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Introduction Complications after otoplasty procedure can be divided into early- and late-period complications, with the former occurring up to 14 days postoperatively and the latter occurring after the initial 14-day period. Indications for revision surgery of ear deformations after primary otoplasty are generally related to late complications. The majority of patients demand secondary treatment because of unsatisfactory cosmetic results. Methods A total of 32 patients (18 male and 14 female patients) underwent revision otoplasty with the same surgeon between May 2015 and May 2018. Patient ages ranged from 24 to 70 years. In total, 21 patients underwent bilateral revision otoplasty, whereas 11 patients underwent unilateral revision otoplasty. Patients were also evaluated for complaint and deformity type such as suture extrusion, recurrence, asymmetry, and postauricular area sensitivity or pain. Patients were also evaluated for previously performed primary otoplasty technique. Results There were mainly 4 long-term complications for revision otoplasty: suture extrusion, asymmetry, recurrence, and long-term pain and sensitivity in the posterior auricular area. In 12 cases, the complaint was suture extrusion; in 8 cases, patients complained about both suture extrusion and asymmetry. Bilateral recurrence was present in 10 cases, and in 2 cases, revision otoplasty was performed because of long-term pain and sensitivity. Discussion In this study, it was aimed to demonstrate that posterior perichondrioadipodermal flap is a safe and simple method for revision otoplasty. The technique is highly advantageous if the primary otoplasty technique is a cartilage-sparing method. However, if the primary otoplasty technique is a cartilage-sculpting method, the efficiency of this technique remains unknown because no patient in this study had cartilage-sculpting otoplasty as primary otoplasty, which is possibly the main drawback of this study.

Background Scalp defects can be reconstructed either with skin graft, local flaps, free flaps, or tissue expansion. Tissue expanders have been proved to be fruitful in the pediatric population. Scalp expansion has proved to be useful in the reconstruction of posttraumatic and postburn alopecic defects. Selective nerve block can be added for attenuation of sympathetic stimulation and decrease surgical stress in cranial surgeries. In this study, a comparison was done between using selective nerve block and without selective nerve block in both stages of tissue expansion procedure. Patients and methods This study included 32 different children who underwent tissue expansions in the management of postburn alopecia. Pediatric patients presented with postburn alopecia of the scalp with mature scar were included in this work. Results Postoperative analgesics were less in children who had received scalp block, whereas it was shorter in patients who did not receive any scalp block. Meperidine consumption was much more less in patients who received selective scalp nerve block. Pain score was markedly decreased in children who had received selective scalp nerve block in the immediate postoperative period. Children who received scalp block showed marked attenuation in the surgical stress responses with minimal changes in heart rate and mean arterial blood pressure after skin incision. Conclusions Scalp nerve block is considered an excellent choice for postoperative pain control with less need for opioid analgesia.

Background Wound tension reduction is still a challenge to surgeons. Over the years, many techniques have been proposed to avoid this issue. In this paper, we present a new suture technique. Objectives To investigate the tension-reduction effectiveness of the modified subcutaneous buried horizontal mattress suture compared with the vertical buried mattress suture technique. Methods Two suture techniques, the vertical buried mattress suture (group A) and the modified subcutaneous buried horizontal mattress suture (group B), were performed on paired samples of symmetrical skin flaps. An equal pulling force was applied to each paired sutured flap, and the dehiscences of the samples in the two groups were compared. Then, after the periodic mechanical pulling force was recorded, the dehiscences were compared again. Results The dehiscences of the vertical buried mattress suture samples (group A) were much wider than their corresponding samples. Modified subcutaneous buried horizontal mattress suture samples (group B) remained well closed with no or minimal dehiscence, under various tensions, even after mechanical pulling force was applied. Conclusion The modified subcutaneous buried horizontal mattress suture greatly decreased the tension on the dermis and subcutaneous tissue in our in vitro experiment.

Background Management of keloids has remained a conundrum, because an optimum treatment regimen has yet to be elucidated. Currently, treatment varies widely between more conservative measures, such as steroid injections, topical medications, and silicone sheeting, to more aggressive options, such as surgery and postoperative radiation. The latter combination has been touted to have superior results, with the lowest rates of pathologic scar recurrence. Methods We performed a retrospective review to critically evaluate the effectiveness of surgical excision and radiation treatment in patients with keloids. Surgical resection of surgeon-selected keloids, combined with state-of-the-art postoperative cutaneous radiation therapy, was used at a major tertiary referral center. For patients with poor follow-up, phone calls were made to determine recurrence. In addition, we present a review of the current literature to provide a comprehensive synopsis of current keloid treatment. Results A total of 69 patients' records were reviewed. There were a total of 84 keloids upon pathology review. The overall recurrence rate for all keloids was 27%, and in those followed greater than 1 year, recurrence for keloids was 74%. About half the patients with more than 1 year of follow-up experienced recurrence more than 1 year after treatment. Conclusions At this time, the evidence supporting surgery and radiation for the treatment of keloids remains equivocal, and randomized controlled studies are needed to determine the efficacy of this treatment protocol. Most importantly, our data reinforce the need for long-term follow-up in this patient population.

Purpose To determine the current postoperative mobilization care practice patterns of burn surgeons after split-thickness skin grafting and to assess potential inconsistencies in management strategies. Methods A cross-sectional study of active burn surgeons was conducted with an online questionnaire (SurveyMonkey) comprising 7 demographic and 22 mobilization-related questions. Results Seventy-three (22%) of the 337 members of the American Burn Association mailing list consented to participate in the study, of whom 71 completed the demographic questions and 59 completed the mobilization-related questions. The majority of respondents had more than 10 years of burn care experience (68%) and practiced in an American Burn Association-verified center (70%). Standardized postoperative autograft mobilization protocols were used by 68% of respondents. Most (66%) never or rarely immobilized the upper extremity without joint involvement. When the elbow or wrist was involved, 73% always or very often immobilized. Similarly, 63% never or rarely immobilized the lower extremity without joint involvement. Most immobilized when the knee (70%) or ankle (63%) was involved. Immobilization duration was most commonly 3 or 5 days. Most respondents (71%) reported following Nedelec and colleagues' recommendation that "early postoperative ambulation protocol should be initiated immediately after lower extremity grafting," although there was practice variability. Conclusions Our findings reveal that the majority of survey respondents do not immobilize the extremities after autograft without joint involvement. When grafts cross major joints, most surgeons immobilize for 3 or 5 days. Despite some practice variability, surveyed burn surgeons' current lower extremity ambulation practices generally align with the 2012 guidelines of Nedelec et al.

