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Background:  One set of perforators can supply its own perforasome as well as the adjacent perforasome. The process of tissue expansion can mimic the effect of surgical delay to include more perforasomes into the perforator flap. By combining the perforasome theory with the technique of tissue expansion, large and various expanded perforator flaps can be achieved., Methods:  From July 2007 to July 2014, we performed eight different types of expanded perforator flaps in a total of 83 cases: 41 supraclavicular artery perforator flaps, 11 superficial cervical artery perforator flaps, 15 lateral thoracic perforator flaps, 6 internal mammary artery perforator flaps, 6 thoracoabdominal perforator flaps, 2 facial artery perforator flaps, 1 posterior interosseous perforator flap, and 1 ulnar collateral artery perforator flap. During the follow-up period, the survival rate, color, texture, and retraction of the flaps were assessed., Results:  The dimensions of the flaps ranged from 8 × 6 to 25 × 25 cm. Minor flap necrosis occurred in 20.5% of the cases, and severe flap necrosis developed in 2.4% of the cases. The donor sites were closed primarily in all but three cases. During the follow-up period (average, 13 months; range, 8-18 months), no flap contracture was observed with a good color and texture match., Conclusion:  By combining the concept of perforasome with the technique of tissue expansion, flaps with large dimensions and reliable blood supply can be achieved, allowing a more flexible design to reconstruct various and challenging skin lesions., Competing Interests: Conflict of Interest: None., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Purpose: The aim is to describe a technique with orthograde dissection of the anterior tibial artery (ATA) used as the recipient vessel for the end-to-end (ETE) anastomosis in defect reconstruction around the knee and for proximal/middle third leg defects with free anterolateral thigh (ALT) and gracilis flaps., Patients and Methods: Between March 2009 and May 2014, 22 patients undergoing lower extremity reconstruction were evaluated. Of those, 4 patients were included. The locations of injury were 3 defects around the knee and 1 defect at the proximal and middle third of the lower leg (mean defect size 18 x 8.5 cm and a range of 17-20 x 5-10 cm). There were 2 cases after trauma and 2 cases with infection. Two free gracilis and 2 free ALT flaps were performed of equal size to the defects. The mean flap pedicle length was 11 cm (range of 7-16 cm) and the mean length of the mobilized recipient vessels was 10.5 cm (range of 6-14 cm)., Results: One flap loss (ALT) occurred, requiring a salvage procedure with a latissimus dorsi flap, whereas wound dehiscence at the donor site and a hematoma below the ALT flap was observed in 2 cases, requiring small revision. After a mean follow-up of 52 months (range of 38-87 months), there was stable soft tissue coverage in all patients., Conclusion: By orthograde dissection of the ATA, an adequate vessel length and size may be achieved, improving arc of rotation to successfully cover more distant defects., (© 2017 Wiley Periodicals, Inc.)

Several methods have been described for the correction of congenital thoracic wall deformities. Our aim was to investigate the feasibility and clinical results of using standard anatomic breast implants with modified anatomic positioning according to the defect in congenital thoracic wall deformities. Between 2014 and 2015, 5 patients diagnosed with pectus excavatum (PE, n = 4) or pectus carinatum (PC, n = 1) and breast asymmetry or hypoplasia were evaluated. In all patients, a submammary incision and dual-plane subpectoral placement of texturized, anatomic implants were performed. In patients with PE, the lower pole of the implant was positioned medially to compensate for the caved chest. In patients with PC, the lower pole of the anatomic implant was positioned laterally to compensate for the prominent sternum. Outcome measures were satisfaction, minor and major complications, and morbidity. The mean surgery time was 95 ± 14 minutes, and the mean implant volume was 287 ± 56 cm 3 (273 ± 60 cm 3 on the right side and 305 ± 60 cm 3 on the left side). After a median follow-up of 25 months (range: 2-35), all patients healed uneventfully, and a satisfactory correction of the thoracic wall deformity was achieved. Thus, by adjusting the lower pole of anatomic breast implants in a horizontal plane according to the thoracic defect, we showed satisfactory results. Our technique has a low complication rate and can be recommended for the correction of mild to moderate PE or PC.

