction. This study aimed to identify independent predictors of mastectomy flap necrosis and to determine clinically meaningful cut-off values to guide intraoperative risk stratification.

Methods A retrospective review was conducted of 339 breasts in 324 patients who underwent NSM with prepectoral DTI reconstruction at a single tertiary center between November 2018 and December 2024. Patients with less than 6 months of follow-up were excluded. The primary outcome was mastectomy flap necrosis, categorized as major (requiring operative debridement) or minor (managed conservatively). Clinical variables included patient demographics, comorbidities, oncologic treatments, incision type (lateral radial or inframammary fold), mastectomy weight, implant size, and intraoperative minimum and maximum flap thickness. Univariate and multivariable logistic regression analyses were performed to identify independent predictors. In the lateral radial cohort, receiver operating characteristic (ROC) curve analysis was conducted to determine optimal cut-off values for continuous predictors.

Results Major flap necrosis occurred in 18.0% of breasts and minor necrosis in 3.2%. The mean mastectomy weight was 326.9 ± 154.5 g. Minimum flap thickness was significantly thinner in the lateral radial group than in the inframammary fold group (3.68 ± 1.03 mm vs. 4.84 ± 1.03 mm, p < 0.001), and major necrosis was more frequent in the lateral radial group (19.6% vs. 5.3%, p = 0.026). On univariate analysis, incision type, body mass index, mastectomy weight, implant size, and minimum flap thickness were associated with major necrosis. In multivariable analysis, mastectomy weight and minimum flap thickness remained independent predictors (p < 0.01), whereas incision type lost statistical significance. When both major and minor necrosis were analyzed together, hypertension was also independently associated with necrosis. Maximum flap thickness was not associated with flap necrosis. In the lateral radial cohort, ROC analysis identified thresholds of 350 g for mastectomy weight and 5 mm for minimum flap thickness. Breasts with mastectomy weight ≥350 g had higher odds of necrosis, whereas a minimum flap thickness ≥5 mm was associated with a markedly reduced risk.

Conclusion Mastectomy weight and minimum flap thickness are the most reliable determinants of mastectomy flap necrosis after NSM with prepectoral DTI reconstruction. Although incision type appeared significant in univariate analysis, its effect was attenuated after adjustment for flap thickness, suggesting that preservation of adequate minimum flap thickness is more clinically relevant than incision selection alone. ROC-derived thresholds of 350 g and 5 mm provide practical guidance for intraoperative risk assessment and may help determine the suitability of immediate implant-based breast reconstruction.

Introduction: Head and neck lymphoedema (HNL) is a common sequela of head and neck cancer (HNC) treatment, reported in over 90% of patients. Disruption of lymphatic drainage due to tumour burden, radiotherapy (RT), and surgery leads to lymphatic stasis, inflammation, and fibrosis. HNL may be internal, affecting the upper aerodigestive tract, or external, involving the skin and subcutaneous tissues, resulting in significant functional morbidity. Computed tomography (CT) is routinely used in staging and post-treatment surveillance of HNC and allows assessment of both internal and external HNL. This study aimed to determine the prevalence and severity of HNL on CT following RT and to identify patient- and treatment-related risk factors.

Methods: This single-centre retrospective cohort study included 229 patients treated with RT to the head and neck region at Austin Health, Victoria, between 2019 and 2024. Eligible patients underwent CT or PET/CT within one year prior to RT and at three months post-RT. The degree of lymphoedema was assessed by a single reader using the CT Lymphoedema and Fibrosis Assessment Tool (CT-LEFAT), evaluating external fat stranding at six anatomical locations and internal soft-tissue thickness at the epiglottis and prevertebral space. Baseline, 3-month, and additional 6- and 12-month CT scans were analysed when available. Statistical analysis was performed by an institutional biostatistician.

Results: The mean age of the study population was 63.9 years; 77.3% were male and 22.7% female. Squamous cell carcinoma accounted for 92.6% of cases. Treatment included RT alone in 45.8%, RT with tumour resection without neck dissection in 19.7%, and RT with tumour resection and neck dissection in 34.5%. External fat stranding and increased epiglottic thickness were frequently identified, with greater severity at three months compared to baseline. Patients undergoing combined modality treatment, particularly surgery with neck dissection, demonstrated more severe HNL. Bilateral RT and longer RT duration were significantly associated with increased HNL severity. Higher fat stranding scores were observed on CT compared with PET/CT. Twelve-month data are currently undergoing statistical analysis.

Conclusion: HNL is highly prevalent on CT following HNC treatment, particularly in patients receiving extensive surgical and radiotherapy interventions. CT-based assessment, as part of routine post-treatment surveillance, enables early identification of patients with oedema and fibrosis and may help guide targeted monitoring and early intervention strategies.

Background: Enteral glutamine supplementation has been advocated for severe burn patients based on early randomized controlled trials (RCTs) demonstrating reduced infectious morbidity and shorter hospital stays. However, the large RE-ENERGIZE trial (2022) reported null findings, challenging previous recommendations. This study re-evaluates the efficacy of enteral glutamine using a dual statistical framework. Methods: We systematically searched PubMed, Embase, and Cochrane CENTRAL for RCTs comparing enteral glutamine supplementation versus placebo or standard care in adults with severe burns. Both frequentist random-effects meta-analysis and Bayesian meta-analysis were performed. Outcomes included mortality, overall infection, length of hospital stay (LOS), and duration of mechanical ventilation (MV). Results: Five RCTs (n=1,359) were included. Frequentist analysis yielded non-significant results for all outcomes, with 95% confidence intervals crossing the null. In contrast, Bayesian analysis revealed posterior probabilities of benefit of 85.6% for mortality (OR 0.54, 95% CrI 0.15–1.47) and 86.5% for LOS (MD −4.60 days, 95% CrI −12.90 to 3.47). The probability of benefit for overall infection was modest (62.9%), while duration of MV showed a 63.4% probability of harm. Conclusion: Although enteral glutamine does not achieve conventional statistical significance, Bayesian analysis demonstrates substantial probabilities of benefit for mortality and LOS. These findings caution against dismissing glutamine based solely on frequentist interpretation and support consideration in selected populations.

Background: Dermal substitutes have become integral to the management of full-thickness skin defects (1). Biodegradable Temporising Matrix (BTM) is a fully synthetic bilayer polyurethane matrix that requires a two-stage procedure, whereas Matriderm is a bovine collagen-elastin scaffold that permits single-stage reconstruction. Comparative clinical data between these matrices remain limited(2,3).

Aim: To compare scar quality outcomes between BTM and Matriderm in full-thickness skin defects.

Methods: A prospective comparative study was conducted over 18 months at a tertiary care centre after institutional ethical approval. Twenty-six patients with full-thickness defects (post-burn contracture release, keloid excision, and scar resurfacing) were enrolled, with thirteen patients in each of the BTM and Matriderm groups. Infected wounds, major vessel exposure requiring flap coverage, severe peripheral vascular disease, and immunocompromised patients were excluded. Scar quality was assessed at 3 months and ≥1 year using the Vancouver Scar Scale (VSS), Patient and Observer Scar Assessment Scale (POSAS 3.0), and high-frequency ultrasound (25 MHz) for dermal thickness(4). Graft take percentage was evaluated at 3 weeks. Statistical significance was set at p<0.05.

Results: Overall scar quality outcomes at both time points were comparable between groups across VSS, POSAS, and ultrasound thickness measurements. However, graft take at 3 weeks was significantly higher in the Matriderm group, suggesting more reliable early integration. Complication rates, including infection and recurrence, were similar.

Conclusion: Both BTM and Matriderm provide comparable long-term scar outcomes in dermal reconstruction. Matrix selection appears to depend more on wound bed characteristics, surgical expertise, and logistical considerations rather than composition alone. Larger studies with functional and cost-effectiveness analyses are warranted.

References: 1. Van den Bosch AS, Verwilligen RA, Pijpe A, Bosma E, Lucas Y, van Zuijlen PP, Middelkoop E, National Burn Care, Education & Research Group The Netherlands, van Baar ME, van Dammen L, Geelen SJ. Application of dermal substitutes in the surgical treatment of full‐thickness wounds: outcomes of an international survey. International Wound Journal. 2024 Jul;21(7):e14932. 2. Crowley K, Balaji S, Stalewski H, Carroll D, Mariyappa-Rathnamma B. Use of Biodegradable Temporizing Matrix (BTM) in large trauma induced soft tissue injury: a two stage repair. Journal of Pediatric Surgery Case Reports. 2020 Dec 1;63:101652. 3. Ryssel H, Germann G et al. Dermal substitution with Matriderm® in burns on the dorsum of the hand. Burns. 2010 Dec 1;36(8):1248-53. 4. ME, Mokkink LB, Tyack Z, et al Development of the Patient Scale of the Patient and Observer Scar Assessment Scale (POSAS) 3.0: a qualitative study. Quality of Life Research. 2023 Feb;32(2):583-92

Background: The deleterious effects of chronic cocaine abuse on nasal structures are well-documented. Cocaine's potent vasoconstrictive properties can lead to ischemia of the mucoperichondrium, resulting in septal perforation and subsequent loss of dorsal support. This often manifests as severe saddle-nose deformity, posing a significant reconstructive challenge due to the compromised vascular bed.

Purpose: While cocaine-induced nasal deformities are common in Western countries, they are extremely rare in East Asia. We aim to present the surgical management and outcome of the first documented case in Taiwan, highlighting the feasibility of autologous reconstruction in this distinct patient population.

Methods and Materials: We present a single case of a 30-year-old patient with severe saddle nose deformity and extensive septal perforation secondary to chronic cocaine abuse. The reconstruction was performed using autologous costal cartilage for dorsal augmentation and structural support, combined with conchal cartilage for tip refinement. No alloplastic materials were used to minimize the risk of infection and extrusion in the compromised tissue.