Introduction The obese or ptotic breast demonstrates significant difficulty in breast reconstruction after mastectomy with increased rates of perioperative complications compared with the general population, regardless of reconstruction type. Implant-based reconstruction in this patient population with the traditional horizontal elliptical skin-sparing mastectomy tends to have aesthetically displeasing qualities secondary to skin flap redundancy and blunting of the breast contour. Wise-pattern closures have been described with submuscular direct-to-implant and 2-stage reconstructions, with more favorable complication profile when staged. Our study aims to report outcomes and safety of a prepectoral 2-stage wise-pattern closure technique in the obese and/or ptotic population. Methods A retrospective chart review was performed to identify all overweight, obese, and/or grade III ptotic patients who have undergone a 2-stage, wise-pattern skin closure with prepectoral placement of tissue expander by a single surgeon. Patient demographics, comorbidities, and perioperative descriptors were reported. Delayed wound healing, infection, seroma formation, and explantation or reoperation were recorded for each patient involved in the study. Results Thirty-seven obese and/or ptotic breasts among 21 patients underwent immediate prepectoral tissue expander placement with wise-pattern skin reduction closure with mean body mass index of 35.3 kg/m, and 25% of patients were diabetic The most common complication rates by breast were seroma formation (50%) and wound/dehiscence at T-point (28.6%), which all ultimately healed with intervention as described. One major (2.7%) and 1 minor (2.7%) infection were successfully treated with antibiotics. There were no cases of implant exposure. Two operative complex repairs and 1 elective explantation were performed. Diabetes and increasing body mass index were statistically associated with an increased overall perioperative complication rate. Conclusions Prepectoral, 2-stage breast reconstruction with wise-pattern skin reduction performs well in obese and/or ptotic patients with favorable rates of perioperative complications. Wound dehiscence was prevalent but managed with wound care when complex repair was not required to expedite adjuvant chemotherapy. Infection rates and reoperation rates were low, and all patients reported positive aesthetic results at the completion of reconstruction.

INTRODUCTION With increasing health care expenses and limited resources, it is important to evaluate potential means of reducing cost while maintaining efficacy and safety. The purpose of our study was to compare the cost and outcomes of surgical excision of nonmelanoma skin cancer (NMSC) in the operating room versus an outpatient procedure clinic. METHODS A retrospective review of patients undergoing excision of biopsy-confirmed NMSC at the Miami Veterans Affairs Hospital between December 1, 2015, and December 1, 2016, was completed. Patients treated in the operating room and procedure clinic were included. Treatment outcomes were assessed for all identified patients. Patients undergoing excision and primary closure were included for cost comparison.Procedure costs were estimated using Current Procedural Terminology codes for treatments provided and the 2017 conversion factor of $35.7751. If a second operation for positive margins was necessary, cost to treat the lesion included costs from both procedures. If multiple lesions were treated, total cost was divided by the number of lesions to calculate cost per lesion treated. Costs per lesion managed in the operating room and clinic were compared using the Student t test. RESULTS Sixty-five patients underwent excision of 94 NMSCs in the operating room. Nineteen patients underwent excision of 20 NMSCs in the procedure clinic. One patient treated in the clinic required re-excision in the operating room with frozen section for a positive margin.Thirty-three patients managed in the operating room and 19 patients managed in the procedure clinic were included for cost analysis. Average costs per lesion excised in the operating room and procedure clinic were calculated to be $1923.43 ± 616.27 and $674.88 ± 575.22, respectively (P < 0.001). CONCLUSIONS Excellent oncologic outcomes were achieved for both operating room and procedure clinic excision. Excision in the operating room excision was significantly more expensive than in the procedure clinic. Excision in a procedure clinic offers an opportunity to reduce costs while maintaining quality care.

Background Most head and neck melanomas occur on the face, with the cheek being the most frequently affected site. So far, small numbers of researches on cheek melanomas have yielded insufficient and controversial results. In this trial, we aimed to define the histopathological and clinical features specific to cheek melanomas and to compare them with other head and neck melanomas by using a large group of patients from a single tertiary center. Patients and methods A total of 98 cheek melanomas and 183 other (noncheek) head and neck melanoma cases were analyzed retrospectively. Results The median age was 62 years and malar/zygomatic was the mostly affected site (78.6%). The cheek melanomas developed more frequently in females (61.2%) and most of them were associated with lentigo maligna histopathological subtype (49.2%) and early-stage disease (stage 0-II) (77.6%). The cheek melanomas were found more significantly associated with older patients (P = 0.05), females (P = 0.0001), lentigo maligna subtype (P = 0.0001), lower vertical growth phase (P = 0.03), and early-stage of disease (P = 0.0001) compared with other lesions that developed other sites. Furthermore, they were associated with lower relapse rates (18.6% vs 39.5%, P = 0.0001) and the 5-year recurrence-free survival rate of cheek melanomas was 80% (P = 0.002). Moreover, the 5-year overall survival rate of cheek melanomas was 62%, and they were found to be associated with a favorable overall survival (P = 0.004). Conclusions Cheek melanomas are associated with lower relapse rates and favorable outcomes compared with other (noncheek) head and neck melanomas.

Background Surgical excision with adjuvant radiotherapy has gained attention as an effective treatment of keloid. The Asian population is challenged with a high incidence of keloid occurrence with a specific genetic predominance. The annual reported incidence of new keloid cases in Taiwan is around 30,000, but the disease control rate and effectiveness by means of surgical excision with adjuvant radiotherapy is not yet clear. Methods A retrospective chart review of the included consecutive keloid patients receiving surgical excision and radiotherapy was performed from 2013 to 2016 in a single institute. The reported risk factors were collected to investigate according to the outcome analysis. The Vancouver Scar Scale and the Japan Scar Workshop (JSW) Scar Scale were used to evaluate the correlation with keloid recurrence. Results In this series, the overall recurrence rate was 32%, reported with an average follow-up of 28 months. Independent risk factors varied according to the different outcome variables. Only JSW classification score independently predicted the risk of keloid recurrence (odds ratio, 1.305; P = 0.02). Both the Vancouver Scar Scale and the JSW system showed a good correlation with keloid recurrence (correlation efficiency, 0.529 and 0.54; P = 0.0437 and 0.0165, respectively). Conclusions This preliminary report revealed convincing evidence of feasibility and effectiveness of applying adjuvant radiotherapy after keloid excision in the Taiwanese population. A more delicate biological equivalent dose of radiotherapy with an effective local control should be considered to improve the final outcome.

Background Although there are numerous skin closure methods, there is no special method for suturing triangular skin wounds. The authors have summarized and modified their experience with a 3-dimensional (3D) continuous suturing technique for triangular wounds. Methods From December 2015 to September 2017, the 3D continuous suturing technique for triangular wounds has been used in 32 cleft lip repairs (48 surgical triangular incisions) and 11 cases of facial trauma (15 traumatic triangular wounds). The patients, 3 months to 39 years of age, had triangular flaps designed for esthetic purposes or triangular defects secondary to accidents. To evaluate the effectiveness of this technique, the mean follow-up was 7 months (range, 1-15 months). Results The 3D continuous suturing technique for triangular wounds can shorten the suturing time, decrease the number of thread knots, and shorten the time of surgery. All patients healed well and the stitches were removed 7 days postoperatively. The wound on both sides of the triangle was well arranged, with a good appearance and no scar hyperplasia. Conclusions Our experience showed that the 3D continuous suturing technique for triangular wounds is a time-saving and convenient method and can make the wounds closed tighter, more stable, and reliable. The technique can be applied to any type of triangular wounds or incisions and is not limited to the clinical scenarios described in this article.

Background Numerous conventional wound reconstruction methods, such as wound undermining with direct suture, skin graft, and flap surgery, can be used to treat large wounds. The adequate undermining of the skin flaps of a wound is a commonly used technique for achieving the closure of large tension wounds; however, the use of tension to approximate and suture the skin flaps can cause ischemic marginal necrosis. The purpose of this study is to use elastic rubber bands to relieve the tension of direct wound closure for simultaneously minimizing the risks of wound dehiscence and wound edge ischemia that lead to necrosis. Materials and methods This retrospective study was conducted to evaluate our clinical experiences with 22 large wounds, which involved performing primary closures under a considerable amount of tension by using elastic rubber bands in a skin-stretching technique after a wide undermining procedure. Assessment of the results entailed complete wound healing and related complications. Results All 22 wounds in our study showed fair to good results except for one. The mean success rate was approximately 95.45%. Conclusions The simple skin-stretching design enabled tension-free skin closure, which pulled the bilateral undermining skin flaps as bilateral fasciocutaneous advancement flaps. The skin-stretching technique was generally successful.