Background: Abdominal cutaneous sensitivity loss after abdominoplasty is an undesirable outcome. However, little is known in the literature about sensitivity changes of the neo-umbilicus after abdominoplasty. The aim of this study was to evaluate post-abdominoplasty cutaneous sensitivity of the neo-umbilicus using clinical, quantitative, and reproducible methods., Methods: Patients who underwent abdominoplasty were included, whereas the control group consisted of healthy volunteers with similar demographic characteristics but who did not undergo abdominoplasty. The umbilicus was divided into five zones, and superficial tactile sensitivity and spatial orientation were assessed subjectively (score 1-4) and objectively (Semmes-Weinstein monofilament examination)., Results: Twenty patients (45 ± 12 years) operated on consecutively between April 2012 and May 2016 and 14 healthy volunteers in the control group (39 ± 9 years) could be included. Although there were statistically significant differences (p = 0.0005) in the average cutaneous pressure thresholds between the control group (0.4 g/mm 2 , range 0.07-2 g/mm 2 ) and the study group (0.4 g/mm 2 , range 0.07-4 g/mm 2 ), patient satisfaction after a mean follow-up of 33 ± 16 months (range 10-62 months) was acceptable (mean satisfaction score 1.8 ± 0.7). Furthermore, spatial perceptions were precise in all patients and similar to the control group., Conclusion: Our long-term results indicate that spontaneous reinnervation of the neo-umbilicus after abdominoplasty together with accurate spatial orientation can occur., Level of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background: Removal of large facial benign cutaneous lesions remains challenging. Serial or complete excisions together with local flaps or expander-based reconstructions are required. However, those techniques are time-consuming and may contribute to poor cosmetic and functional outcomes., Objective: The authors describe the resection and reconstruction of large facial benign cutaneous lesions by using Stepwise, Multi-Incisional, and Single-Stage (SMISS) approach., Methods: The authors performed a retrospective review from all patients with large facial benign cutaneous lesions who underwent "SMISS" approach for reconstruction between September 2013 and December 2014., Results: The authors treated 47 patients (32 female and 15 male; mean age 23.5 years, range 9-50 years). Follow-up was for 12 months or longer. The mean length of major axis was 43.91 mm, minor axis 32.10 mm, and scar 66.91 mm. Good to excellent outcomes were achieved in all patients with a mean Vancouver scar scale score of 3.46 ± 0.39 (Cronbach α = 0.890) and mean visual analog scale score of 8.02 ± 0.69 (Cronbach α = 0.946)., Limitations: This was a nonrandomized, unblinded clinical case series with a limited sample size., Conclusion: For the excision and reconstruction of large facial benign cutaneous lesions, "SMISS" technique can be considered as a suitable option, leading to excellent results and a high patient satisfaction.

Background: The incidence of breast cancer related lymphedema is approximately 5%. Far infrared ray (FIR) treatment can potentially reduce fluid volume and extremity circumference as well as the frequency of dermato-lymphangitis (DLA). However, there is no published data on the oncological safety of FIR and the potential for activation of any residual breast cancer cells. The aim of this study is to investigate the safety of far infrared ray (FIR) treatment of postmastectomy lymphedema, clinically and in vitro., Methods: Patients who underwent mastectomy more than 5years ago complicated by upper extremity lymphedema for more than 1year were included. The enrolled patients were divided into an FIR treatment group and a control group (conservative treatment using bandage compression). Outcome measures included tumor markers (CA153, CA125), ultrasonography of relevant structures and monitoring for adverse reactions 1year after treatment. For the in vitro part of the study, the effects of FIR on human breast adenocarcinoma cell lines (MCF7, MDA-MB231) compared to the effects of FIR on human dermal fibroblasts as a control were considered. The viability, proliferation, cell cycle and apoptotic statistics of the adenocarcinoma and human dermal fibroblast cell lines were analyzed and compared., Results: Results demonstrated that after treatment with FIR, tumor marker (CA153, CA125) concentrations in both the FIR and control groups were not elevated. There was no statistically significant difference between FIR and control group marker expression (p>0.05). Furthermore, no patients were diagnosed with lymphadenectasis or newly enlarged lymph nodes in these two groups. Importantly, there were no adverse events in either group. The in vitro experiment indicated that FIR radiation does not affect viability, proliferation, cell cycle and apoptosis of fibroblasts, MCF-7 and MDA-MB-231 cells., Conclusions: FIR should be considered as feasible and safe for the treatment of breast cancer related lymphedema patients 5years after mastectomy. FIR does not promote recurrence or metastasis of breast cancer and is a well-tolerated therapy with no adverse reactions., (Copyright © 2017. Published by Elsevier B.V.)

