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The fastest-growing age group undergoing cosmetic procedures are those over age 60, i.e. the aging patient group. While advanced age is a known predictor for increased surgical complications, the effects of age on complications in specific plastic procedures have yet to be thoroughly investigated. To determine the relationship between increased age and risk of surgical complications following body contouring procedures, specifically: abdominoplasty, brachioplasty, mastopexy, bilateral reduction, and thigh lift. A retrospective analysis of all patients undergoing body contouring procedures of the categories mentioned above between 2000-2018 at a tertiary university medical center. Patients were divided into two age groups: those below and those above, age 60. Data analysis included: demographics, underlying medical conditions, procedure type, and occurrence of postoperative complications (according to the Clavien-Dindo classification system). 803 body contouring procedures were identified, with 12% performed on the aging population. Aging patients had more underlying medical conditions than the younger ones. While the distribution of procedure type was similar in both groups, mastopexy was more common in aging patients. Of the 107 procedures identified as having complications, 37 were classified as grade I, 38 as grade II, and 32 as grade III. As a categorical variable, no relationship was found between the age of the patients and an increased risk of postoperative complications (age cut-off as 60). However, as a continuous variable, increased age did increase the overall risk of postoperative complications, although no optimal age as a cut-off point was identified. In multivariant analysis, diabetes mellitus with abdominoplasty was identified as a risk factor for postoperative complications. Conclusions: When undergoing body contouring procedures, we found that patients over the age of 60 are not at increased risk for postoperative complications than those under that age. Although age as a continuous variable was found to increase the overall postoperative complications, no optimal age could be defined as a cut-off point.

Introduction: Osteoradionecrosis is one of many potentially severe complications of radiotherapy for nasopharyngeal carcinoma. Osteoradionecrosis of the skull base is life-threatening due to the critical proximity of the pathological process to vital structures, for example, the intracranial cavity, the upper spine, and major blood vessels. Reconstructive options following surgical debridement of the anterior skull base and upper spine osteonecrosis have been scarcely described in the literature., Case Presentation and Management: We present a rare case of osteoradionecrosis of the clivus and cervical vertebrae C1-C2 in a patient previously treated with chemoradiotherapy for nasopharyngeal carcinoma, presenting as severe soft tissue infection of the neck. Aggressive surgical debridement and reconstruction with a two-paddle free anterolateral thigh flap was performed using a combination of transcervical and transnasal endoscopic approaches. A novel endoscopic procedure in the sphenoid sinus enabled flap anchoring in this complex area., Discussion: Surgical modalities for osteoradionecrosis of the skull base and upper spine are discussed and review of the literature is presented., Conclusion: Reconstruction of the anterior skull base with a well-vascularized free flap following ablative surgery should be considered in management of life-threatening osteoradionecrosis of the area. Endoscopic opening of the sphenoid sinus and creating a funnel-shaped stem is a newly described technique that guarantees precise placement of the flap and is a valuable adjunct to the reconstructive armamentarium.

Background: Congenital nasal cleft is a very rare yet challenging deformity to reconstruct. Atypical craniofacial clefts that involve the nasal ala are designated as number 1 and number 2 under the Tessier classification system. These clefts typically present as notches in the medial one-third of either nasal ala and may be accompanied by a malpositioned cartilaginous framework. Nasal clefts are smaller and far less common than familiar clefts of the lip and palate, but they pose equally challenging reconstructive planning., Methods: Our described technique relies on usage of existing nasal tissue near the cleft. Local tissue rearrangement using a laterally based rotational alar flap, a medially based triangular flap, and a nasal wall advancement flap restores normal anatomy and provides an aesthetically pleasing result., Results: Five children with isolated nasal cleft were treated by the senior author (A.M.) between 2010 and 2017. All patients presented with clefts of the soft tissue with no underlying cartilaginous involvement. There were no postoperative complications. Excellent aesthetic outcome was achieved in all patients., Conclusion: Isolated nasal cleft can be properly corrected with the described procedure in a single stage and with optimal result.