Results: At 7-month post-operative follow-up, the patient demonstrated significant improvement in both aesthetic contour and nasal airway function. The dorsal height was restored, and tip projection was maintained without complications such as graft resorption or infection.

Conclusions: Reconstruction of cocaine-induced nasal deformity is technically demanding due to poor tissue quality. However, the use of autologous rib and ear cartilage provides a robust and reliable solution. This case demonstrates that even in regions where such pathology is rare, adherence to the principles of autologous reconstruction yields superior results compared to alloplastic implants.

Purpose Intravascular papillary endothelial hyperplasia (IPEH), or Masson's tumor, is a rare, benign reactive vascular lesion that clinically and histologically mimics angiosarcoma. (1) Although typically considered to have a negligible recurrence rate, challenges arise when differentiating recurrent lesions from true vascular malignancies.(2) This study evaluates the recurrence potential and diagnostic pitfalls of IPEH over a 10-year period. Methods A retrospective review of patients pathologically diagnosed with IPEH at a single medical center from 2014 to 2024 was conducted. We analyzed patient demographics, anatomic distribution, recurrence rates, and histopathological profiles (3), emphasizing the role of immunohistochemistry and molecular testing (e.g., FISH) in differentiating malignant mimics.(4) Results Thirty-two patients (14 males, 18 females; mean age, 51.2 years) were identified. The most common locations were the upper extremities (31.3%) and head (31.3%). Over the 10-year follow-up, two patients (6.25%) experienced local recurrence. No true malignant transformation was observed; however, molecular diagnostics (such as FUS fusion screening) were critical in distinguishing recurrent IPEH from emerging epithelioid vascular neoplasms.(5) Conclusion IPEH carries a distinct preliminary recurrence rate of 6.25%, challenging its reputation as a strictly non-recurrent entity. Complete surgical excision is essential. In recurrent or histologically ambiguous cases, plastic surgeons must maintain a high index of suspicion for malignant mimicry, utilizing modern molecular diagnostics to guide appropriate treatment.

References:

1. Masson P. Hemangioendotheliome vegetant intravasculaire. Bull Soc Anat Paris. 1923;93:517-532.
2. Boukovalas S, et al. Intravascular Papillary Endothelial Hyperplasia (Masson's Tumor): Diagnosis the Plastic Surgeon Should Be Aware of. Plast Reconstr Surg Glob Open. 2017;5(1):e1122.
3. Hashimoto H, et al. Intravascular papillary endothelial hyperplasia. A clinicopathologic study of 91 cases. Am J Dermatopathol. 1983;5(6):539-546.
4. Dashti NK, et al. A unique epithelioid vascular neoplasm of bone characterized by EWSR1/FUS-NFATC1/2 fusions. Genes Chromosomes Cancer. 2021;60:219-228.
5. Ng HJH. Intravascular Papillary Endothelial Hyperplasia: Case Report of a Recurrent Masson's Tumor. J Hand Microsurg. 2021;13(1):32-35.

Purpose As competency-based surgical education evolves internationally, there is increasing demand for structured, curriculum-aligned, digitally accessible resources. e-LPRAS (e-Learning for Plastic, Reconstructive and Aesthetic Surgery) has been developed by the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) in partnership with NHS England e-Learning for Healthcare (eLfH) as a structured online educational program. Methods e-LPRAS provides a comprehensive, syllabus-mapped digital platform accessible to surgical residents and multidisciplinary professionals (1). Content consists of hundreds of individual topics (or sessions) arranged in 9 Modules: Essentials; Surgical Principles; Head and Neck Surgery; Congenital Head, Neck, and Skin; Upper Limb; Breast and Chest wall; Lower Trunk; Lower Limb; and Burns. The resource is intended primarily for plastic surgery residents but also for consultants, non-consultant career grade surgeons, and accessible to allied health professionals in NHS health or care organizations. Non UK NHS health or care organizations do not qualify for free access to the eLfH Hub, but may still be able to access the platform (1). Infographic summaries have been added as condensed, high-yield revision tools designed to facilitate rapid knowledge consolidation and examination preparation. These cover topics such as: Squamous cell carcinoma, Hypertrophic and keloid scars, Perforator flaps, Role of the multidisciplinary team in cleft lip and palate, Metacarpal fractures, Complications of open fractures of the open limb, and the Initial management of electrical burns. Results User data confirms over 9000 session launches per year in the UK, with multidisciplinary engagement including registered medical or dental practitioners (approximately 43%), alongside nursing registrants, students and social care professionals (approximately 57% combined non-medical users); e-LPRAS is provided subscription-free for all NHS workers. Hundreds of additional sessions are launched by international users. Trainees from at least ten Lower and Middle Income Countries (LMICs) have also benefitted from charitable funding for free access, including users from Ethiopia, Nepal, Kenya, Sri Lanka and Nigeria. The Infographics are among the most accessed e-LPRAS learning resources, and currently represent two of the top ten most frequent launches. Conclusions e-LPRAS represents a well-used structured, curriculum-mapped, digitally scalable educational platform supporting plastic surgery education across professional levels and geographic regions. Its multidisciplinary engagement and international access initiative position it as a transferable model for contemporary surgical education.

References 1 e-lfh hub programs: plastic reconstructive and aesthetic surgery. Updated 2026. https://www.e-lfh.org.uk/programmes/plastic-reconstructive-and-aesthetic-surgery/

Purpose The UK National Flap Registry (UKNFR) was established by the British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS) initiated by its Clinical Effectiveness Subcommittee (1) to facilitate major free and pedicled flap data collection. Participation in quality assessment and audit is integral to appraisal and revalidation as required by the UK General Medical Council (GMC). The cross-specialty UKNFR is supported by its sister surgical associations: BAHNO, BAOMS, ABS and BSSH. The first case was added on 1st August 2015 and the first UKNFR report (2) was published in 2019 incorporating its first 5751 cases. There are currently over 14,000 cases entered. Methods The emphasis is on risk factors relevant to primary outcome measures: return to theatre, length of stay and flap success, the latter in binary format: 100% success, partial success or total failure. Among risk factors are: age, BMI, ASA, smoking status, hypertension, diabetes, immunosuppression and pulmonary disease. Indication, recipient and donor sites, flap composition and technical aspects related to microvascular surgery such as length of pedicle, diameter of vessels, suture(s) and anastomotic success; grade of surgeon(s) and whether performing flap elevation, anastomotic work or donor site closure are recorded. Users are also encouraged to obtain consent for patient-reported outcome measures (PROMs) for Breast reconstruction and Lower limb trauma cases, via BREAST-Q and modified Enneking Score. Results Between 2017 and 2024 a total of 10,417 operation records were added to UKNFR. Consultants by specialty: 59% Plastic surgeons, 21% General or Breast surgeons, 17% Maxillofacial or Head and Neck (H&N) surgeons Recipient sites: 56% Breast, 28.6% H&N, 8% Lower limb, 5.5% Trunk and perineum Breast flaps: Indications included Tumor immediate 53%, Tumor delayed 42%, Risk reduction 10% 35.2% of Breast reconstruction cases had received preoperative chemotherapy and 34.7% preoperative radiotherapy; 17.5% were current or ex-smokers H&N indications: 83% Tumor immediate, 7% Tumor delayed; 73% received Forearm, ALT or Fibula flaps; 61% were current or ex-smokers. Total flap survival for Breast cases: 98.1%; H&N 95%; Lower limb: 94.7%; unplanned reoperation rates: Breast 2.9%, H&N 11.6%, Lower limb 14.3% Breast Recon PROMs Breast Q Scores for 1070 cases; satisfaction with outcome median of 94/100, satisfaction with breasts median of 86/100. Conclusions Available outputs from UKNFR emphasize this Specialty's focus on Cancer, Trauma and Congenital cases and range from a reports of all cases (2) to Unit or Departments, through to individual users' dashboards for appraisal or revalidation. They can focus on KPIs relating to process or outcome: such as duration of surgery or length of stay; anastomosis or flap success, unplanned reoperations or PROMs. There is potential for benchmarking if participation can be maximized and confirmed, and for risk stratification as used in Cardiac surgery (3).

References 1 Cole RP, Browne JP. Towards performance measurement in reconstructive surgery: A multicentre pilot study of free and pedicled flap procedures. JPRAS 2006; 59(3):257-262. doi.org/10.1016/j.bjps.2005.06.006 2 First UKNFR Report. December 2019. https://www.bapras.org.uk/media-government/news-and-views/view/first-uknfr-report-published 3 Nashefa SAM, Roques F, Sharples LD, et al. EuroSCORE II. European Journal of Cardio-Thoracic Surgery 2012; 41:734–745. doi.org/10.1093/ejcts/ezs043

Purpose: Accurate pre-therapeutic classification of soft tissue tumors is essential for treatment planning and limb-sparing strategies. Ultrasound-guided core needle biopsy (CNB) is widely used, but concerns remain regarding its diagnostic reliability compared with open biopsy. This study evaluated the accuracy of ultrasound-guided CNB in a specialized sarcoma center.

Methods: A retrospective single-center analysis was performed including all patients presenting in 2021 to the Sarcoma Center Kiel (University Hospital Schleswig-Holstein) with an indeterminate soft tissue lesion who underwent ultrasound-guided CNB followed by surgical resection. Inclusion required a single sonography-guided CNB and available final histopathology. CNB was performed using 14-gauge automated devices under real-time ultrasound guidance. Diagnostic concordance between CNB and resection histology was assessed for tumor dignity (benign vs malignant), histologic subtype, and grading.