Although various reconstruction surgery techniques are available to repair posterior heel defects, the compound defects reconstruction is an ongoing surgical challenge. Complex, free tissue flaps are often clinically used in this repair operation but the techniques have some disadvantages, including intraoperative tedious dissections, vascular anastomosis, and postoperative thrombogenesis. Here, we present a single-stage procedure for Achilles tendon and its overlying skin defects repair with a complex posterior tibial artery perforator-based tissue flap on 3 patients. This method can repair the Achilles tendon and the soft tissue defects simultaneously in a relatively short operative time. The prognosis of the 3 operative patients described here was great for participating in exercise and daily work unassisted 18 to 26 months after operation. Clinical results indicate that our operative method can be effective in repair of Achilles tendon and its overlying skin defects without major complications.

Hypertrophic scars and keloids remain a challenge in surgery. We appreciate that our understanding of the process at cellular and molecular level, profound as it is, when it comes to the clinical evidence much is left to be desired. Although the bench to bedside conundrum remains, the science of translational research calls for an even higher level of cooperation between the scientist and the clinician for the impetus to succeed.The clinicians alerted us to the possible theories in the pathogenesis of keloid formation, inter alia, the ischemia theory, mast cell theory, immune theory, transforming growth factor β interaction, mechanical theory, and the melanocyte stimulating hormone theory. All of the above presupposed a stimulus that would result in an uncontrolled upregulation of collagen and extracellular matrix expression in the pathogenesis of the keloid. This bedside to bench initiative, as in true science, realized more ponderables than possibilities.By the same token, research into the epidermal-mesenchymal signaling, molecular biology, genomics, and stem cell research holds much promise in the bench top arena. To assess efficacy, many scar assessment scores exist in the literature. The clinical measurement of scar maturity can aid in determining end points for therapeutics. Tissue oxygen tension and color assessment of scars by standardized photography proved to be useful.In surgery, the use of dermal substitutes holds some promise as we surmise that quality scars that arise from dermal elements, molecular and enzyme behavior, and balance. Although a systematic review shows some benefit for earlier closure and healing of wounds, no such review exists at this point in time for the use of dermal substitutes in scars.Adipose-derived stem cell, as it pertains to scars, will hopefully realize the potential of skin regeneration rather than by repair in which we are familiar with as well as the undesirable scarring as a result of healing through the inflammatory response.Translational research will bear the fruit of coordinating bench to bedside and vice versa in the interest of progress into the field of regenerative healing that will benefit the patient who otherwise suffers the myriad of scar complications.

Scalp tissue expansion is a reliable technique for reconstruction of scalp alopecia and other deformities. However, the conventional practice involves establishing temporary wound coverage before expander placement, expansion, and definitive reconstruction. We propose that immediate (at the time of injury and initial wound debridement, leaving an open wound during expansion) tissue expander placement may be a reasonable approach to the management of full-thickness scalp wounds not amenable to primary closure.We performed a retrospective chart review identifying all patients who underwent immediate placement of scalp tissue expanders at the Lviv Burn Center (Lviv Medical University Burn Center, Ukraine).A total of 15 patients were identified who received a total of 21 tissue expanders at the time of acute burn treatment. The indications included electrical burn (46.7%), trauma (20%), tumor resection (13.3%), flame burn (13.3%), and chemical burn (6.7%). Of the 21 expanders placed, 4 (19%) complications were reported. There was 1 (4.7%) implant exposure and 3 (14%) implant infections. All of the patients in this series had complete reconstructions after removal of their expanders because all complications occurred toward the end of expansion.Immediate placement of tissue expanders is a reasonable approach that greatly expedites scalp reconstruction. In this series, the complication rate was consistent with or slightly higher than published rates of complications in conventional techniques. Immediate expansion may be especially useful when other reconstructive options (such as free tissue transfer) are unavailable or not feasible.

Methylene blue (MB) is a near-infrared fluorophore that provides a stable visual map of skin perfusion after intravenous injection. We explored the capability of MB to predict submental flap postoperative outcome using a single intraoperative measurement. Submental flaps were created in N = 15 pigs and imaged using the FLARE imaging system immediately after surgery and at 72 hours. Using the first 3 pigs, optimal MB dosing was found to be 2.0 mg/kg. Training and validation sets of 6 pigs each were then used for receiver operating characteristic analysis. In the training set, a contrast-to-background ratio (CBR) threshold of 1.24 provided the highest sensitivity and specificity to predict tissue necrosis at 72 hours. In the validation set, this threshold provided a prediction sensitivity of 95.3% and a specificity of 98.0%. We demonstrate that a single intraoperative near-infrared measurement can predict submental flap outcome at 72 hours.

Review of the literature regarding rodent experimental flap models reveals fundamental differences in applied surgical procedures. Although some authors isolate the flap from its wound bed, others do not. This study was planned to investigate to what extent the insertion of a silicone sheet affects physiological wound healing in experimental flap surgery. An extended epigastric adipocutaneous flap (6 × 10 cm) was raised in 16 male Lewis rats. In the control group (group C), flaps were immediately inset without any intervention. In the experimental group (group M), a silicone sheet barrier was placed between the flap and the wound bed. Mean flap survival area and flap perfusion were evaluated. Microvessel density was visualized by immunohistochemistry, and semiquantitative real-time polymerase chain reaction addressed differential gene expression. All animals were investigated on postoperative day 5. Flap survival area and flap perfusion were found to be similar. Immunohistochemistry, however, demonstrated a significantly increased number of CD31-positive small vessels in group C. The insertion of the silicone sheet barrier (group M) was accompanied by a significantly enhanced expression of proinflammatory genes and a suppression of proangiogenic genes. Our results show that although the silicone membrane has no influence on the surgical outcome in terms of flap survival and perfusion, it does lead to significant molecular alterations in pathways involved in physiological wound healing. These alterations are artificially induced by the foreign body material and conceal the true driving forces of the healing process. As the latter might include relevant therapeutic targets to ameliorate surgical results, we regard wound bed isolation as a dispensable procedure in the study of rodent flap models.

Nonmelanotic skin cancer is the most common human neoplasia and its incidence is rising. The completeness of resection is the most important quality feature of surgical treatment of nonmelanotic skin cancer, as a complete resection distinctly reduces local recurrence. In this trial, we analyze the incomplete resection rate of nonmelanotic skin cancer (N = 524) through plastic surgery assistant doctors in the first 3 years of surgical training. We find that the incomplete resection rate of nonmelanotic skin cancer decreases significantly (P = 0.026) from mean 12.1% in the first year of training to mean 5.7% in the third year of training, despite a gain in difficulty level concerning tumor localization. Moreover, we identify the following tumor features as a risk factor for incomplete resection: facial tumors (P = 0.034), recurrent lesions (P = 0.032), and the tumor class of the superficial basal cell carcinoma (P = 0.010). We prove that complete excision of nonmelanotic skin cancer distinctly depends on the surgeon's experience level.

