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OBJECTIVE: Desmoid tumor is a rare benign but locally aggressive monoclonal and fibroblastic proliferation. It lacks metastatic potential but is associated with a high local recurrence after surgery. It is either characterized by the Beta-catenin gene (CTNNB1) or the adenomatous polyposis coli gene (APC) mutation. The most appropriate treatment approach is watchful waiting with periodic follow-ups for asymptomatic patients. However, symptomatic patients who are not good candidates for surgery due to high morbidity risk may benefit from medical therapy. The new drugs targeting programmed cell death protein 1 (PD-1) and programmed death-ligand 1 (PD-L1) display promising results in many cancer types. This study assessed the PD-L1 status of desmoid tumors in 18 patients. PATIENTS AND METHODS: Biopsy and resection materials of 18 patients diagnosed with desmoid tumors between April 2016 and April 2021 were retrieved and assessed for PD-L1 expression. The prepared slides were immunohistochemically stained with PD-L1 antibody using Leica Bond® automated immunohistochemistry stainer. RESULTS: No positive PD-L1 staining of the desmoid tumor cells was detected in any specimens. Intratumoral lymphocytes were present in all specimens. However, five of them were positively stained for PD-L1. CONCLUSIONS: Based on the results of our study, anti-PD-1/PD-L1 therapy may not be a valuable option in desmoid tumor treatment due to the lack of expression of PD-L1 by desmoid tumor cells. Nevertheless, the presence of positively stained intratumoral lymphocytes may warrant further studies. [ABSTRACT FROM AUTHOR]

Introduction/Objective. Chordomas are rare tumors of a notochordal origin. Wide surgical resection is recommended for treatment. However, it is associated with a high risk of morbidity and mortality. Additionally, these tumors are resistant to chemotherapy. Thus, targeted therapy is needed for the treatment of chordomas. Programmed death ligand 1 (PD-L1) is a promising target for cancer treatment. Here, we investigated PD-L1 expression in patients with chordoma in a single-center study. Methods. Formalin-fixed paraffin-embedded blocks were evaluated for immunohistochemical analysis to evaluate PD-L1 expression. Clinicopathological variables, such as sex, age, and follow-up data (recurrence and outcome), were retrospectively collected from the patients’ medical records. Results. Ten patients diagnosed with sacral chordoma in a single institution between December 2015 and November 2021 were included in this study. The median patient age was 57 years and the median follow-up period was 40 months. The surgical margins were negative in all cases, without any preoperative medical treatment. Four of the ten patients showed PD-L1 positivity on immune cells. These patients showed local recurrence, without metastasis. In these cases, the median time to local recurrence was 15 months. All the patients with the disease were alive. Conclusion. This study demonstrated that PD-L1 positivity in immune cells can be used as a predictive marker for local recurrence at the time of surgical treatment. This can potentially be used to determine the necessity to administer immunotherapy.