Results: Twenty-eight patients underwent CNB; 23 patients with subsequent resection were included in the primary analysis. Mean age was 61.96 ± 19.06 years (range 24–93), and 52.17% were female. Final histology most commonly demonstrated lipoma (n = 6), liposarcoma (n = 5), and pleomorphic sarcoma (n = 2); overall, 43.48% were soft tissue sarcomas. Among 10 sarcoma cases, grading distribution was G3 in 50.0%, G1 in 30.0%, and G2 in 20.0%. CNB achieved 100.0% accuracy for distinguishing benign from malignant lesions (23/23). Concordance for histologic subtype and grading was also 100.0%. Differentiation between G1 liposarcoma and lipoma was correct in all relevant cases (9/9). No false-positive or false-negative malignant diagnoses were observed.

Conclusions: In this single-center cohort, ultrasound-guided CNB demonstrated excellent diagnostic reliability for soft tissue tumors, including sarcoma, with perfect concordance for dignity, subtype, and grading compared with resection histology. These findings support ultrasound-guided CNB as a safe, minimally invasive, and resource-efficient first-line diagnostic procedure when performed in specialized sarcoma centers. Larger multicenter studies are warranted to confirm these results and further evaluate safety outcomes.

References: 1. Birgin E, Yang C, Hetjens S, et al. Core needle biopsy versus incisional biopsy for differentiation of soft-tissue sarcomas: a systematic review and meta-analysis. Cancer. 2020;126(9):1917-1928. 2. Cernakova M, Hobusch GM, Amann G, et al. Diagnostic accuracy of ultrasound-guided core needle biopsy versus incisional biopsy in soft tissue sarcoma. Sci Rep. 2021;11:17832. 3. Klein A, Fell T, Birkenmaier C, et al. Relative sensitivity of core-needle biopsy and incisional biopsy in the diagnosis of musculoskeletal sarcomas. Cancers (Basel). 2021;13(6):1393.

BACKGROUND

Gigantomastia is an uncommon but serious and debilitating disorder that involves a massive overgrowth of the breast tissue that causes severe chronic musculoskeletal pain, postural abnormalities, skin problems and considerable psychological distress. Massive breast tissue has been shown to alter the spinal biomechanics and spinal alignment leading to increased cervical and thoracic strain which can lead to functional impairment. Altered posture can also cause secondary visual discomfort due to altered ergonomically correct positioning. Though, as mentioned above, reduction mammoplasty is considered the gold standard treatment for gigantomastia, the biochemical and molecular mechanisms of excessive breast tissue proliferation are poorly defined.

OBJECTIVE

This article reviews current surgical treatment options for gigantomastia and evaluates potential biochemical and molecular mechanisms of the hormonal and growth factor profiles that contribute to disease development and postoperative functional outcomes.

METHODS/MATERIALS

Peer reviewed articles were used to evaluate surgical reduction mammoplasty techniques for the treatment of gigantomastia. In addition, patients diagnosed with gigantomastia underwent an endocrine evaluation prior to surgery. Hormonal profiling included leptin, thyroid stimulating hormone (TSH), parathyroid hormone (PTH), follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, estradiol, testosterone, insulin like growth factor-1 (IGF-1) and transforming growth factor beta (TGF-β). The goal of this study was to identify and describe possible relationships between adipokine signaling, hormonal sensitivity, growth factor production and stromal remodeling in breast hypertrophy.

RESULTS

Reliable vascular perfusion and preservation of sensation were documented in patients who underwent pedicled reduction mammoplasty. Free nipple grafts were recommended when pedicles did not meet safety standards [1,2]. Endocrine assessments revealed a wide range of prolactin, estradiol and leptin values in patients evaluated indicating a relationship between adipocyte signaling and glandular hypertrophy [3]. High values of IGF-1 and TGF-β suggested the presence of proliferative and fibrotic processes involved in glandular expansion and stromal remodeling. Regardless of the technique employed, all patients experienced significant relief of musculoskeletal pain, respiratory discomfort, improved posture and increased ability to engage in physical activities after undergoing a surgical reduction of their breasts [3,4].

CONCLUSION

The data collected indicates that reduction mammoplasty provides significant functional improvements beyond aesthetic improvement. Elaboration of hormonal and growth factor characterization will provide further insight into the mechanisms of gigantomastia and help guide individualized treatment planning. Combining an endocrine evaluation with surgical decisions will likely enhance long term patient outcomes and reduce recurrence rates.

REFERENCES 1.Dancey A, Khan M, Dawson J, Peart F. Gigantomastia: a classification and review of the literature. Journal of Plastic Reconstructive & Aesthetic Surgery; 2008. 2.Hidalgo DA. Vertical Mammaplasty. Plastic and Reconstructive Surgery; 2005. 3.Kerrigan CL, et al. Reduction Mammaplasty Improves Health Status and Quality of Life. Plastic and Reconstructive Surgery; 2001. 4.Dafydd H, Roehl KR, Phillips LG. Redefining Gigantomastia. Annals of Plastic Surgery; 2011.

Aim: To demonstrate the application of Immersive Virtual Reality (VR) in the management of zygomaticomaxillary complex (ZMC) fractures.

Purpose of the study: The challenges we faced in management of ZMC fractures are complex 3D anatomy with multiple articulations, rotation and posterior displacement of the fracture fragments, assessment of apparent and true orbital floor defect, changes in the orbital volume and increased chances of malunion in delayed presentation. Immersive VR has shown promising potential to fill the gap between knowledge-based and experiential learning of facial fractures in surgical training [1]. Virtual surgical planning in maxillofacial fractures permits the surgeon to visualize the facial skeletal deformity and position orientation of fracture fragments with respect to surrounding structures and plan the desired reduction more precisely [2]. We used Immersive VR to aid us in the management of ZMC fractures.

Methods: This is a prospective study conducted from February 2023 to January 2025. Patients with ZMC fractures presenting after a period of 3 weeks due to various causes were included in the study. CT facial bones with 3D reconstruction were done. VR constructs were reconstructed using ImmersiveView 5 software by ImmersiveTouch. The VR constructs were studied using an Oculus and controllers. The following were studied in the virtual environment – fracture site and rotation displacement of the fracture fragments, location of the infraorbital nerve with respect to the fracture, distance of the optic nerve from the infraorbital rim. Preoperative planning was done. All patients underwent surgical correction with open reduction and internal fixation. Postoperatively patients were followed up for 6 months.

Our Experience: Eight patients who presented late with ZMC fractures were studied. Late presentation was due to other associated major injuries. All patients underwent CT and VR constructs were generated in 2 days. The simulated environment improved our three-dimensional perception of the fractures, the malunion and nerve entrapment. The surgeon was at liberty to explore different views of the fracture, the rotation, malunion, relation to adjacent structures and attempt reduction fixation virtually. The knowledge thus gained was applied during fracture fixation. All patients recovered well without postoperative complications.

Results: Creation of VR modules and preoperative planning were done for all 8 patients. Prior virtual knowledge of the fractures helped us in choosing the approach, the plate type, site of placement of screws. Virtual planning prevented unpleasant intraoperative encounters and postoperative complications. It considerably reduced our operative time.

Conclusion: Immersive Virtual Reality aided in preoperative planning and eased subsequent intraoperative fixation of ZMC fractures with reduced operative time.

References: 1. Obaid, Oday MD; Corcoran, Julia MD; Patel, Pravin K. MD. The Role of Virtual Reality in Operative Learning of Zygoma Fractures: Description and Validation. Plastic and Reconstructive Surgery - Global Open 10(10S):p 18, October 2022. DOI: 10.1097/01.GOX.0000898396.19111.95 2. Thakker JS, Pace M, Lowe I, Jung P, Herford AS. Virtual Surgical Planning in Maxillofacial Trauma. Atlas Oral Maxillofac Surg Clin North Am. 2019 Sep;27(2):143-155. doi: 10.1016/j.cxom.2019.05.006. Epub 2019 Jun 22. PMID: 31345490.

Purpose: Patient-reported outcomes are increasingly emphasized in breast reconstruction, and the BREAST-Q is a validated tool to quantify satisfaction and quality-of-life domains after breast surgery [1]. This study evaluated the impact of secondary fat grafting on satisfaction and well-being in Japanese patients who underwent flap- or implant-based breast reconstruction, and explored factors associated with BREAST-Q outcomes. Methods and Materials: After institutional review board approval, consecutive postmastectomy reconstructions completed between January 2017 and October 2024 were retrospectively reviewed. Patients were categorized into four groups: flap reconstruction followed by secondary fat grafting (Flap-FG), flap reconstruction alone (Flap-only), implant reconstruction followed by secondary fat grafting (Imp-FG), and implant reconstruction alone (Imp-only). Secondary fat grafting was performed ≥3 months after reconstruction in patients dissatisfied with asymmetry, insufficient volume, contour deformity, or contracture. One year after the final operation, patients completed BREAST-Q subscales (satisfaction with breasts, satisfaction with outcome, psychosocial well-being, sexual well-being; 0–100). Group comparisons were conducted using appropriate parametric/nonparametric tests and Fisher's exact test. Multivariable regression (forced entry) was performed to identify predictors of BREAST-Q outcomes, including age, obesity (BMI >25), laterality, smoking, neoadjuvant radiotherapy, reconstruction type (flap vs implant), and secondary fat grafting. Among 190 eligible patients, 163 responded (response rate 85.8%): Flap-FG (n=22), Flap-only (n=43), Imp-FG (n=30), Imp-only (n=68). Median injected fat volume was 88 mL (Flap-FG) and 80 mL (Imp-FG). Patient-reported outcomes were assessed 1 year after the final procedure. Results: In patients without fat grafting, Flap-only showed higher breast satisfaction than Imp-only (P=0.044), consistent with prior reports that reconstruction modality can influence satisfaction [2]. When comparing reconstruction with versus without secondary fat grafting, the Flap-FG group demonstrated a significant improvement only in satisfaction with outcome versus Flap-only (P=0.018). In contrast, the Imp-FG group showed significantly higher scores than Imp-only across all domains: satisfaction with breasts (P=0.005), satisfaction with outcome (P=0.037), psychosocial well-being (P<0.001), and sexual well-being (P<0.001). These findings align with the growing evidence that fat grafting can improve patient-reported outcomes after postmastectomy reconstruction [3,4]. In multivariable regression, secondary fat grafting remained independently associated with higher BREAST-Q scores across domains, whereas neoadjuvant radiotherapy was associated with lower scores. Conclusions: Secondary fat grafting is effective for improving patient-reported outcomes after breast reconstruction, with a particularly strong benefit in implant-based reconstruction. These findings support proactive consideration of secondary fat grafting for patients dissatisfied with their initial reconstruction, while also highlighting the potential negative impact of radiotherapy on patient-reported outcomes.