Few reports about body contouring surgery after massive weight loss (MWL) have been produced in the developing countries. As Mexico is considered a developing country, we performed a retrospective analysis of medical records of patients who underwent this type of surgery to evaluate their demographic characteristics as well as their outcomes and complications. Results from 684 patients with MWL, 69 (10%) had abdominoplasty; the type of abdominoplasty influenced the operative time, bleeding, and complications (P < 0.05); the body mass index influenced the weight of resected tissue (P < 0.000) and hospital stay (P < 0.020), but did not affect the type of abdominoplasty performed, surgical time, complications, reoperation, or transfusion rates. In contrast with the developed countries, in these procedures, operating time was higher and the patients had more surgical bleeding with higher rates of transfusion and a longer hospital stay, but with the same clinical results and percentage of complications.

Skin defect closure after injury or disease may present significant reconstructive challenges. Traditional epidermal coverage alone in the form of skin grafts often fall short in providing stable cover to restore structure and function of the skin. Excessive wound contraction and scar formation, particularly in defects of dermis and epidermis, may create functional and aesthetic problems. Progress in our understanding of molecular biology and tissue engineering have produced major advances in skin substitute technology, particularly relating to the dynamic cellular/extracellular matrix interaction that is critical to successful incorporation of a skin substitute. However, currently available skin substitutes still exhibit a range of problems including excessive wound contraction and scar formation, poor host tissue incorporation, revascularization and, in some cases, structural deficiencies in matrix design. The design principles and structural composition of the matrix must take into account collagenous forms, inherent resistance, porosity, and hydration. The ultimate matrix should be one that promotes intrinsic regeneration by encouraging cellular incorporation and cellular/extracellular cross communication. Attention to basic structural details rather than reliance on specialized cellular or peptide additions to the mix may well produce the advances we seek in improved incorporation of bioengineered skin substitutes.

Initial efforts at biologic skin replacement strategies were mainly directed toward keratinocyte regeneration and epithelial replacement. It soon became evident that without a good dermal scaffold, the long-term efficacy of epithelial replacement was very limited. Further studies have focused on matrix replacement predominantly involving collagen frameworks with or without cellular additions. The fibroblast is central to the process of dermal regeneration and to the success of biologic matrix design. The sequence of cellular focal adhesion, integrin phosphorylated activation, intracellular and extracellular signaling, cytoskeletal activation, changes in cell morphology, and cytokine growth factor interaction are all important in influencing cell proliferation, cell spreading, neocollagenesis, and collagen translocation. A basic acellular matrix with chemical composition and correct physical structure (pore size and resistance) that takes cognizance of this sequence of matrix deposition and fibroblast functionality should be successful in promoting intrinsic healing and dermal replacement.

In breast reconstruction, sensation in the reconstructed breasts affects the patients' quality of life along with its aesthetic outcome. Fortunately, less invasive procedures such as breast-conservative surgery (BCS) and skin-sparing mastectomy (SSM) have greatly contributed to the improved aesthetic outcome in immediate breast reconstruction. However, there are few reports on the recovery of breast sensation after BCS and SSM. We retrospectively reviewed 104 consecutive patients who underwent immediate breast reconstruction with the latissimus dorsi myocutaneous flap between 2001 and 2006 at our institution. The sensations of pain, temperature, touch, and vibration were examined at the nipple and skin envelope during the follow-up period (range: 12-61 months, mean: 31 months), and a stratified analysis was performed to determine the critical factors affecting the sensation recovery after BCS and SSM. We found that large breast size significantly impaired the recovery of sensation in the nipple and skin envelope after BCS as well as SSM. Older age and high body mass index value were the factors which negatively affected the sensation in the skin envelope after SSM. While all our BCS patients underwent postoperative radiation therapy, it did not negatively affect the recovery of sensation in SSM patients. On the basis of these findings, we could further improve the sensation of the reconstructed breasts after BCS and SSM. Especially after SSM, the use of innervated flaps is recommended in the patients with large breast, increased age, or obesity when the nipple-areola complex is resected.

Reconstruction of soft tissue defects with standard myocutaneous or fasciocutaneous flaps often results in contour deformities due either to intrinsic characteristics of the flap or due to initial overcorrection of the defect when postoperative radiation therapy is planned. In such cases, revision with suction-assisted lipectomy is often necessary to achieve optimal cosmetic results. Since liposuction has been associated with decreased tissue perfusion, there remains significant concern that revision of irradiated flaps with liposuction places the patient at high risk for tissue necrosis and wound healing difficulty. To determine the safety of liposuction on irradiated tissue, the authors reviewed our experience of 9 patients treated for cancer with extirpation of tumor and immediate reconstruction with a free or pedicle flap. All patients required radiation therapy and ultimately underwent revision with liposuction due to contour irregularity. Flaps were treated with 60 to 64 Gy and between 30 and 300 mL of fat was removed at 6 weeks to 9 months after final dose of radiation therapy. All patients achieved improvement in contour with no significant fat or skin necrosis. We conclude that suction-assisted lipectomy of irradiated tissue is safe and effective for flap revision following conventional doses of radiation therapy.

Background: Single large-area or 2 small- to moderate-sized raw areas in the hand and forearm are difficult to cover with conventional groin or superficial inferior epigastric artery (SIEA) flaps. Though abdomen is a favorable donor site for a pedicled distant flap for soft tissue coverage of the hand and forearm, pedicle flaps based on paraumbilical perforators are not commonly used. Methods: We herein describe a method of soft tissue coverage using 2 flaps based on 1 paraumbilical perforator in certain difficult clinical situations, unsuitable to be covered with groin or SIEA flaps. By virtue of having a very narrow common pedicle for 2 substantially large flaps close to the chosen paraumbilical perforator, the configuration of it prompted us to call these twin flaps wing flaps, or a winged version of paraumbilical pedicle flaps. The wing flap described was used to cover twin raw areas (in 6 cases) and a large area (in 1 case) in the hand and forearm. Results: All 7 flaps went on to heal very well and served the purpose. The only complication observed was a minor thumb web contracture in one case, which improved with physiotherapy. Conclusion: The winged version of pedicled paraumbilical perforator flaps should find a place in the surgical armamentarium for soft tissue coverage in the hand and forearm in difficult situations. The advantages and simplicity of these flaps have been described, based on our experience in a small series of 7 cases.

Trials demonstrating the efficacy of biologic therapy for moderate to severe hidradenitis suppurativa (HS) have inspired new multidisciplinary treatment strategies. We present our experience with combined biologic and surgical therapy for recalcitrant HS.Between 2011 and 2014, 21 patients (57 cases) with Hurley Stage III HS underwent radical resection with delayed primary closure alone, or in combination with adjuvant biologic therapy. Demographic data, treatment regimen, outcomes, and complications were retrospectively reviewed for all cases.Eleven patients underwent combined surgical and biologic therapy, whereas radical resection alone was performed in 10 patients. The average soft tissue deficit, before closure, for the combined and surgery-only patients was 56 cm and 48.5 cm, respectively (P = 0.66). Biologic agents including infliximab (n = 8) and ustekinumab (n = 3) were initiated 2 to 3 weeks after closure and were continued for an average of 10.5 months. Recurrence was noted in 19% (4/29) and 38.5% (10/26) of previously treated sites for combined and surgery-only patients (P < 0.01). For the combined cohort, the disease-free interval was approximately 1 year longer on average (P < 0.001); however, this difference was reduced to 4.5 months when considering time to recurrence after cessation of biologic therapy (P = 0.09). New disease developed in 18% (2/11) and 50% (5/10) of combined and surgery-only patients, respectively (P < 001). No adverse events were noted among patients who received biologic therapy.Lower rates of recurrence and disease progression, as well as a longer disease-free interval may be achieved with the use of adjuvant biologic therapy after radical resection for recalcitrant HS.