Background: Burn scar reconstruction is extremely challenging, even for the most proficient reconstructive surgeon. Within the arsenal of tools at the plastic surgeon's disposal, tissue expansion provides an efficient modality for reconstruction despite the reported complication rates., Objectives: To critically review our experience with tissue expansion for burn scar reconstruction, comparing particularly the adult and pediatric populations., Methods: We conducted a retrospective study of the outcomes of patients who underwent burn scar reconstruction with tissue expansion at Hadassah Medical Center between January 2003 and July 2012. The data included patient age, anatomical site of expansion, number of procedures, and associated complications. The outcomes of the above-mentioned populations were also compared with those in a control group of patients undergoing reconstruction with tissue expansion for indications other than burn scars., Results: Sixty-seven tissue expansion procedures were carried out in 50 patients, 42 in the pediatric population (< 16 years of age) and 25 in the adult population. Complications were observed in 10 of the 42 pediatric procedures (23.8%) and in 3 of the 25 adult procedures (12%). This difference was found to be statistically significant. When the complication rate for each population was compared to its control group (tissue expansion for indications other than burn scar reconstruction, such as reconstruction for motor vehicle accident scarring, congenital nevi, or vascular malformations), no statistically significant difference was found between them (complication rates 19.8% and 12.5%, respectively). Furthermore, there was no statistically significant difference in complication rates between the different anatomical areas of expansion within both populations undergoing burn scar reconstruction. Most of the complicated cases completed successful reconstruction., Conclusions: Tissue expansion is a useful surgical tool in post-burn scar reconstruction, both in the adult and pediatric populations and in all anatomic sites, despite consistently high complication rates, especially in the pediatric population. This complication rate is not higher than in patients undergoing tissue expansion for indications other than burn scar reconstruction.

Background: Large congenital melanocytic nevi entail significant medical and cosmetic ramifications for patients and families. Reconstruction is a challenging endeavor, especially when the lesion is present on the limbs. The literature describes various methods by which a plastic surgeon can address reconstruction; yet, to date, there has been no series describing a method that provides consistent results with low complication rates. In this study, we describe our surgical technique for reconstruction of the upper extremity after excision of large circumferential CNM with a pre-expanded bi-pedicled flap, namely the "sleeve" flap., Methods: A systematic review of our database of pediatric patients treated for large and giant nevi was performed. Patients with large and giant circumferential upper extremity nevi were retrieved, and their charts reviewed for demographics, number of procedures performed, duration of follow-up, and complications., Results: Over a course of 12 years, eight patients with large or giant circumferential nevi of the upper extremity were treated at our institution with "sleeve" flap reconstruction. Mean follow-up time was 36 months. A single complication was seen. All reconstructions achieved satisfactory results, both functionally and cosmetically., Discussion: We describe our surgical approach for treating upper extremity large and giant circumferential nevi with pre-expanded bi-pedicled "sleeve" flaps. When properly planned and executed, this technique enables successful treatment of large and giant nevi of the arm and the forearm. Although arduous and complex, the process yields excellent aesthetic results with low complication rates. This technique is promising as the reconstructive option of choice for these difficult lesions., (Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: The complexity of structures within the periorbital region makes reconstruction of this area particularly a challenging endeavor. Within the literature, different techniques have been described for reconstruction of the external lamellae of the upper and lower eyelids as well as the medial and lateral canthal regions.Herein, we present the expanded pedicled forehead flap as a versatile and useful surgical option for reconstruction of various defects around the eye globe., Patients and Methods: A tissue expander is inserted underneath the forehead skin and serially expanded. The pedicle of the expanded pedicled flap is designed either from the superior portion of the expanded skin and interpolated to reconstruct the upper and lower eyelids, and the medial or lateral canthal areas; or from the inferior portion of the expanded skin and interpolated over the eyebrow to reconstruct the area between the upper eyelid crease and eyebrow.Fifteen patients with periorbital nevi or severe scarring were treated using the expanded forehead flap between the years 2003 and 2012. Thirteen patients had complex periorbital defects involving multiple anatomic areas, and 2 patients had defects confined to the upper eyelid area only., Results: Operative and postoperative course for 13 patients was uneventful. One patient had a late infection of the tissue expander but nonetheless continued with the reconstructive process. In 1 patient, the tissue expander was removed due to infection, and subsequent reconstruction was not carried out. The aesthetic and functional results of reconstruction were very good, and with excellent skin color and thickness match. In 1 patient, the flap was defattened in an ancillary procedure. No partial or complete flap loss was observed in this study., Summary: We conclude that the expanded pedicled forehead flap is a safe and reliable method for reconstruction of different segments of the periorbital region, while providing good aesthetic and functional reconstructive results with minimal donor-site morbidity.