References [1] Pusic AL, Klassen AF, Scott AM, et al. Development of a new patient-reported outcome measure for breast surgery: the BREAST-Q. Plast Reconstr Surg. 2009;124:345–353. [2] Eltahir Y, Krabbe-Timmerman IS, Sadok N, et al. Quality of life after autologous versus alloplastic breast reconstruction: a systematic review and meta-analysis. Plast Reconstr Surg. 2020;145:1109–1123. [3] Bennett KG, Qi J, Kim HM, et al. Association of fat grafting with patient-reported outcomes in postmastectomy breast reconstruction. JAMA Surg. 2017;152:944–950. [4] Sowa Y, Inafuku N, Tsuge I, et al. Patient-reported outcomes after autologous fat grafting in prosthetic breast reconstruction. Ann Plast Surg. 2023;90:123–127. [5] Mashiko T, et al. Secondary Fat Grafting in Breast Reconstruction: Comparison Between After Autologous Flap and After Silicone Implant. Plast Reconstr Surg Glob Open. 2025;13:e6866.

Introduction

Breast reconstruction following cancer-related surgery plays a pivotal role in breast cancer treatment, focusing not only on restoring anatomical form but also on enhancing overall patient well-being. The lateral intercostal artery perforator (LICAP) flap has increasingly been adopted as a dependable and flexible technique for both partial and total breast reconstruction. It supplies well-perfused autologous tissue while preserving underlying musculature and minimizing donor-site morbidity.

Methods: We describe our two-year experience with the LICAP flap in a cohort of 69 patients who underwent autologous total breast reconstruction. This analysis includes indications and patient selection, preoperative planning strategies, operative details, and postoperative care protocols. Clinical outcomes were assessed by evaluating complication rates, cosmetic appearance, functional results, and patient-reported satisfaction.

Results: The LICAP flap provided stable vascular perfusion and satisfactory breast contouring, with minimal morbidity at the donor site. It was particularly advantageous for women with small- to moderate-sized breasts and for those wishing to avoid muscle-sacrificing reconstructive options. A small number of patients developed postoperative complications, including partial wound dehiscence, localized infection, and temporary venous congestion of the flap. All complications were promptly recognized and managed conservatively or with minor interventions, leading to full resolution without lasting aesthetic or functional impairment. Overall cosmetic outcomes were highly satisfactory, and functional recovery was uneventful in most cases. Assessment using the BREAST-Q questionnaire demonstrated high levels of postoperative satisfaction, along with notable improvements in psychosocial health and quality of life.

Conclusion: Based on our experience, the LICAP flap represents a reliable, reproducible, and cosmetically favorable technique in contemporary breast reconstruction. It achieves an effective balance between surgical safety, limited donor-site impact, and strong patient-reported outcomes. Even when minor complications arise, they can be successfully addressed, reinforcing the LICAP flap as a valuable option in modern reconstructive practice.

Purpose: Reconstruction of critical-sized composite lower extremity defects with associated bone loss remains surgically demanding, particularly in the setting of chronic osteomyelitis. This study compares clinical and functional outcomes of suprafascial versus subfascial elevated anterolateral thigh (ALT) perforator flaps, with emphasis on flap durability, bone graft consolidation, osteomyelitis recurrence, and functional recovery. Methods: A retrospective review was performed of 320 patients who underwent ALT perforator flap reconstruction for composite lower extremity defects with concomitant bone defects at a single tertiary center between January 2016 and December 2023. Fifty-four patients with critical-sized defects (≥25 × 15 cm²) met inclusion criteria. Forty-five patients underwent subfascial elevation and nine underwent suprafascial elevation. Outcome measures included bone graft consolidation, osteomyelitis recurrence, total or partial flap necrosis, Lower Extremity Functional Scale (LEFS) scores, and time to full weight-bearing ambulation. Results: Bone graft consolidation, osteomyelitis recurrence, operative time, length of hospital stay, LEFS scores, and time to full weight-bearing ambulation did not differ significantly between groups, although outcomes consistently favored subfascial elevation. No cases of total flap necrosis occurred in either group. Partial flap necrosis was significantly less frequent in the subfascial group compared with the suprafascial group (p < 0.05). Conclusions: In patients with critical-sized composite lower extremity defects, subfascial elevation of ALT perforator flaps was associated with a lower incidence of partial flap necrosis compared with suprafascial elevation. Although no significant differences were observed in other clinical or functional outcomes, this finding suggests that elevation plane may influence flap-related complications in complex reconstructions involving chronic osteomyelitis. Further prospective studies with larger cohorts are required to confirm these observations.

Background: It is widely discussed whether oncoplastic surgery (OPS) and lumpectomies are comparable regarding surgical outcomes and complications. This study evaluates the quality of the surgical treatment of breast cancer (BC) patients, who underwent breast-conserving surgery (BCS) with or without oncoplastic techniques. Methods: From September 1st, 2020 until December 31st, 2021, 130 patients were included in a retrospective, observational, single institution quality assurance study. Inclusion criteria were BC patients, who either underwent OPS or lumpectomy. The patients were evenly distributed in two groups (n=65) and matched on age and/or surgeon and/or date of operation. Variables included patient and tumour characteristics, surgical details and techniques, and complications. Statistical analysis was performed in R Studio. Results: Demographics, tumour histology and use of neoadjuvant therapy were homogenous between the two groups. Tumours were significantly larger in the OPS group (25.00 vs. 15.00 mm, P<0.001) and significantly more multifocal (P=0.002). The median operation time was significantly longer in the OPS group compared to the BCS group (140 vs. 73 minutes, P<0.001). Regarding complication rates and time to adjuvant therapy, no statistical differences were found [radiotherapy (RT): BCS =57.27 vs. OPS =58.40 days or chemotherapy (CT): BCS =46.14 vs. OPS =49.85 days]. Conclusions: The complication rate of oncoplastic treatment in this study is comparable to lumpectomy, despite the being higher on the reconstructive ladder. OPS does not prolong time to adjuvant therapy

Introduction Neurofibromatosis type 1 was described in 1882 by the German pathologist Friedrich Daniel von Recklinghausen. It is an autosomal dominant genetic disease with an incidence of 1 in 3,000 live births (1). It presents as ´café-au-lait´ macule on the skin and neurofibromas under the skin, leading to significant aesthetic sequelae. The facial variety is usually plexiform or diffuse, generally occurring unilaterally and producing hemi-hypertrophy of the facial soft tissues due to the presence of benign tumors around the nerves (2). Surgical treatment consists of resecting the tumor tissue without damaging healthy structures or nerves.

Methods A retrospective observational study was conducted on patients operated on by the plastic surgery team at Hospital del Salvador, Chile, between January 2011 to December 2025 for facial Von Recklinghausen 's disease. Demographic variables and local and late complications were analyzed. Surgical Technique: Under general anesthesia, the affected area was infiltrated with 1/500,000 norepinephrine. The surgery consisted of a subcutaneous supra-SMAS rhytidectomy, resecting skin and exuberant tumor while respecting healthy tissues and nerves. In the eyelid, resection of the skin and superficial orbicularis muscle was performed, respecting the frontal branch of the facial nerve. Thorough hemostasis was performed using bipolar cautery, followed by tension-free layered closure. All patients provided photographic consent. A 12-month follow-up was conducted.

Results Four cases of facial von Recklinghausen were treated: 3 males and one female. Two cases presented lesions on the left side of the face and two in the left upper palpebral area. Ages ranged from 30 to 74 years. Macroscopically healthy soft parts were preserved, respecting the branches of the facial nerve, with no neurological sequelae in the 4 patients. All were discharged the following day. There were no partial or total flap losses. Nor were there infections, dehiscence, or hematomas. The biopsies confirmed the diagnosis and ruled out the presence of malignant tumors. After a 12-month follow-up, there was no pathological scarring. Recurrence was clinically small in terms of hypertrophy of the involved tissues in 1 case.

Conclusion Facial von Recklinghausen's disease is rare, and patients are usually treated during childhood. Our series presents adult patients who were not treated at the appropriate time. The results of this series encourage continued surgical treatment of this pathology in these locations, achieving good results as long as nerve structures are respected and not injured.