Background Although hedgehog inhibitor therapy (HHIT) is offered as isolated medical treatment for extensive basal cell carcinoma (BCC), there is little evidence on the use of HHIT before definitive surgical intervention. In order to better define the utilization of HHIT for extensive BCC, we evaluated the impact of neoadjuvant HHIT on the subsequent surgical resection and reconstruction. Methods An IRB-approved, retrospective chart review was performed of patients who received HHIT as initial treatment for extensive BCC. Patients who discontinued HHIT and underwent surgical resection were included. Evaluation included BCC tumor response to HHIT, operative data, pathological data, radiation requirements, and evidence of tumor recurrence. Results Six patients were identified with tumors of the face/scalp (n = 4), trunk (n = 1) and upper extremity (n = 1). Hedgehog inhibitor therapy continued until tumors became unresponsive (n = 3, mean = 71 weeks) or side effects became intolerable (n = 3, mean = 31 weeks). In each case, a less extensive surgery was performed than estimated before HHIT. In 3 cases, significant bone resection was avoided. All resected specimens contained BCC. Four specimens exhibited clear margins. Postoperative radiation was performed in cases with positive margins (n = 2), and 1 patient experienced local recurrence. Length of follow-up was 5.7 to 11.8 months (mean = 8.23 months). Conclusions Although HHIT was not curative for extensive BCC, HHIT can decrease the morbidity of surgical treatment and increase the likelihood of curative resection. For patients with extensive BCC, a combined neoadjuvant use of HHIT and surgical treatment should be considered.

The split-thickness skin graft (STSG) donor sites have been treated with various and plenty of dressing techniques and materials. An ideal STSG donor site dressing should have antibacterial, hemostatic, and promoting epidermal healing properties. We have performed a prospective study to evaluate the effect of the oxidized regenerated cellulose on STSG donor site healing. Between January 2002 and January 2005, 40 patients who were operated in any kind of reconstructive operations with STSG donor sites were included in the study. One half of the wound was covered with oxidized regenerated cellulose and the other half of the same wound of the same patient was covered with fine mesh gauze treated with Furacin (nitrofurazone). The patients were grouped into 2 depending on the dressing technique: group I, semiclosed and group II, closed. The wounds were evaluated for healing time, infection, pain perception of the patient, and final esthetic results. The oxidized regenerated cellulose side of the group I was healed in a mean of 6.5 +/- 0.51 days; in group II, 5.4 +/- 0.50 days (range, 5-6 days). The fine mesh gauze treated with Furacin in group I was healed in a mean of 9.9 +/- 0.97 days (range, 8-11 days); in group II, 8.4 +/- 0.99 days (range, 7-10 days). There was a statistical significance between the oxidized regenerated cellulose side and the fine mesh gauze side (P < 0.001) in group I and group II separately. The difference between group I and group II was statistically significant in the oxidized regenerated cellulose side (P < 0.001), and the difference between group I and group II was statistically significant in the fine mesh gauze side (P < 0.005). The antibacterial, hemostatic, and absorbable property of the oxidized regenerated cellulose could ensure the utilization as an alternative STSG donor site dressing, especially because the positive influence over the wound healing was proven.

The pulsed dye lasers (PDL) are the gold standard in the treatment of port wine stains (PWS). However, clearance rates vary widely, and many lesions are not completely cleared with laser treatment. This article reviews the use of different types of PDL for the treatment of PWS. Longer pulse durations and higher fluences in conjunction with skin cooling are required for larger vessels. Controversy still exists as to which wavelength induces greater photothermal damage to the blood vessels in PWS. The incomplete response of PWS to the conventional PDL is due to the suboptimal irradiation parameters of energy fluence, pulse duration, and wavelength currently used in clinical settings. New-generation PDL are more effective than conventional PDL, but vessels smaller than 30-50 microm appear resistant to all kinds of PDL treatment.

Ablative laser resurfacing with the CO2 and Er:YAG lasers has become a well-accepted and well-reported modality for skin rejuvenation of photoaged and photodamaged skin. However, the side effects associated with these lasers, such as exudation and crusting followed by prolonged erythema, are often socially disturbing for the patient. A nonablative 1,320-nm pulsed Nd:YAG system has been developed that controls dermal collagen damage while preserving the epidermis. Thirteen patients are presented on whom periocular wrinkle treatment was carried out during two sessions 1 month apart. Side effects were minimal. Histology showed improvement in the previously typical sun-damaged dermis. However, although physician assessment noted a trend toward macroscopic improvement, almost all patients failed to see any improvement. The authors conclude that further studies of the ideal parameters are required before the 1,320-nm Nd:YAG laser can be indicated successfully in stand-alone, nonablative wrinkle removal. In addition, patients should be selected carefully, and a complementary minimally aggressive technique should be used to restore a youthful appearance to the epidermis.

A novel method of tattoo removal in which the enzymatically separated epidermis of an excised tattoo was grafted in situ was applied to 3 patients. Unlike the conventional skin-grafting procedure, this method resulted in the complete obliteration of the tattoos without donor site scars. In 1990, Hosokawa and colleagues first reported a technique similar to the one described, but the enzymatic process required surgery to be performed over two consecutive days and, thus, it did not become an established procedure. A modification of Hosokawa's method enabled the authors to reduce the enzymatic processing time to an hour using Dispase. The thinning of the tattooed skin using a Paget's-type dermatome before its exposure to an enzymatic solution facilitated the enzyme's infiltration of the basal layer of the epidermis. Hence, the time taken for the epidermis to separate from the tattooed skin was markedly shortened. Although laser removal continues to be the optimal treatment method, skin grafting or other abrasive procedures, including dermabrasion and cryosurgery, are still necessary for those patients who want complete tattoo obliteration over a shorter time frame and at less expense. In these patients the authors recommend that their procedure be offered as an alternative treatment to laser removal.

The purpose of this study was to prefabricate a new combined composite (chimeric) flap that consists of four different tissues. The tissues were prefabricated around two independent pedicles that ultimately join as a single main pedicle. In the inguinal area of 36 rats, the saphenous and the superficial inferior epigastric (SIE) pedicles were dissected and prepared as vascular carriers. A fascial graft and a local muscle flap were wrapped around the saphenous pedicle. The SIE pedicle was then implanted under the abdominal skin to supply a future skin flap. An ear cartilage graft was also inserted under the abdominal skin and adjacent to the implanted SIE pedicle. After allowing 2-, 4-, 6-, and 12-week prefabrication periods in different groups of nine animals, the prefabricated tissues were raised around two pedicles nourished by the femoral pedicle and then transferred. Flap survival was assessed by observation, microangiography and histology. The skin flaps showed survival rates of 52 +/- 17% (mean +/- standard error of the mean), 64 +/- 16%, 86 +/- 11%, and 100 +/- 0% of the total areas in the 2-, 4-, 6-, and 12-week prefabricated flaps respectively. None of the control grafts that were prepared on the contralateral side survived totally. A significant difference was found between the 12- and 2-week (p < 0.008), 12- and 4-week (p < 0.02), and 6- and 2-week (p < 0.05) prefabrication groups. Histologically, fascial and cartilage grafts, and portions of muscle were viable in the 2- and 4-week groups. Also, noticeable necrosis was found in the skin flaps in these groups. The muscle showed mild (at 2, 4, and 6 weeks) and moderate (at 12 weeks) atrophy. After prefabrication for 6 weeks, all tissues demonstrated good survival. This study shows that a combined composite flap can be prefabricated successfully in rats after a 6-week period of prefabrication.