Background: Congenital pigmented nevi of the auricle are uncommon. The authors' approach is to excise these nevi and perform reconstruction because of the risk of malignant transformation and the aesthetic and psychological effects these nevi can have on the child. This study presents the authors' experience in treating congenital nevi of the ear and suggests treatment principles and guidelines for the reconstructive surgeon., Methods: Fourteen patients with congenital nevus of the ear were treated from October of 1992 to September of 2008 by the senior surgeon (B.S.B.). Nevi involving the more stable areas such as the concha can be resected and grafted early; the antihelix, scapha, and triangular fossa area can be resected and grafted next; and the helical rim, having the most easily distorted cartilage, should be treated last. Lobule reconstruction requires combined flaps and a dermal fat graft or a postauricular fascial fat flap., Results: Successful reconstruction was achieved in 10 patients. Three patients require final revision procedures (lobule reconstruction). One patient, early in our series, developed a deformed helical rim resulting from skin grafting at age 16 months, before the cartilage was firm enough to withstand the contraction forces of the skin graft. All subsequent patients with helical rim involvement had treatment delayed until the ear was at or near completion of its growth., Conclusions: Congenital nevi of the ear present a challenging reconstruction surgeon. The authors developed a treatment plan that breaks the ear down to aesthetic units and considers the location of the nevus, patient age, and the firmness of the cartilage.

Adequate coverage of complex, composite scalp defects in previously radiated, infected, or otherwise compromised tissue represents a challenge in reconstructive surgery. To provide wound closure with bony protection to the brain, improve cranial contour, and prevent or seal cerebrospinal fluid (CSF) leaks, composite free tissue transfer is a reliable and safe option. We report our experience with the latissimus dorsi/rib intercostal perforator myo-osseocutaneous free flap in the reconstruction of bony and soft tissue defects of the cranium and overlying scalp. The surgical technique, design, and outcomes of the latissimus dorsi/rib intercostal perforator myo-osseocutaneous free flap reconstruction in five patients with cranial defects between 2003 and 2007 were retrospectively evaluated. Patient characteristics, defect size, underlying cause, reconstructive details, and complications were analyzed. All patients (age 43 to 81) had composite defects ranging from 36 to 750 cm2 (mean size 230 cm2) for the bony component and from 16 to 400 cm2 (mean size 170 cm2) for the soft tissue defect. All patients had a history of prior or current infection of the affected area, and two patients had a CSF leak. Defects were due to malignancy and infection (n = 2), infiltrative cutaneous mucormycosis with osteomyelitis (n = 1), and hemorrhagic stroke requiring craniectomy (n = 2), complicated by infection and failed cranioplasty in one patient and continuous CSF leak in the other. The latissimus dorsi composite free flap consisting of skin, muscle, and vascularized rib can successfully cover large complex cranial defects, provide skeletal support, improve contour, and significantly enhance functional outcome with limited donor site morbidity., (Copyright Thieme Medical Publishers.)

Reconstruction of complex tissue deficiencies in which each missing component is in a different spatial relationship to each other can be particularly challenging, especially in patients with limited recipient vessels. The chimera flap design is uniquely suited to reconstruct these deformities. Chimera flaps have been previously defined in many ways with 2 main categories: prefabricated or intrinsic. Herein we attempt to clarify the definition of a true intrinsic chimeric flap and provide examples of how these constructs provide a method for reconstruction of complex defects. The versatility of the intrinsic chimera flap and its procurement from 7 different vascular systems is described. A clarification of the definition of a true intrinsic chimera flap is described. In addition, construction of flaps from the lateral femoral circumflex, deep circumflex iliac, inferior gluteal, peroneal, subscapular, thoracodorsal, and radial arterial systems is described to showcase the versatility of these chimera flaps. A true intrinsic chimera flap must consist of more than a single tissue type. Each of the tissue components receives its blood flow from separate vascular branches or perforators that are connected to a single vascular source. These vascular branches must be of appropriate length to allow for insetting with 3-dimensional spatial freedom. There are a multitude of sites from which true intrinsic chimera flaps may be harvested.

Background: Congenital melanocytic nevi of the eyelids and periorbital region are unusual. Although their malignant potential can be debated, they present a significant aesthetic concern and also disturb lid function. In this article, the authors present an expanded approach to evaluation and treatment of these patients., Methods: Forty-four consecutive patients, aged 6 months to 18 years, were treated from 1980 to 2008. All patients had congenital nevi involving one or both eyelids, with or without extension into the surrounding periorbital area and face. Follow-up ranged from 6 months to 20 years., Results: All patients were treated successfully with excision and reconstruction of their congenital eyelid and/or periorbital nevi. The involved ciliary border was preserved in all but one case, where the exophytic lesion presented function concerns. Complications included asymptomatic lateral ectropion in three patients. Asymmetry of the palpebral apertures, before treatment, was present in at least half of the patients with extensive facial nevi, and the abnormalities causing these differences may impact efforts to obtain final lid symmetry. A single patient died as a result of extensive metastatic melanoma from an extracutaneous site., Conclusions: Early evaluation and treatment of these nevi may help in preventing the aesthetic, functional, and health-related issues for the patients. Although the current group of infants and young children will not reach full facial growth for more than another decade and a half, and therefore await critical assessment of their long-term outcomes, the authors hope that the experience gained to date will assist surgeons in managing these complex reconstructions.