1. Evans DG, et al. Birth incidence and prevalence of tumor-prone syndromes: estimates from a UK family genetic register service. Am J Med Genet A, 152A(2), 327–332 (2010).
2. Jenny P Garzon. Expanding the phenotype of neurofibromatosis type 1 microdeletion syndrome. Am J Med Genet C Semin Med Genet ,196(4):e32095 (2024)

Purpose Sustainable cleft care in low-resource settings requires not only short-term surgical missions but also long-term development of local surgical leadership. We report a 15-year, single-center cleft lip and palate program in Madagascar that emphasizes progressive responsibility, advanced case-based training, and cultivation of future local trainers, and evaluate how this model maintained continuity after a five-year interruption caused by the COVID-19 pandemic. Methods Since 2011, an international cleft team has conducted 11 surgical missions at the same hospital in Madagascar. The program was designed as a long-term partnership with local healthcare professionals, including a Japanese-Malagasy midwife who has been permanently stationed at the hospital for more than four decades and supports patient identification and long-term follow-up. Educational activities were structured in a stepwise manner. Local surgeons first acquired independent competency in routine and less complex unilateral cleft lip procedures. Subsequently, progressively more complex procedures were introduced. During the 2024 and 2025 missions, technically complex cleft palate cases and atypical bilateral cleft lip deformities were intentionally utilized as structured live surgical demonstrations with step-by-step intraoperative teaching for intermediate-level local surgeons. Training focused on operative planning, flap design, tissue handling, and intraoperative troubleshooting, with progressive transfer of responsibility under direct supervision. Experience A Malagasy physician who initially participated as an observer during the first mission subsequently completed postgraduate training in Japan and became the first locally trained plastic surgeon in Madagascar. Additional local surgeons have since undergone structured training through the same program and currently participate as independent operators and instructors. During the COVID-19–related interruption, local surgeons continued cleft surgery and postoperative follow-up without visiting teams, maintaining both clinical services and educational activities. After resumption of missions in 2024–2025, a noticeable shift in the case mix was observed toward higher surgical complexity, reflecting the increasing capability of local surgeons to independently manage routine cases. Results Following the five-year interruption caused by the COVID-19 pandemic, the case mix during the 2024 and 2025 missions shifted toward technically complex cleft palate and atypical bilateral cleft lip deformities, reflecting the increasing ability of local surgeons to independently manage routine and less complex cases. Across the entire program, a total of 205 cleft operations have been performed to date, with no reoperations, no blood transfusions, and no postoperative palatal fistula following primary palatoplasty. Conclusions A long-term, single-center partnership that combines progressive surgical responsibility with advanced case-based intraoperative teaching can sustain cleft care and education even after prolonged external disruption. Our educational strategy focuses not only on transferring operative techniques, but also on fostering local surgeons to become future trainers and clinical leaders who can independently manage complex cleft cases and guide the next generation of Malagasy surgeons. This model provides a practical framework for transforming mission-based activities into sustainable, locally led cleft care systems in low-resource settings.

Background: Cartilage-sparing otoplasty is widely performed to correct prominent ears, yet the optimal suture material remains unclear. This systematic review and meta-analysis evaluated whether suture absorbability and filament structure influence recurrence and postoperative complications.

Methods: Following PRISMA 2020 guidelines, three databases were searched (2000–2025). Studies reporting cartilage-sparing otoplasty with outcomes stratified by suture material were included. Random-effects meta-analyses of logit-transformed proportions were performed using restricted maximum likelihood estimation. Subgroup analyses compared monofilament absorbable, monofilament non-absorbable, and braided non-absorbable sutures. Univariable meta- regression assessed the influence of study characteristics, cartilage scoring, and fascial flaps.

Results: Twenty studies comprising 3,443 ears met inclusion criteria. Mean follow-up duration was approximately 19 months, ranging from 2 months to 18 years across studies. The pooled recurrence rate was 2.92% (95% CI, 1.57–5.39%; I² = 73%). Recurrence differed significantly by suture type (p = 0.030), lowest with braided non-absorbable sutures (1.09%; 95% CI, 0.26–4.52%), higher with monofilament non-absorbable sutures (4.01%; 95% CI, 0.19–8.23%), and highest with monofilament absorbable sutures (8.61%; 95% CI, 6.16–11.89%). Extrusion (1.39%; 95% CI, 0.62–3.06%) and hematoma (0.64%; 95% CI, 0.34–1.21%) were rare. Necrosis occurred in 0.99% of patients (95% CI, 0.58–1.70%), and infection occurred in 1.09% of patients (95% CI, 0.59–1.98%). Meta-regression did not identify significant moderators of recurrence.

Conclusions: Recurrence remains the principal complication after cartilage-sparing otoplasty and is more common with absorbable and monofilament sutures. Non-absorbable braided sutures demonstrated the lowest recurrence rates without increasing other complications and may provide the most durable correction.

Introduction: Plantar ulcers occur in about 30 percent of the patients suffering from Hansen's disease, a malady that afflicts approximately 4 million people worldwide, despite effective therapy available. Recurrent plantar ulcers in anesthetic feet in leprosy continue to challenge the clinicians. Despite numerous methods described in the literature to deal with this problem, very few studies have postulated the role of neuropathy caused by Mycobacterium leprae. There is evidence that bacterial colonization occurs preferentially in superficial peripheral nerves due to cooler temperatures of the superficial nerves and defective heat stress response of M. leprae. Also, the afflicted nerves suffer from ischemia from inflammation, trauma, or mechanical stress due to nerve compression at fibro-osseous tunnels near the joints, contributing to the development of neuropathy. We postulate that compression at tarsal tunnel due to compression of tibial nerve is a major contributor towards development of distal neuropathy that causes and perpetuates the occurrence of plantar ulcers in Hansen's disease. Logically, the release of tibial nerve and the medial and lateral plantar nerves should arrest or even reverse the development of distal neuropathy, thus, leading to long lasting healing of such ulcers. Method: We performed tarsal tunnel release in eighteen leprosy patients with forefoot ulcers from January 2025 to December 2025. All the patients were also treated for leprosy by effective antimicrobial therapy as per the recommended guidelines. Full release of posterior tibial nerve along with its branches, viz., nerve of Baxter, medial and lateral plantar nerves, till they enter the sole of the foot was performed. The spectrum of presentation of patients varied from ulcers under the heads of first, second, and fifth metatarsals and the heel, alone or in varied combinations. The size of the ulcers at its maximum length ranged from 1–4 cm. Post procedure, the ulcers were subjected to offloading by total contact casting and no surgical procedures, or any specialized dressings were used. Results: The tarsal tunnel release procedure used as single treatment modality successfully resulted in spontaneous healing of all the ulcers without any significant complications. The duration of total healing varied from four to sixteen weeks. Sixteen patients reported significant recovery of sensations in the sole of the foot compared to their pre-procedural state. All the patients reported subjective improvement in mobility owing to improved biomechanics of the operated foot. All the patients continued to be ulcer free till six months of follow up after the initial healing of the ulcers. Conclusion: Tarsal tunnel release of the involved foot in leprosy patients with plantar ulcers led to spontaneous healing without the need for any ancillary procedures or specialized dressings. The continued remission of the ulcers after the healing suggests long term beneficial effect of the surgical procedure, likely by reversing the neuropathy of Hansen's disease. Clinicians must focus on neuropathy being the leading contributor towards the development of plantar ulcers in patients with Hansen's disease.

Objectives To describe the ten surgical modifications to the Millard technique developed at our national referral center (Hospital General Dr. Manuel Gea González), analyze their impact on aesthetic and functional outcomes in unilateral cleft lip repair and obtain patient-reported outcomes through the validated CLEFT-Q scale. Methods A retrospective analysis of 108 out of 150 patients with unilateral cleft lip operated with the Millard´s modified technique between 2010–2024 at our hospital, who completed the questionary successfully. The CLEFT-Q scale was used to evaluate the functional and aesthetic satisfaction of the patients. The ten surgical modifications implemented are: 1. Pre- and Post-operative Botulinum Toxin A Injection: Reduces muscle tension, dehiscence, and hypertrophic scarring. 2. Infraorbital Nerve Block with Ropivacaine 0.2%: Improves analgesia and decreases anesthetic dosage. 3. More Circular Rotation ("A") Flap: Enhances philtral height and Cupid's bow symmetry. 4. Elongation of the "C" Flap: Lengthen columella and facilitates nasal floor closure. 5. Internal Dissection of Nasal Ala and Caudal Septum Release: Corrects nasal asymmetry. 6. Incision and Internal Suturing of the Nasal Ala: Refines alar contour and stability. 7. Reinforced Reconstruction of the Nasal Floor (Nasal and Oral Mucosal Lining): Reduces nasal vestibular fistulas and increases nasal volume. 8. Orbicularis Oris Muscle Release and Reapproximation at Wet–Dry Junction: Restores continuity, prevents whistle deformity. 9. Z-Plasty in the Upper Lip Vestibule: Elongates the vestibule and relieves tension, improving oral continence. 10. Transfixion Sutures on Alar Cartilage: They maintain nasal projection and symmetry. Finally the individual results were translated to the Rasch System and reported as measures of standard deviation. Results In this cohort, 57.6% were male; mean age at surgery was 1.6 ± 4.03 years and at interview 8.81 ± 6.38 years; 61.5% had left-sided clefts and 80.4% were incomplete. Appearance scores were jaw 72.67 ± 4.17, face 71.87 ± 7.23, and nose 64.8 ± 4.44. Quality-of-life scores were social 83.81 ± 12.37, school 82.81 ± 13.62, psychological 79.38 ± 15.52, and speech 79.88 ± 13.92, with favorable eating and drinking outcomes. Conclusions: The ten refinements to the Millard technique provide a reproducible algorithm for achieving tension-free closure and balanced nasal-lip contour. Patients demonstrated high satisfaction in aesthetic domains, excellent psychosocial well-being, and strong functional outcomes. References Blanco-Davila F. Incidence of cleft lip and palate in the northeast of Mexico: a 10-year study. J Craniofac Surg. 2003;14(4):533-537. doi:10.1097/00001665-200307000-00027. Hozyasz K, Mazur J, Chełchowska M. Stezenia alpha-tokoferolu u matek dzieci z rozszczepami wargi oraz z rozszczepami wargi i podniebienia [Alpha-tocopherol levels in mothers of children with cleft lip or with cleft lip and palate]. Ginekol Pol. 2006;77(4):255-262. Fisher DM, Sommerlad BC. Cleft lip, cleft palate, and velopharyngeal insufficiency. Plast Reconstr Surg. 2011;128(4):342e-360e. doi:10.1097/PRS.0b013e3182268e1b Mohamed Elekiaby, Tarek Gobran, Ahmad Rozik, Wael Mansy, Omar Elekiaby. (2021). Postoperative Parents' Satisfaction in Cases of Unilateral Cleft Lip Repaired by Millard's Procedure. Annals of the Romanian Society for Cell Biology, 25(6), 18266–18277. Knezevic P, Blivajs I, Dediol E, Macan D, Virag M. The modification of rotation-advancement flap made in 1950. Act Stomatol Croat. 2017; 51(1):60-4. doi:10.15644/asc51/1/8

Introduction: Severe battlefield wounds are characterized by inflammation and difficult healing and ideal dressing is needed to treat such cases. Gold nanoparticles (AuNP) have been demonstrated to possess anti-inflammatory properties and induce proliferation depending on their particle size. Gelatin methacryloyl (GelMA) is a modified gelatin polymer with good biocompatibility. This study investigates 3D-printed GelMA scaffolds containing 2nm AuNPs, fibroblasts, and keratinocytes to promote wound healing.