Body contouring after massive weight loss (MWL) is a rapidly growing area in Plastic Surgery. Panniculectomy/abdominoplasty is primarily a cosmetic procedure with some functional benefits (a large pannus may hamper mobility, prevent further weight loss, and cause recurrent skin infections) and hence many insurance companies are changing their guidelines to include this as a medical procedure. This study assesses reimbursements for a large academic institution in Massachusetts for panniculectomies/abdominoplasties performed in MWL patients. We performed a retrospective review of charges and reimbursements for panniculectomy/abdominoplasty in MWL patients performed at Lahey Clinic. Records for patients who underwent a "medical" panniculectomy by a single surgeon from August 2002 to August 2006 were reviewed with special emphasis on the charges, reimbursements, insurance carriers, and prior preauthorizations. Fifty-two patients underwent a medical panniculetomy/abdominoplasty (Current Procedural Terminology code 15831) for laxity of skin/pannus as a result of MWL. All patients except Medicare required and obtained precertification for the procedure. Patient ages ranged from 35 to 59 years, which included 42 females and 10 males (n = 52). Forty-three underwent bariatric surgery; their procedures were performed between 13 and 62 months after their initial surgery. Weight loss ranged from 65 to 345 pounds. Body mass index at the time of the surgery ranged from 22 to 48. The standard surgical charge for a medical panniculectomy at Lahey Clinic is $3,086. The range of reimbursements was zero to the full amount with the mean reimbursement of $615 and the median being $899. Reimbursements for panniculectomies are remarkably low and in many instances (35% in our series) absent despite obtaining prior precertification of medical necessity. Although insurance companies have extended their indications for panniculectomy/abdominoplasty, we think that it is a cosmetic procedure. Plastic surgeons must bear these reimbursements in mind when faced with a patient requesting this.

The Q-switched ruby laser (694 nm, 25-40 nsec) is an effective and safe therapeutic device for the treatment of tattoos and well-defined, benign, pigmented epidermal and dermal lesions. Because of its selective mode of action, dermal pigments of natural and artificial origin are destroyed photothermically and removed without scar. This method is exceptionally suited for the elimination of lay and professional tattoos, traumatic tattoos, and permanent makeup. Other frequent indications include benign pigmented lesions such as lentigines, freckles, café-au-lait spots, seborrheic keratosis, and Becker nevi. As a dermal pigmented lesion, the nevus of Ota is perfectly treatable. However, chloasma can no longer be considered an indication for ruby laser treatment due to unsatisfactory results. Melanocytic nevi and congenital nevi should be treated only in clinical studies. The effectiveness of the long-term epilation of dark hair with this laser device has to be verified in future investigations. Particularly attractive is the nonproblematic and straightforward removal of pigmented lesions in precarious anatomic regions like the lips, eyelids, and genitals (e.g., benign melanosis of the lips or of the penis, seborrheic keratosis of the lid angle).

Our understanding of muscle, fascia, and skin flap physiology is based largely on data obtained from rodent, rabbit, or canine models. The presence of a well-developed panniculus carnosus confounds the extrapolation of data from these animals to humans. This study attempted to define microsurgically applicable musculocutaneous and fasciocutaneous flaps in the pig that would be comparable to flaps commonly used in humans. Lead oxide was injected into each axillary artery of three standard white domestic swine. Gross dissection and radiographic studies were used to define the specific anatomic fasciocutaneous territory served by the branches of the circumflex scapular artery. Eight musculocutaneous flaps based on the thoracodorsal artery and eight fasciocutaneous flaps based on the circumflex scapular artery were elevated. Although all flaps survived in their entirety, the fasciocutaneous flaps did not, as in man, have an easily dissectable axial blood supply. This finding suggests that the porcine scapular fasciocutaneous flap, although reliable as a pedicled flap, is difficult to employ as a free tissue transfer.

Basal cell nevus syndrome (aka Gorlin syndrome, Gorlin-Goltz syndrome, nevoid basal cell carcinoma syndrome, and fifth phacomatosis) is a rare but well-described autosomal dominant condition with variable penetrance. We present a female patient who has been successfully treated using local surgical excision and diligent skin surveillance for more than 4 decades, demonstrating that simple local incision is an efficacious and reasonable surgical alternative that may circumvent the specialization and expense of Mohs technique.

Dermatofibrosarcoma protuberans (DFSP) is a relatively rare cutaneous tumor that is clinically challenging since it is locally highly invasive and aggressive, although it rarely metastasizes. Traditionally, wide and deep local surgical excision has been regarded as the treatment of choice for DFSP. However, even 3-cm-wide local excision margins have resulted in a local recurrence rate of 11%. In recent years, reports of DFSPs successfully treated with Mohs micrographic surgery have been appearing in the literature. The DFSP literature is reviewed here, including worldwide experience reported to date in the use of Mohs surgery to excise DFSPs. Using this margin control technique, the recurrence rate is shown to be 2.4%, much lower than the best previously reported recurrence rate of 11% when wide local excision was used. Three-dimensional reconstructions of DFSPs, based on Mohs micrographic surgical technique, are also presented. These illustrations provide new insight into the growth characteristics of these tumors and why Mohs micrographic surgery is emerging as the treatment of choice for DFSP.

Giant congenital melanocytic nevi (GCMN) occur in 1:20,000 livebirths and are associated with increased risk of malignant transformation. The treatment of GCMN from 1981 to 2010 in a tertiary referral center was reviewed evaluating the modalities used, cosmetic results, associated complications, and malignant transformation. Of 35 patients, 25 underwent surgery. Curettage was most frequently used (64%) followed by excision and tissue expansion (20%). Six percent of the patients treated with curettage, and 78% of the patients who received excision surgery required more than 1 planned procedure, and 25% versus 44% required unplanned additional surgery, respectively. Complications were noted in 25% and 67% of the patients, respectively. Cosmetic result was satisfying in 76% of patients without difference between the groups. No malignant transformation was found during a mean follow-up of 11 years. Curettage is a gentle alternative to excision with a lower complication rate and good cosmetic outcome.