Background: Presently, many techniques have been described to make the epicanthal fold less prominent. However, visible scarring remains a major concern in most techniques. The aim of this study was to develop a novel design using concealed incisions with minimal tension., Methods: Between December 2010 and May 2015, charts were reviewed from patients who underwent a concealed incision and tension-free technique to correct the epicanthal fold. The intercanthal distance (ICD), interpupillary distance (IPD), scar visibility, and cosmetic results were evaluated preoperatively and 1 year after the surgery. The ratio of the ICD to IPD (ICD ratio) was calculated, and the visibility of the scar was assessed., Results: In total, 136 patients (mean age 25.2 ± 2.7 years, range 20-32 years) were included. The preoperative median ICD ratio was 0.60 (range, 0.54-0.68) and decreased to 0.54 (range, 0.48-0.62) postoperatively. The median ICD ratio reduction was 9.1% (range, 3.6%-22.0%; P < 0.001, Wilcoxon signed-rank test). One hundred and thirty-four patients (98.5%) had no visible scarring or minimal scarring visible only under close inspection. Two patients (1.5%) experienced a more prominent scar, but none of them developed a severe scar requiring revision. The aesthetic outcome judged by the patient and surgeon was excellent or good in all cases., Conclusions: From our experience, the scar after medial epicanthoplasty can be minimized by using a concealed incision and tension-free technique. Our technique is an effective and individualized method, leading to a high satisfaction rates., (Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Many studies of gluteal augmentation techniques have been published in recent decades, including case reports, retrospective and prospective case series, and multicenter survey reviews. However, to date, there has been no study of the overall complications or satisfaction rates associated with the broad spectrum of techniques., Objectives: The authors performed a comprehensive literature review to determine outcomes and complications of gluteoplasty techniques, including patient satisfaction., Methods: A search on PubMed/Medline was performed for clinical studies involving gluteal augmentation techniques. A priori criteria were used to review the resulting articles., Results: Fifty-two studies, published from 1969 through 2015, were included - representing 7834 treated patients. Five gluteal augmentation techniques were identified from these studies: gluteal augmentation with implants (n = 4781), autologous fat grafting (n = 2609), local flaps (n = 369), hyaluronic acid gel injection (n = 69), and local tissue rearrangement (n = 6). The overall complication rates of the most commonly utilized techniques were: 30.5% for gluteal augmentation with implants, 10.5% for autologous fat grafting, and 22% for local flaps. Patients' satisfaction was reported as consistently high for all the five techniques., Conclusions: Implant-based gluteal augmentation is associated with high patients' satisfaction despite a high complication rate, while autologous fat grafting is associated with the lowest complication rate yet including serious major complications such as fat embolism. Local flaps and local tissue rearrangements are the ideal procedures in case of massive weight loss patients. A paucity of data is available for hyaluronic acid gel injections, which appear to be effective but temporary and expensive., (© 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com)

Objective: The popularity of the superficial circumflex iliac artery perforator (SCIP) flap has been limited by factors such as variable vascular anatomy and short arterial pedicle. This article aimed to delineate flap design and harvest strategies based around either the proximal or distal perforators of the superficial circumflex iliac artery (SCIA) and propose a set of strategies that can help deal with the limitations of the flap., Method: From August 2011 to June 2015, the SCIP flap was used in 80 patients for soft tissue defects at our institution. We utilized vessel imaging navigation to get a detailed overview of the vascular anatomy preoperatively. Flaps were designed on the basis of either the proximal or distal perforators of the SCIA. Backup strategies and surgical maneuvers were suggested to solve the problems that emerged during surgery., Results: In total, 51 flaps were raised on the basis of the proximal perforators of the superficial branch of the SCIA, whereas 25 cases were based on the distal perforators from the deep branch, and in four cases, the pedicle was switched to the superficial inferior epigastric artery. In eight cases, the arterial pedicle lengthen technique was applied with a maximum length of 10 cm. All donor sites were closed directly with inconspicuous scars., Conclusion: These surgical strategies simplified the intraoperative decision-making and overcame the shortcomings of the SCIP flap. We believe that the SCIP flap has a great potential to become a new workhorse flap in the field of reconstructive