Materials and methods: First, we detected the viability of fibroblasts and keratinocytes in AuNP/GelMA. We used nude mice in this study for wound healing research. We applied Masson trichrome staining to observe collagen deposition and re-epithelialization. We applied immunohistochemistry assay to analyze the expression of fibroblast differentiation biomarker (α-SMA), pro-inflammatory cytokines (IL-1β、IL-6、IL-10), and apoptosis (cleaved caspase-3) in wound tissue.

Results: AuNP/GelMA supported robust cell viability and significantly accelerated wound closure with enhanced re-epithelialization and collagen deposition. The treatment modulated the microenvironment by downregulating pro-inflammatory IL-1β/IL-6 and upregulating anti-inflammatory IL-10 (P < 0.05). Additionally, increased α-SMA (P < 0.001) and reduced cleaved caspase-3 (P < 0.01) indicated promoted remodeling and suppressed apoptosis. Conclusion: We found that the optimized composition of AuNP/GelMA bioinks is suitable for 3D-printed full-thickness skin substitutes in wound healing after burn injury. This structure could further reduce the inflammation and apoptosis in the wound bed. Based on this. AuNP/GelMA skin substitutes may benefit clinical health in the future.

THE BATMAN FLAP MODIFICATION TO THE GOLDILOCKS MASTECTOMY RECONSTRUCTION Doran Kalmin1, Mansoor Mirkazemi1

1 Department of Plastic and Reconstructive Surgery, Monash Health, Melbourne Australia

Background and Objective The Goldilocks mastectomy, introduced by Richardson and Ma in 2012, provides an autologous reconstructive option for patients unsuitable for or declining traditional implant-based or free flap reconstruction. Despite advantages such as reduced morbidity and avoidance of alloplastic material, the procedure often results in a wide breast base with inadequate central projection and suboptimal aesthetics Objective This flap modification aims to improve central projection and wide based providing a more aesthetic outcome Methods We describe a single-stage modification-the Batman flap-that enhances projection and breast contour while maintaining the simplicity of the original technique. Using standard Wise-pattern markings, medial and lateral inferior dermal triangles are raised, folded, and sutured centrally to narrow the breast base and augment projection. The technique was performed on a 39-year-old woman with BRCA2-associated breast cancer undergoing bilateral skin-sparing, nipple-sacrificing mastectomies. Results The procedure was completed bilaterally without complications. Postoperatively, the patient demonstrated satisfactory breast symmetry, improved central mound projection, and a natural lower pole contour. No donor-site morbidity or wound dehiscence occurred. The patient reported high satisfaction with her aesthetic outcome and recovery. Conclusion The Batman flap modification effectively addresses one of the principal limitations of the Goldilocks mastectomy-poor projection-by redistributing redundant lateral and medial tissue toward the midline to create a rounded, aesthetic breast mound. This entirely autologous, single-stage approach is particularly suitable for patients with large, ptotic breasts or those contraindicated for prolonged reconstructive surgery. It offers a safe, reproducible method that preserves the core benefits of the Goldilocks technique while achieving superior cosmetic outcomes.

Background: The diagnosis of breast implant-related infections is often underestimated in reconstructive breast surgery, despite being crucial for establishing a rapid and effective therapeutic protocol. To date, the gold standard relies on microbiological cultures of periprosthetic fluid and intraoperative tissue biopsies. However, this approach typically requires a waiting time of 5–6 days, during which patients frequently receive empirical, non-targeted antibiotic therapy. This may reduce treatment effectiveness and may contribute to the growing global issue of antimicrobial resistance. Methods: At our institution, we implemented a novel diagnostic protocol based on a PCR microarray platform, capable of identifying bacterial pathogens included in the panel directly from clinical specimens within 6–8 hours. We conducted a prospective study including 40 patients with suspected implant-related breast infections. Each case underwent both standard culture analysis and PCR microarray testing. Results: The PCR microarray demonstrated non-inferior diagnostic performance compared to standard culture methods, with full clinical applicability in guiding early and targeted antimicrobial therapy. All included patients were successfully treated according to the established protocol. Conclusions: Rapid molecular diagnosis using PCR microarray provides a reliable alternative to conventional cultures for implant-related breast infections, significantly reducing diagnostic turnaround time and potentially enabling earlier targeted treatment, with possible benefits for clinical outcomes and antimicrobial stewardship.

Background: Several series have been published demonstrated the usefulness of the PAP flap in breast reconstruction in terms of its hidden donor site and as a good option for slim patients. However, the presence of a distal located perforator often results in surgeons utilising different skin paddle patterns that negate the advantage that the PAP flap affords as a hidden donor site. This study aims to assess whether inclusion of a distal PAP perforator, outside the skin paddle, during a free flap breast reconstruction negatively affects clinical outcomes.

Methods: We performed a prospective observational cohort study from 1st January 2021 and 31st December 2023 of patients who underwent free-flap breast reconstruction using PAP flaps. Clinical outcomes including flap loss, fat necrosis and donor site complications were recorded and analysed. Patients were asked to complete BODY-Q questionnaires pre-operatively and one year post-operatively to assess donor site morbidity.

Results: During the study period 102 PAP flaps were performed in 81 consecutive patients. Median age was 48 years (IQR 45-53), median BMI was 21.8 (IQR 20.2-23.4). In 77 flaps (75.4%), the perforator was located outside the flap skin island and within the distally recruited fat. In 10 flaps (9.8%), the perforator was located within the skin island and in 15 flaps (14.7%), one perforator was located within the skin island and one within the distally recruited fat. There was one flap loss, one partial flap loss and five cases of clinical fat necrosis. There was no correlation between perforators' location outside the skin paddle on flap loss, partial flap loss or fat necrosis. There was no statistical difference between pre-operative and post-operative satisfaction with buttock 52 vs 57 (p=0.68) and satisfaction with inner thigh 55 vs 55 (p=0.73) respectively.

Conclusion: In this prospective series of 102 consecutive free PAP flaps for breast reconstruction, we confirm that using a perforator located outside the skin paddle does not have negative clinical consequences.

References:

1. Angrigiani C, Grilli D, Thorne CH. The adductor flap: A new 
method for transferring posterior and medial thigh skin. 
Plast Reconstr Surg. 2001;107:1725–1731. 


2. Allen RJ, Haddock NT, Ahn CY, et al. Breast reconstruction with the profunda artery perforator flap. Plast Reconstr Surg. 2012;129:16e–23e. 


3. Ito R, Huang JJ, Wu JC, Lin MC, Cheng MH. The versatility of profunda femoral artery perforator flap for oncological reconstruction after cancer resection-Clinical cases and review of literature. J Surg Oncol. 2016 Aug;114(2):193-201. doi: 10.1002/jso.24294. Epub 2016 Jul 4. PMID: 27377593.

4. Haddock NT, Teotia SS. Consecutive 265 Profunda Artery Perforator Flaps: Refinements, Satisfaction, and Functional Outcomes. Plast Reconstr Surg Glob Open. 2020 Apr 7;8(4):e2682. doi: 10.1097/GOX.0000000000002682. PMID: 32440397; PMCID: PMC7209884.

5. Atzeni M, Salzillo R, Haywood R, Persichetti P, Figus A. Breast reconstruction using the profunda artery perforator (PAP) flap: Technical refinements and evolution, outcomes, and patient satisfaction based on 116 consecutive flaps. J Plast Reconstr Aesthet Surg. 2021 Dec 1:S1748-6815(21)00635-5. doi: 10.1016/j.bjps.2021.11.085. Epub ahead of print. PMID: 34975000.