The presence of excess skin after massive weight loss, particularly in the thighs, not only contributes to a negative body image but can also lead to functional deficits in mobility. In the present study, we quantified the health state utility of living with excess skin in the thighs in an attempt to objectively establish the burden on the quality of life in patients living with excess thigh skin laxity.Using visual analog scale (VAS), time trade-off (TTO), and standard gamble (SG), we compared the utility outcome scores for thigh skin excess with monocular and binocular blindness from a prospective sample of medical students and the general population. Utility scores were compared using paired t test. Linear regression was performed using age, race, and education as independent predictors of each of the utility scores.One hundred thirty-four prospective participants were enrolled during a 6-month period, and 112 participants met our inclusion criteria. The utility outcome scores for thigh lift (VAS, TTO, and SG, 0.77 ± 0.15, 0.90 ± 0.11, and 0.89 ± 0.14, respectively) were statistically different from binocular blindness (VAS, TTO, and SG, 0.37 ± 0.18, 0.70 ± 0.23, and 0.70 ± 0.26; P0.001), but other than VAS (0.67 ± 0.15, P0.001), similar to monocular blindness (TTO and SG, 0.89 ± 0.13 and 0.81 ± 0.14, respectively; P0.05). SG (0.89 ± 0.14 vs 0.97 ± 0.02, P = 0.003) and TTO (0.89 ± 0.11 vs 0.95 ± 0.03, P = 0.038) were different between general population and medical students, respectively, corresponding to 3.96 versus 1.80 potential years willing to be traded (P0.05). Additionally, SG was higher in whites versus nonwhites who were willing to take a potential 8% chance of mortality compared to 15%, respectively (P = 0.001), to achieve "perfect" health.We have objectified the utility of living with thigh deformity after massive weight loss. Our sample population if faced with the condition was willing to sacrifice a potential 3.6 years of life and potentially undergo a procedure with 11% chance of mortality to address excess thigh laxity.

INTRODUCTION Every year, nearly 1.2 million people are affected by nonmelanoma skin cancers (NMSCs) in the United States. Most published data focus on comparing the efficacy of Mohs micrographic surgery (MMS) versus traditional surgical excision (TSE) for NMSCs in H-zone lesions of the face. There is paucity of data regarding the 2 treatments in other areas such as the non-H-zone areas of the face, the trunk, and extremities. Our study focused on the efficacy of the 2 treatments in areas of the body where the skin was not of premium. METHOD A retrospective chart review was performed of patients with NMSCs treated with TSE at the West Los Angeles Veterans Affairs Hospital between 2000 and 2008. Patients with at least a 3-year follow-up were selected for the study. Institutional review board approval was obtained before commencement of the study. Age, sex, and race-matched patients were selected in the MMS group. Data collected included demographic data, tumor characteristics, surgical treatment, reconstructions, recurrence rates, complications, and follow-up course. Data were analyzed using SigmaStat 3.5. RESULTS A total of 588 patients were treated for NMSCs at our institute between 2000 and 2008, of which 289 patients had non-H-zone, extremity, and trunk lesions. The follow-up period for these patients was at least 3 years. Average age of this group was 67.1 (11.4) with 89.9% being males. Age, sex, and race-matched group of 200 patients treated with MMS for NMSCs were randomly chosen from the same time range. Average size of lesions was 17.4 (16.9) mm in the TSE group and 1.1 (0.4) mm in the MMS group (P < 0.05). Primary reconstruction was performed in non-premium areas (ie, non-H-zone areas of the face, the trunk, and extremities) in 98.7% patients in the TSE group and 61.5% patients in the MMS group (P < 0.05). Secondary reconstructive rate was 1.3% in TSE compared to 37.5% in MMS. Overall recurrence rate was 4.8% (compared to 3% with MMS). Of the 29 patients who had recurrences within the TSE group, 27 were H-zone lesions and 2 were non-H-zone lesions. DISCUSSION One of the primary goals of NMSC management is to treat the lesion with adequate oncologic margins, while preserving maximal function and cosmesis. Our data look at the non-premium areas to quantify the clinical efficacy of TSE versus MMS. The size of lesions treated by TSE was significantly larger than those treated by MMS in all areas of the body. The primary closure rates were significantly higher and secondary procedure rates significantly lower in the TSE group compared to the MMS group, in non-premium areas. Our data suggest that patients with NMSCs may be more effectively treated with TSE than MMS in non-premium areas of the body. Additional studies are ongoing, including economic modeling and cost analysis.

Ultrapulse carbon dioxide laser ablation of rabbit skin was investigated. Macroscopic and microscopic appearance of the ablation site was evaluated for 1 month. The Ultrapulse carbon dioxide laser was set in the ultrapulse mode and the parameters selected were 250 mJ of energy per pulse and 2 W average power with the 3-mm spot size collimated handpiece. Macroscopic investigation showed that ultrapulse carbon dioxide laser ablation removed rabbit skin precisely and bloodlessly without char formation. Skin re-epithelialization without scarring and perfect hair growth restoration within 3 weeks were impressive. Microscopic investigation demonstrated a layer of tissue thermal necrosis measured as 70 +/- 10 microns. During the first 2 weeks, laser ablation wound re-epithelialization begins with multiplying epidermal layers (from 2-3 cell layers to about 13 to 15 cell layers). There were marked fibroblastic reactions and capillary congestion within papillary dermis. By the end of 4 weeks, the thickened epidermal layer appeared normal. The repaired papillary dermal collagen showed a relative compact configuration and greater cellularity in Masson stain was found 2 to 3 weeks later and also was near normal 4 weeks after laser treatment. These findings suggest that Ultrapulse's delivery of short-duration, high-energy pulses may provide a new approach (laser dermal ablation) to damage selectively the epidermis and papillary dermis of rabbit skin in one single-pulse impaction with uneventful wound healing within 1 month.

Pathological vasospasm and free radical production contribute to skin flap necrosis. This study was undertaken to determine if postoperative combination therapy with the vasodilator nitroglycerin and the anti-free radical agent allopurinol would result in an additive enhancement of skin flap survival in the rat model. Thirty-one Sprague-Dawley rats were randomized into four groups and two cranially based dorsal skin flaps were raised on each rat. Both surgeon and data collector were blinded to treatments and all agents were given postoperatively. Control rats demonstrated 51 +/- 7.4% skin flap survival. Mean flap survival was significantly increased in groups receiving single agent therapy with either transdermal nitroglycerin (63 +/- 12% survival, mean +/- 2 SEM, p < 0.05) or intravenous allopurinol (62 +/- 10% survival, p < 0.01). No additional survival was seen in rats receiving both agents, which displayed 61 +/- 13% survival (p < 0.05, compared with controls). This study provides the first well-controlled demonstration that postoperatively applied transdermal nitroglycerin significantly enhances skin flap survival and includes a discussion of reasons for lack of additive effect of these agents.

Plastic and reconstructive surgeons have long sought the ideal material to fill and enhance defects of the head and body. Many of the most widely used materials present problems for the surgeon or the patient, so the search continues. For the past 15 months, we have been using expanded polytetrafluoroethylene (ePTFE) Gore-Tex Soft Tissue Patch to fill in nasolabial and glabellar creases and to augment malar bones and the chin. Early evaluation indicates that ePTFE performs well with very few problems, with a high level of patient and surgeon satisfaction. Histological examination of 3-month explants from the postauricular subcutaneous plane and the antecubital fossa indicate minimal inflammatory response and some collagen penetration into the interstices of the prosthesis.

The effect of tissue expansion on the growth potential of autogenous cartilage grafts was studied in 10-day-old New Zealand white rabbits. The rabbits were divided into two groups: In Group 1 (n = 12) after 2 weeks of tissue expansion by using a 10-ml tissue expander, a cranially based 4 x 4-cm dorsal skin flap was raised and a 1 x 1-cm autogenous cartilage graft from the midportion of the left ear was transplanted beneath the flap in each rabbit. In Group 2 (n = 12) elevation of dorsal skin flaps and transplantation of the grafts were performed in the same way but without a previous tissue expansion. The grafts were removed at 30 and 60 days after transplantation in both groups, for histological examination and measurement of the dimensional changes to determine the growth rate. In both groups, histological examination revealed characteristic findings for cartilage growth, however, Group 1 (expansion) demonstrated a statistically significant increase in the growth of cartilage grafts when compared with Group 2 (control) (p = 0.0001). The results of this study indicate, from the standpoint of acceptance and growth potential of autogenous cartilage framework, that there is no drawback to using this tissue expansion technique for reconstruction of the ear in childhood.