surgery., (Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Nipple reconstruction is an important last step in the process of autologous or implant-based breast reconstruction. A multitude of techniques have been described, among others the S-flap. To prevent nipple retraction after surgery, we modified the originally described method by Cronin., Methods: By adding an S-shaped incision line, the flap can be transposed with less tension and sutured on top of the new nipple along a curved line. Furthermore, two small triangular flaps were inserted at the base for reinforcement and reduced linear contraction. Assessment was completed by measuring nipple diameter and projection with a caliper., Results: A total of 16 patients underwent the technique, of whom 11 could be followed after 3 and 6 months. Overall patient satisfaction with the aesthetic result was high, and we observed no infection or necrosis. Nipples were stable in size and shape at 6 months. Although reduction of 68% in projection and 31% in diameter was observed, the nipples remained pleasantly similar to the contralateral non-operated side., Conclusions: The modified S-flap is a simple and reliable technique for moderate-sized nipple reconstruction. By providing more tissue at the base, size and projection remain stable and durable. Moreover, by a modified linear incision line at the base, tension and subsequent scar contraction is minimal., Level of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background: Little is known about the influence of the underlying tissue as donor for nipple-areola complex (NAC) reconstruction. Also, there is a complete lack of knowledge about the fate of nipple volume., Objectives: The goal of this retrospective, single-institution study was to analyze a case series after nipple reconstruction using a multimodal evaluation including 3-dimensional (3D) laser scanner analyses., Methods: Unilateral mastectomy patients after either expander-based or autologous breast reconstruction using the skate flap were included. NAC caliper measurement of nipple and areola size was performed. 3D laser scanner analysis (Minolta Vivid 900) was used to calculate nipple volume, measurement of nipple, and areolar projection and diameter. Sensitivity was evaluated using the Semmes Weinstein test and patient satisfaction by a visual analog scale (VAS 1-10)., Results: A total of 10 patients were included in the expander group and 12 patients were included in the flap group. After a median follow-up period of 32 months in the expander group and 34 months in the flap group, non-contact 3D laser surface scanning revealed a difference in projection of 55 to 60% compared to the contralateral side. The contraction in all 3 dimensions led to a dramatic difference in nipple volume with 12 ± 8% (flap reconstructions) and 12 ± 7% (expander reconstructions). Sensitivity of the areola showed better values after expander-based reconstruction. Despite the significant discrepancy in nipple volume and projection as well as areolar diameter, overall patient satisfaction was acceptable (VAS 4.1 ± 3.5)., Conclusions: Volume assessment revealed a massive asymmetry to the intact nipple but not between expander and flap reconstructions. Although asymmetry of the areola and nipple remains, patient satisfaction is acceptable. LEVEL OF EVIDENCE 4., (© 2016 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Purpose: To describe a medial epicanthoplasty technique using a stepwise, customized design and to review the outcome in Asian patients after the treatment of medial epicanthal fold., Design: Retrospective, noncomparative and interventional case series with the introduction of a new surgical technique., Participants: Forty-eight consecutive Asian patients with primary medial epicanthal fold., Methods: Patient charts were reviewed from patients (mean age, 24.6 ± 3.8 years; range, 19-40 years) with a stepwise z-epicanthoplasty. The intercanthal distance (ICD), interpupillary distance (IPD), and scar visibility were evaluated at regular intervals (preoperative, immediate postoperative, 3 months, 6 months, and 1 year after the operation). The ratio of the ICD to IPD (ICD ratio) was calculated, and the visibility of the surgical scar assessed., Main Outcome Measures: Postoperative improvement in ICD ratio and scar quality., Results: The preoperative median ICD ratio was 0.60 (range, 0.57-0.66) and decreased to 0.57 (range, 0.52-0.60) postoperatively. The median ICD ratio reduction was 5.6% (range, 2.6-14.1%; P < 0.001, Wilcoxon signed-rank test). Forty patients (83.3%) had no visible scarring or scarring only visible under close inspection. Eight patients (16.7%) experienced a more apparent scar, but none of them developed a severe scar requiring revision., Conclusions: The modified z-epicanthoplasty using a stepwise design is a customized and effective technique for the treatment of the epicanthal fold. This method has a short learning curve, is widely applicable to various types of epicanthal fold, and has a high satisfaction rate with a stable long-term result.