Purpose: Surgical scars remain a significant aesthetic and functional concern after reduction mammoplasty. Autologous nanofat grafting delivers a high concentration of adipose-derived stromal vascular fraction (SVF), which contains multipotent cells, endothelial progenitors, and immunomodulatory factors that may modulate scar formation through paracrine signaling and extracellular matrix remodeling (1,2). This study evaluates the effect of centrifuge-free mechanically isolated nanofat on surgical scar quality in reduction mammoplasty, with particular emphasis on the regenerative contributions of SVF. Methods and Materials: A prospective, paired-control clinical trial was conducted from April 2024 to May 2025. Eligible patients undergoing bilateral reduction mammoplasty were enrolled. Following standard layered wound closure, nanofat was prepared via mechanical emulsification and filtration without centrifugation to preserve native SVF components (1). Nanofat was injected intradermally and subdermally along one vertical scar per patient; the contralateral scar received standard closure alone and served as an internal control. Clinical scar evaluation was performed at 1, 3, 6, and 12 months using the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS). High-frequency ultrasound assessed dermal thickness and architectural homogeneity. In a subset of patients undergoing minor revisional procedures at 6 months, biopsy specimens were obtained for histologic analysis, including collagen organization and microvascular density. Only patients completing 12-month follow-up were included in final analysis. Experience: Forty-five patients (90 scars) completed 12-month follow-up. No serious adverse events were attributed to nanofat administration. Minor transient edema occurred in three patients and resolved spontaneously. Results: At 12 months, nanofat-treated scars demonstrated significantly improved VSS and POSAS scores compared with control scars (P < 0.01). Ultrasound evaluation revealed reduced scar thickness and increased dermal homogeneity at treated sites (P < 0.05). Histologic assessment showed more organized collagen fiber architecture with reduced disorganized type III collagen and increased microvascular density, supporting enhanced angiogenesis and extracellular matrix remodeling. These findings align with reported SVF effects on immunomodulation, angiogenesis, and antifibrotic activity in surgical wounds (2,3). The balanced remodeling and increased early vascularity observed clinically mirror outcomes reported in recent controlled nanofat scar studies (1,4). Conclusions: Centrifuge-free nanofat grafting significantly improves both subjective and objective parameters of surgical scar quality after reduction mammoplasty. The regenerative benefit appears mediated by the preserved SVF, which promotes angiogenesis, immunomodulation, and favorable collagen remodeling. The bilateral reduction mammoplasty model provides a robust internal control for evaluating scar modulation strategies. Nanofat enriched in SVF represents a safe and biologically rational adjunct for optimizing surgical scar outcomes and warrants further mechanistic exploration and long-term follow-up. References Ramaut L, Improvement in Early Scar Maturation by Nanofat Infiltration. Aesthetic Surg J Open Forum. 2024. Zocchi ML. Potential benefits of adipose-derived SVF and MSCs in wound healing. Eur J Plas Surg. 2024. Alsabri G, Alavi S, Maningky M, et al. The Effectiveness of Nano Fat in the Management of Skin Scars: A Systematic Review. Aesth Surg J Open Forum. 2025. Chen Z, et al. New challenges in scar therapy: clinical use of fat and nanofat. J Plast Surg Hand Surg. 2024.

We compared TIGR®Mesh (EU) to ADM for DTI in our patients for the last two years. Nano or smooth surface -"Free foating" implant with minimial interaction to surrounding tissue! Should be fixed to the thoracic wall to prevent pseudoptosis and lateral displacement? How? Resorbable mash for DTI as a first choice, TIGR®Mesh (EU) or FLEX™P4HB (USA)! ADM for "two stage reconstrution" (irradiation, infection, contracture)!

Background: Breast reconstruction following mastectomy is associated with significant improvement of quality of life and psychosocial well-being, therefore it is part of the treatment plan of many breast cancer patients, either immediate – at the time of the mastectomy, or delayed – after completion of adjuvant therapy. The optimal timing of reconstruction is still debated, and choosing the best approach for each patient is often a complex clinical decision making process, which takes into account oncologic safety, presence or absence of radiation therapy, type of mastectomy performed, choice of reconstructive technique, use of implants, and patient characteristics and preference. Objective: To compare clinical outcomes, complication rates and short-term oncologic outcomes between recipients of immediate and delayed breast reconstruction. Methods: Patients having undergone mastectomy with either immediate or delayed reconstruction in the General Surgery and Plastic Surgery departments of Bucharest University Emergency Hospital were reviewed. Variables such as oncologic characteristics, reconstructive method, PMRT, and postoperative complications were analyzed. Results were compared to data available in literature. Results: Early postoperative complications and rates of surgical site infection were similar among both categories of patients. Data in literature indicates that that immediate breast reconstruction generally increases the risk of complications in comparison with delayed reconstruction and were more likely to develop hematomas or seromas (1). Patients who have undergone post-mastectomy radiation therapy demonstrated slightly higher rates of complications both after immediate and delayed reconstruction, such as capsular contracture, wound dehiscence, or implant exposure. Studies show that despite slightly higher complication rates, immediate breast reconstruction required less interventions and was less time-consuming than delayed breast reconstruction following PMRT (2), which we also observed in our patients. There were no significant delays observed in initiation of adjuvant therapy attributable to reconstruction timing, and no differences in short-term oncologic outcomes, similar to what other studies have shown. (3) Conclusion: Both immediate and delayed breast reconstruction are safe and effective approaches when individualized to patient factors and treatment plans. Immediate reconstruction offers psychosocial and logistical benefits, while delayed reconstruction may reduce radiation-associated complications in select patients. Multidisciplinary coordination is essential to optimise oncologic safety and reconstructive outcomes. References: 1. Matar DY, Wu M, Haug V, Orgill DP, Panayi AC. Surgical complications in immediate and delayed breast reconstruction: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg. 2022;75(11):4085-4095. 2. Kooijman MML, Hage JJ, Scholten AN, van Duijnhoven FH, Breugem CC, Woerdeman LAE. Advantages of immediate implant-based breast reconstruction over delayed breast reconstruction in women treated with postmastectomy radiotherapy for breast cancer. Breast Cancer Res Treat. 2025;212(1):37-46 3. Bargon CA, Young-Afat DA, Ikinci M, et al. Breast cancer recurrence after immediate and delayed postmastectomy breast reconstruction-A systematic review and meta-analysis. Cancer. 2022;128(19):3449-3469.

Purpose Bibliometric analyses provide quantitative insight into research productivity, impact, and thematic development within surgical specialties. The purpose of this study was to analyze the most influential plastic surgery publications affiliated with Italy and evaluate citation impact, collaboration patterns, study design characteristics, and research themes.

Methods A bibliometric analysis was conducted using the Web of Science Core Collection. Publications with at least one author affiliated with an Italian institution and indexed in major plastic surgery journals were retrieved without restriction on publication year. Only original articles and review articles published in English were included. Records were ranked according to total citation count, and the 100 most-cited publications were selected for detailed analysis. Extracted variables included citation metrics, authorship patterns, institutional affiliations, journal distribution, and international collaboration. Study design and level of evidence were classified according to the Oxford Centre for Evidence-Based Medicine (OCEBM) framework. Bibliometric mapping and thematic analysis were performed using the bibliometrix R package and VOSviewer.

Experience A total of 2,469 Italian-affiliated plastic surgery publications were identified, accumulating 47,680 citations with a cumulative H-index of 80.

Results The 100 most-cited publications received a mean of 123.6 citations (range 71–896). Plastic and Reconstructive Surgery was the most represented journal (39 articles), followed by Aesthetic Plastic Surgery (16), Microsurgery (12), and the Journal of Plastic, Reconstructive and Aesthetic Surgery (10). Highly cited publications originated from multiple academic and clinical institutions across Italy, reflecting a broad national contribution to plastic surgery research. International collaboration occurred in 37% of publications, most frequently involving the United States and the United Kingdom. The most common study design was case series (49 articles), followed by cadaveric or laboratory-based studies (13) and systematic reviews (7). According to the OCEBM classification, most studies were Level IV evidence (56%), while higher levels of evidence were less frequently represented. Thematic analysis showed that aesthetic surgery (27 articles) represented the most frequent research domain, followed by lymphatic surgery (10) and peripheral nerve surgery (9).

Conclusion Italian plastic surgery research demonstrates substantial international impact, with highly cited publications concentrated in leading specialty journals and supported by significant international collaboration. Despite strong citation impact, the predominance of lower-level evidence highlights the need for higher-quality prospective and randomized studies to strengthen the evidence base of future research.

Background - Segmental mandibulectomy for oral malignancies often result in thin overlying skin or through-and-through defect which needs a second coverage over fibula. We present the use of distal FHL muscle based on peroneal pedicle in chimeric fashion in providing a second coverage and discuss the merits and limitations of this simple modification. Methodology - Patients undergoing segmental mandibulectomy for oral cancer were included. Patients were categorized into Group A without skin defect (Cordeiro Type A) and Group B with skin defect (Cordeiro Type B). Group A received Free Fibula (FFF) and chimeric FHL muscle while Group B received FFF and chimeric FHL musculocutaneous paddle. This distal paddle was propelled over fibula to complete soft tissue (+/- skin) reconstruction. The skin paddles were carefully planned based on location of perforators in the proximal, mid and distal third of leg to allow efficient flap chimerism. Patients were followed up at post-op 1 month and 3 and 6 months post adjuvant radiation. Outcome – 43 patients received reconstruction with this modification between January 2024 and January 2025. 3 patients who had early recurrence and 1 mortality were excluded. 21 patients came under Group A and 18 under Group B. Contralateral leg was used as donor in 35 patients while ipsilateral leg was used in 4. Only fibula was used in 90% while a second flap was needed in 10%. A second flap was needed when the required fibula length was >160 mm or when the skin/soft tissue defects were extensive. 5 patients needed modification in skin paddle planning because of deficient distal or mid-third perforators. Early complications in muscle only group included 2 intraoral skin paddle losses due to lack of perforators and two oro-cutaneous fistulae, all of which could be managed conservatively due to underlying FHL muscle cover. In FHL myocutaneous group, 2 patients had marginal skin necrosis of outer paddle which could be repaired primarily. 1 patient had plate/bone exposure which needed a second flap cover. All patients received adjuvant radiation except 2. Over 6 months follow-up, there was gradual loss of muscle bulk and soft tissue cover was well maintained. Late or post radiation complications included facial soft tissue atrophy in 10.25%, trismus in 5.13% and plate infection in 5.13%, all of which could be attributed to the extensive skin or soft tissue loss during primary surgery. There was no gait abnormality. Donor sites healed well at final follow-up. 2 patients had adduction deformity of the great toe. Conclusion - This simple modification of free fibula flap gives additional coverage over the fibula thus preventing soft tissue atrophy, bone/plate exposure and osteoradionecrosis. The flap harvest is technically easy and reproducible without adding any donor site morbidity. It needs proximal dissection of peroneal pedicle and a careful planning of the bone, skin paddle and muscle paddle based on the location of perforators. This technique is not suitable for large mandibular defects or extensive skin/soft tissue defects, where adding a second flap or using a Scapular flap may give better outcomes.