Zygomycosis is a rare but very aggressive fungal infection mainly seen in immunocompromised patients. Immediate diagnosis and treatment with antifungal therapy, control of underlying disease, and early surgical debridement is essential. We present two cases of head zygomycosis treated with systemic liposomal amphotericin B, surgical debridement, and immediate free flap reconstruction. A retrospective chart review of two cases of zygomycosis was performed; one with rhino-sino-orbital-cerebral and the other with scalp/cranial zygomycosis. Both patients were treated with systemic liposomal amphotericin B, aggressive debridement, and immediate reconstruction following local control. The multidisciplinary team approach and the surgical technique are discussed. Patient 1 (with rhino-sino-orbital-cerebral zygomycosis) died 2 weeks after diagnosis, and patient 2 (with scalp/cranial zygomycosis) was disease free at 1-year follow-up. Both patients' flaps survived, although patient 2 needed to undergo an arterial revision with an interpositional vein graft within 24 hours of surgery. We concluded that to treat zygomycosis effectively, a multidisciplinary team approach is needed, focusing on immediate diagnosis, empirical antifungal therapy, reversal of underlying predisposing factors, and early surgical debridement. When definitive debridement results in critical structures being exposed, then early wound closure with healthy vascularized tissue is indicated. In these two patients with exposed dura after definitive debridement, immediate closure was performed to minimize the risk of meningeal and cerebral infections.

Background: The integrity of each of the components of the auricle is important for its overall aesthetic appearance. Cartilage-exposing nonhelical defects that are too large to be closed primarily without distorting the auricle may be reconstructed with local flaps., Objective: The objective was to present our experience with the reconstruction of nonhelical medium-sized defects using a variety of simple, one-stage local flaps., Patients and Methods: Eighteen patients who underwent reconstruction of nonhelical auricular defects with local flaps at our center from 2003 to 2006. Defect size ranged from about 10 to 20 mm. Various methods were used for reconstruction as follows: conchal defect (n=11)--pull-through postauricular flap or cutaneous rotation flap from the concha itself; triangular fossa defect (n=3)--transposition-rotation flap from the concha or cutaneous periauricular pull-through flap via the root of the helix; antihelical defect (n=2)--V-Y advancement flap from the skin of the antihelix; and tragus defect (n=2)--periauricular cutaneous flap., Results: All flaps survived. Transient congestion was noted in four patients. The aesthetic results were good, with no auricular deformation., Conclusion: It is important that reconstructive surgeons be familiar with a variety of basic flaps for reconstruction of nonhelical defects. An algorithm for nonhelical flap reconstruction is suggested.

Background: Large defects of the lower lip represent a challenge to the reconstructive surgeon. The reconstructed lip should be sensate, retain muscle function, allow sufficient mouth opening for dentures, and have an acceptable aesthetic appearance. Many surgical techniques for lower lip reconstruction have been reported. We describe a modification of von Bruns' technique for reconstruction of the lower lip and both commissures., Objective: To present a surgical technique for reconstruction of the lower lip and both commissures, which we applied in a patient with a huge squamous cell carcinoma of the total lower lip and part of the upper lip., Methods: Two upper nasolabial flaps, one above the other, were used. The surgical technique is discussed., Conclusion: The technique is simple and is one stage. It provides complete support to the reconstructed lower lip and commissures.

Studies of breast volume and size have failed to take into account the aesthetic value of the nipple-areola-breast proportion. These data are important to plastic surgeons in planning breast reduction, augmentation, and reconstruction. In the current study, the anatomic size of the nipple, areola, and breast was measured in 37 women aged 20 to 64 years, and their proportions were calculated. The areola-breast and nipple-areola proportions were 1:3.4 and 1:3, respectively. The natural nipple-areola-breast proportion is approximately 1:3. This study provides a general guideline for plastic surgeons for planning breast surgery with optimal aesthetic results.