Introduction: Body-contouring (BC) procedures after massive weight loss (MWL) are extensive and numerous. Currently, inconsistent data exist regarding quality-of-life (QoL) scales, and long-term analysis is lacking. The aim of this study was to investigate the long-term outcome of patients who elect to have BC procedures after MWL., Methods: Post-bariatric patients and patients who had dietary weight loss with no history of bariatric surgery (BS) (BC group) were included. Patients after BS with similar demographic characteristics but no BC procedures served as the control group (BS group). The results were compared with severely obese patients who have not yet undergone BS or BC surgery (obese group). Outcome measures include the type of BC surgery with the rates of the associated procedures and outcome satisfaction evaluated after the Moorehead-Ardelt questionnaire (range -3.0 to +3.0)., Results: Fifty-six female and 10 male Caucasian patients with a mean age of 50 years (14 years) who underwent BC procedures between February 1999 and October 2009 were included. Of those, 23 patients completed the survey in 2014 (20 female and three male patients, mean age of 53 years (14 years)) at a final follow-up of 8 years (3 years). Two years (range 1-3 years) after MWL, a total of 51 BC procedures were performed. The most frequent interventions were abdominoplasty (n = 20), followed by rectus plication and liposuction (n = 7 and n = 6, respectively). QoL scores revealed a high overall patient satisfaction in the BC group, which was comparable with the BS group (n = 23). The obese group (n = 17) had a significantly lower overall QoL and lower health-related QoL (HRQoL) subdomains compared with the BC and BS group., Conclusion: BC procedures lead to high and durable patient satisfaction. However, the appropriate management of expectations before surgery is mandatory., (Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Multiple symmetric lipomatosis (MSL) is a rare condition leading to grotesque disfigurement. Complete removal is almost impossible and recurrences inevitable. The objective of this study was to evaluate powered-assisted liposuction (PAL) for the treatment of MSL., Methods: Magnetic resonance imaging (MRI) was performed before and after surgery for quality assessment. To exclude malignancy incisional biopsies were taken before surgery. Outcome measures included aspiration volumes, duration of surgery, early morbidity, recurrence rates, and overall patient satisfaction., Results: Seven male patients aged between 43 and 70 years were identified. The mean liposuction volume equaled 2948±1566 mL, the mean surgery time 74±28 minutes. One hematoma was observed, whereas 1 recurrence rate was noticed after a mean follow-up of 14 months. Malignancy was excluded by histology in 5 patients. Preoperative MRI confirmed the diagnosis with no signs for malignancy and showed an efficient removal of the lesions. After a mean follow-up of 18 months, a high patient satisfaction was achieved., Conclusion: PAL can serve as an efficient method for the treatment of MSL. It has a significant effect on tightening of the skin, leading to a high patient satisfaction., (Copyright © 2015 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Partial joint denervation or surgical neuroma therapy are alternative concepts to treat pain around the ankle joint that preserve joint function and relieve pain by interrupting neural pathways that transmit pain impulses from the joint to the brain. This review article summarizes the indication, anatomic background, operative techniques, and clinical results of joint denervation or neuroma surgery, which, although rarely reported and used, may provide a valuable alternative treatment in selected patients with neurogenous problems around the ankle., (Copyright © 2013 Elsevier Inc. All rights reserved.)