BACKGROUND: Plastic surgeons are faced with increasing numbers of patients presenting for insurance-covered skin excision procedures following bariatric surgery. Panniculectomy for symptomatic relief of rashes is commonly performed, but an isolated infraumbilical amputation-type panniculectomy is a highly unaesthetic procedure, leaving many patients deeply dissatisfied. It may be also fraught with complications due to large incisions and potential for dead-space. In these patients, many surgeons avoid the fleur-de-lis panniculectomy, despite the body contour aesthetic advantage, because of increased time, more scarring, and a perceived increase in complications. METHODS: This is a retrospective chart review of 130 consecutive postbariatric surgery patients who had panniculectomy over a 2-year period at our institution. RESULTS: A total of 30 patients underwent a traditional panniculectomy and 100 patients had a fleur-de-lis panniculectomy. Mean weight loss from bariatric surgery to panniculectomy was 58.2 kg, with an average body mass index (BMI) of 30. Fifty-seven patients had additional procedures performed at the time of panniculectomy. Twenty-two patients (17%) had complications, with 5 in the traditional group (17%) and 17 in the fleur-de-lis group (17%) (P = 1.0). Six males (40%) had more complications compared with 18 females (15.7%) (P = 0.034). Patients with BMI

Excess skin and soft tissue of the thighs after massive weight loss (MWL) can present with varying degrees of severity. The classic medial thigh lift has considerable limitations in the postbariatric population, inspiring the quest for safer and more effective technical solutions. In this study, the circumferential thigh lift (CTL), and CTL with vertical extension, predicated on a theoretical and technical approach that improves safety and aesthetics in thighplasty after MWL, is described and evaluated. Nine patients were treated; all patients experienced MWL and all had previously undergone first-stage contouring with circumferential abdominal dermolipectomy. Patients were treated with a prone-to-supine approach with concomitant suction-assisted lipectomy (SAL). Lumbar and lateral thigh and infragluteal skin and fat were excised to the midaxillary lines and medial thigh meridians. Direct excision of anterolateral thigh skin was carried in a superficial plane into the medial thigh to confluence with the posterior excision. No direct undermining of any skin margin was performed. When soft-tissue excess is limited to the proximal third of the thigh, a horizontal excision pattern is used; with middle and lower one-third thigh excess, a vertical extension is employed. The medial superficial fascial system is anchored to the superficial perineal fascia. Data were reviewed retrospectively. In the 9 procedures performed, 3 achieved MWL by nonsurgical means, and 6 underwent bariatric surgery (bypass or band). Three patients were treated with CTL, and 6 with CTL with vertical extension. There were 3 seromas (33%) treated with percutaneous aspiration. There was 1 case of cellulitis (11%) treated successfully with in-office incision and drainage, and oral antibiotics. There were no hematomas, skin loss, wound dehiscences, lymphedema, or vulvar distortions. The circumferential excision of thigh excess without direct undermining allows for the maintenance of a rich blood supply to skin margins, and concomitant SAL improves thigh contour while providing discontinuous thigh undermining. Anchoring of the superficial fascial system to superficial perineal fascia reinforces the medial lift and prevents scar migration. CTL with or without vertical extension can be combined with SAL to maximize safety and aesthetic results after MWL.

Skin defects around the knee remain a challenge for the reconstructive surgeons. Choosing appropriate flaps for coverage is crucial to preserve the knee joint or to restore its function. On the basis of anatomic results in 20 cadaveric specimens, we found a constant supragenicular fasciocutaneous perforator within 3 cm above the adductor tubercle, which arose from the saphenous branch of the descending genicular artery. Based on it, the distally pedicled anteromedial thigh fasciocutaneous flap can be harvested from the anteromedial thigh. Between 2003 and 2009, we performed the distally pedicled anteromedial thigh flaps in 11 patients. The site of skin defects included the popliteal fossa, proximal 1/3 leg, and amputation stump below knee. The size of skin defects ranged from 15 × 6 cm to 27 × 9 cm, and the corresponding size of the flaps ranged from 15 × 10 cm to 32 × 9 cm. Of 11 flaps, 10 flaps survived unevently, except 1 flap which suffered partial necrosis due to venous congestion. The patients were followed up for 3 weeks to 12 months. The donor site healed uneventfully without complications in all patients. Additionally, the skin paddle matched with the recipient in terms of skin color, texture, and thickness. The anteromedial thigh fasciocutaneous flap pedicled on the supragenicular perforator is a reliable and versatile alternative to cover skin defects around the knee.

Deformities caused by massive weight loss were originally subsidized at the Instituto Nacional de Ciencias Medicas y Nutricion "Salvador Zubiran." This caused great economical losses, which led to the development of a classification to select patients with functional problems secondary to massive weight loss. The parameter used is the size of the pannus in relation to fixed anatomic structures within the following anatomic regions: abdomen, arms, thighs, mammary glands, lateral thoracic area, back, lumbar region, gluteal region, sacrum, and mons pubis. Grade 3 deformities are candidates for body contouring surgery because they constitute a functional problem. Grade 2 deformities reevaluated whether the patient has comorbidities. Lesser grades are considered aesthetic procedures and are not candidates for surgical rehabilitation at the Instituto Nacional de Ciencias Medicas y Nutricion "Salvador Zubiran." This classification allowed an improvement in communication between the different surgical-medical specialties ; therefore, we suggest its application not only for surgical-administrative reasons but also for academic purposes.

In advanced lymphedema, the most important goal of treatment is the control or eradication of infection. Toes are the major cause of infection mainly due to lack of space at the webs. The fibrosis of the soft tissue with impaired circulation of the toes certainly contribute to infection of the toes, foot, and even proximal to the leg. Between 2004 and 2008, 20 patients with severe lymphedema and fibrosis of lower limbs were treated with Charles' procedure and included in this study. The toes were preserved. Excisional therapy is the only choice to decrease the lymphatic load and control the infection. The toes can be preserved if there is only swelling without previous cellulites or verrucous hyperkeratosis and neither deformity nor osteomyelitis of the toes. The surgical technique to treat the toes includes (1) excision of the soft tissue at the dorsum of the toes with preservation of the extensor tendon and its paratenon, to facilitate the take of skin graft, and (2) preservation of skin flaps at the web spaces. This avoids contracture at the web spaces and crowding of the toes, improves foot hygiene, and hence prevents infection. Proper aesthetic and functional results were obtained in all patients and 18 of 20 patients have been free of recurrent infection at 3-years follow-up. In the treatment of advanced lymphedema of the lower extremity, the toes are the major determinant of future infection after surgery. For preservation of toes, careful selection of patients and correct surgical procedure are essential for success.

The surgical treatment of pressure sores has improved with the development of many techniques to provide coverage of these defects. Few deliver sensate coverage. This report describes tissue expansion of back skin to provide definitive sensate coverage of a pressure sore, thereby preventing its recurrence. Follow-up of 5.5 years is presented with a review of the literature.