Background Diabetic Foot Infections (DFIs) are clinically defined by the presence of signs and symptoms of an inflammatory process in a foot wound located below the malleoli [1]. The break in continuity of skin leads to colonisation of the wound by pathological bacteria leading to inflammatory response. As these individuals suffer from peripheral neuropathy, peripheral vascular disease and altered immune response, the signs and symptoms of inflammation may be masked. Early, aggressive, thorough debridement is essential 1st step in the management of these patients [1]. Such debridement often leaves an exposed joint, tendon or a soft tissue defect that requires a free tissue transfer to salvage the limb. Though good outcomes have been reported for free flap in diabetics [2], there is limited literature regarding flap survival following an acute infection. This study aims to evaluate flap outcomes in diabetic patients after an acute necrotising infection [3]. Methods 24 patients (4 female,20 male) who underwent free flap cover for soft tissue defects of the foot/ankle from January 2017 to November 2025 were included. Those who had traumatic defects and those with no available vessels for performing vascular anastomosis were excluded. The primary outcome was flap survival at 30 days after surgery and secondary outcome was any other post-op complication, ulcer recurrence, amputation, ambulation at 1-year post-op. Results 10 patients underwent muscle flap with split skin cover and 10 patients underwent fasciocutaneous flap cover. All free flap survived (100 %),2 patients needed repeat SSG cover within 30 days of free flap surgery. 4 patients (16%) had delayed wound healing. 4 patients (16%) who underwent fasciocutaneous flap underwent flap debulking 3-6 months post-op. 3 patients had ulcer recurrence that needed footwear modification and offloading to heal the wound. None had further amputation and all are ambulant to maintain activities of daily living [1,3]. Conclusion Vascularised tissue transfer after an acute infection in a diabetic patient to cover soft tissue infection, even in the presence of other comorbidities like coronary artery disease or chronic kidney disease or peripheral artery disease is a good option to ensure limb salvage and to ensure an ambulant patient in the long run [1,2,4].

References 1. Ghijsen SC, Thé AF, Coert JH, Zonnevylle EDH, Khoe PCKH, Bakker OJ, Rakhorst HA. Free tissue transfer for limb salvage following acute diabetes-related foot infections: A multicentre outcome study of success and failure. J Plast Reconstr Aesthet Surg. 2025 May;104:191-197. 2. Bhat S, Chia B, Barry IP, Panayi AC, Orgill DP. Free Tissue Transfer in Diabetic Foot Ulcers: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg. 2023 Nov;66(5):670-677. 3. Goodall RJ, Borsky KL, Harrison CJ, Mavromatidou G, Shirley RA, Ellard DR, Rodrigues JN, Chan JK. A Qualitative Study of Patients' Lived Experiences of Free Tissue Transfer for Diabetic Foot Disease. Plast Reconstr Surg Glob Open. 2024 May 20;12(5):e5842. 4. A.J.M. Reed, N.T.Y. Lim, S.W.L. Yip, et al.Outcomes of flap reconstruction for diabetic foot ulcers: A systematic review and meta-analysis of clinical studies Plast Reconstr Surg, 154 (5) (2024), pp. 1118-1130

[Background] The choice between implant-based and autologous breast reconstruction in patients with breast cancer is preference-sensitive. In March 2024, a nationwide resignation of residents in South Korea substantially limited access to immediate deep inferior epigastric perforator free flap (DIEP FF) reconstruction for approximately 18 months. As a result, some patients who initially preferred DIEP FF at our institution underwent direct-to-implant (DTI) reconstruction instead. We evaluated patient-reported outcomes in this externally constrained setting.

[Methods] In this initial report, patients undergoing unilateral prepectoral implant-based breast reconstruction between March 2024 and August 2025 were reviewed. Expander-based cases and those without completed BREAST-Q questionnaires were excluded. Patients who initially preferred DIEP FF were offered temporary expander placement for delayed DIEP FF or conversion to DTI. Those converting to DTI comprised the study group, while patients who initially chose and underwent DTI served as controls. BREAST-Q scores at 6–12 months were compared.

[Results] Among 187 reconstructions performed during the study period, follow-up duration was not sufficient for all patients to complete postoperative assessment. 12 patients were included in the study group and 40 in the control group for analysis. Baseline clinical characteristics were similar between the two groups. Between 6 and 12 months postoperatively, psychosocial well-being, sexual well-being, satisfaction with breasts, and physical well-being scores were lower in the study group, although the differences were not statistically significant.

[Conclusion] Although not statistically significant, patients whose reconstructive preference was externally altered demonstrated consistently lower BREAST-Q scores across domains. These preliminary findings suggest a potential impact of disrupted preference alignment on patient-reported outcomes and support the value of preserving patient choice in reconstructive decision-making whenever feasible.

Introduction: Liposarcomas represent the most common histological subtype of soft tissue sarcomas, rare malignant tumors originating from mesenchymal stem cells. Myxoid liposarcoma accounts for 30–50% of liposarcomas and typically presents in individuals between the 4th and 5th decades of life (1,2). These tumors most frequently occur in the lower extremities, specifically in the proximal thigh (2).

Case report: We report the case of a 50-year-old male with multiple cardiovascular comorbidities who presented with a slowly progressive mass in the anterolateral compartment of the calf. Magnetic resonance imaging revealed a large soft tissue tumor with central necrosis, infiltrating the tibial plateau as well as the tibialis anterior, fibularis longus, and soleus muscles. Fine-needle aspiration cytology established the diagnosis of grade 2 myxoid liposarcoma. Staging investigations excluded distant metastases, and the tumor was stage IIB (T2N0M0G2). Neoadjuvant external beam radiation therapy resulted in significant tumor size reduction. The patient subsequently underwent en bloc tumor excision with bone debridement and reconstruction. Negative surgical margins were achieved, and adjuvant chemotherapy was administered.

Discussions: The surgical management of lower extremity liposarcoma is challenging and requires a multidisciplinary approach. Limb-sparing surgery, combined with adequate preoperative radiotherapy, is preferred, as it offers the advantages of better function and psychological benefits, resulting in an overall improvement in quality of life. However, incomplete resection is associated with high rates of local recurrence, decreased survival, and functional impairment. Although limb-sparing surgery is feasible in carefully selected cases, in highly aggressive and infiltrative tumors, amputation may be needed to achieve oncological safety (3).

1. Osama MA, Chatterjee P, Singh S, Pandey A, Mohta A. Myxoid liposarcoma diagnosed on fine needle aspiration cytology: There is more to it than meets the eye. J Cancer Res Ther. 2025 Jan 1;21(1):303-307. doi: 10.4103/jcrt.jcrt41924. Epub 2024 Jul 17. PMID: 39016314.
2. Adameșteanu MO, Enache V, Zamfirescu D, Lascăr I. Limb-sparing surgery as an alternative for limb amputation in an invasive myxoid liposarcoma--case report. J Med Life. 2015 Apr-Jun;8(2):218-25. PMID: 25866581; PMCID: PMC4392097.
3. Smolle MA, Andreou D, Tunn PU, Szkandera J, Liegl-Atzwanger B, Leithner A. Diagnosis and treatment of soft-tissue sarcomas of the extremities and trunk. EFORT Open Rev. 2017 Oct 17;2(10):421-431. doi: 10.1302/2058-5241.2.170005. PMID: 29209518; PMCID: PMC5702952.

Background: "Wide cleft palate" has historically been described almost exclusively in the setting of bilateral cleft morphology, where tissue deficiency and tension under closure increase complication risk. Common quantitative definitions include cleft width ≥ 15 mm or palatal shelf width <1/3 of cleft width. Despite these standards, wide morphology occurring in unilateral cleft palates remains poorly characterized and is not reflected in commonly used classification systems, creating ambiguity in operative planning and outcome reporting. This study describes wide unilateral cleft palate as a distinct clinical phenotype and reports surgical outcomes from a high-volume cleft center. Methods: A retrospective review was conducted at CLAPP Hospital (January 2013–December 2024). Patients with unilateral cleft palate (complete or incomplete) meeting pre-defined criteria for a "wide" cleft (cleft width ≥ 15 mm and/or palatal shelf deficiency criteria adapted for unilateral morphology) were included. Demographics, cleft measurements (cleft width; right/left palatal shelf widths), operative details, and postoperative outcomes were extracted. Primary outcomes included oronasal fistula and velopharyngeal insufficiency (VPI). Descriptive statistics were reported. Results: Seventy-six patients met inclusion criteria. Mean age at surgery was 9.2 years (SD 9.17; range 1-43), and 63.2% were male (48/76). Mean cleft width was 1.64 cm (SD 0.15; range 1.51-2.21). Mean right palatal shelf width was 0.92 cm (SD 0.13; range 0.58-1.16) and left palatal shelf width was 1.18 cm (SD 0.15; range 0.80-1.60), demonstrating consistent unilateral tissue deficiency. Surgical management prioritized tension-free closure with Bardach two-flap palatoplasty, incorporating aggressive mobilization strategies in complete clefts (including bilateral greater palatine pedicle dissection and levator dissection with posterior retropositioning). Postoperative oronasal fistula occurred in 14.5% (11/76), most commonly at the hard-soft junction. VPI was observed in 13.2% (10/76), with 6.6% (5/76) requiring secondary speech surgery. Conclusion: Wide unilateral cleft palate represents a distinct and underrecognized clinical entity that warrants equal consideration among other phenotypes. Recognition of this phenotype supports updating cleft classification frameworks to incorporate width-based modifiers for unilateral defects and may improve surgical planning and outcomes reporting.