Breast reduction surgery has proven to be a successful treatment for various conditions such as postural disorders, anxiety, dermatological problems, and body image disorders, and is tailored to accommodate each patient's needs and anatomical variations. The author presents a modified approach for reduction mammaplasty using a septum-based superomedial pedicled nipple-areola complex (NAC) flap combined with horizontal dermoglandular pillars. This adjustment enhances desired breast projection, potentially eliminating the need for alternative pedicles in most cases. The limitations and disadvantages of this new technique are discussed. Between July 2015 and July 2021, 85 patients underwent surgery using the horizontal pillar reduction mammaplasty. Clinical data obtained during follow-up visits were recorded. Patients were asked to answer the local version of the Breast-Q, version 2.0, reduction module postoperative scale questionnaire to evaluate breast shape contentment and patient satisfaction at the 1-year follow-up. Necrosis of the NAC was not observed in any patient. The most common complaints in the early postoperative period were pain along the inframammary fold and swelling that extended into the axillary region. The mean values and standard deviations of the postoperative Breast-Q scores were calculated. The postoperative satisfaction with breasts scale mean value was 84.11 ± 12.86, and the postoperative satisfaction with outcomes scale mean value was 81.08 ± 9.97. The horizontal pillar reduction mammaplasty technique is safe, reliable, and easy to perform in breast reduction. Although the initial findings are encouraging, future anatomical and clinical studies are necessary to fully explore this modified technique's functional limitations and long-term outcomes., Competing Interests: Declaration of Competing Interest Authors at this moment declare that they have no conflicts of interest to disclose, (Copyright © 2023 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Unstable femoral neck fractures with medial calcar defects are difficult to manage. The optimal fixation methods for these fractures have been a subject of ongoing debate among orthopedic surgeons. In this study, three different fixation techniques for vertical, medial defected femoral neck fractures were compared., Methods: In this study, a biomechanical analysis was conducted to compare three fixation methods: cannulated screws (Group 1), cannulated screws combined with a medial buttress plate (Group 2), and intramedullary nails (Group 3). Synthetic composite bone models representing vertical collum femoris fractures with medial calcar defects were used. Each group consisted of seven specimens, and, to maintain consistency, a single surgeon performed the surgical procedure. Biomechanical testing involved subjecting the specimens to axial loading until failure, and the load to failure, stiffness, and displacement values were recorded. Normality was tested using the Shapiro-Wilk test. One-way ANOVA and Tukey's HSD post hoc test were used for comparisons., Results: The difference in the load to failure values was statistically significant among the groups, with Group 2 exhibiting the highest load to failure value, followed by Group 3 and Group 1. Stiffness values were significantly higher in Group 2 than in the other groups. Displacement values were not significantly different between the groups. Fracture and displacement patterns at the point of failure varied across the groups., Conclusion: The results of this study indicate that fixation with a medial buttress plate in combination with cannulated screws provides additional biomechanical stability for vertical femoral neck fractures with medial calcar defects. Intramedullary nail fixation also demonstrated durable stability in these fractures. These findings can be used to better understand current management strategies for these challenging fractures to promote the identification of better evidence-based recommendations., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Objective: Desmoid tumor is a rare benign but locally aggressive monoclonal and fibroblastic proliferation. It lacks metastatic potential but is associated with a high local recurrence after surgery. It is either characterized by the Beta-catenin gene (CTNNB1) or the adenomatous polyposis coli gene (APC) mutation. The most appropriate treatment approach is watchful waiting with periodic follow-ups for asymptomatic patients. However, symptomatic patients who are not good candidates for surgery due to high morbidity risk may benefit from medical therapy. The new drugs targeting programmed cell death protein 1 (PD-1) and programmed death-ligand 1 (PD-L1) display promising results in many cancer types. This study assessed the PD-L1 status of desmoid tumors in 18 patients., Patients and Methods: Biopsy and resection materials of 18 patients diagnosed with desmoid tumors between April 2016 and April 2021 were retrieved and assessed for PD-L1 expression. The prepared slides were immunohistochemically stained with PD-L1 antibody using Leica Bond® automated immunohistochemistry stainer., Results: No positive PD-L1 staining of the desmoid tumor cells was detected in any specimens. Intratumoral lymphocytes were present in all specimens. However, five of them were positively stained for PD-L1., Conclusions: Based on the results of our study, anti-PD-1/PD-L1 therapy may not be a valuable option in desmoid tumor treatment due to the lack of expression of PD-L1 by desmoid tumor cells. Nevertheless, the presence of positively stained intratumoral lymphocytes may warrant further studies.

Background and Objectives:  The COVID-19 pandemic has had a negative impact on healthcare in musculoskeletal pathology. There is no standard protocol for pathology services during a pandemic. The study aimed to assess the impact of COVID-19 restrictions on the workload of the musculoskeletal pathology service and the hurdles faced in collaboration with the orthopedic oncology unit in a tertiary reference center in a developing country., Materials and Methods:  The pathology reports from mid-March to mid-June 2019, 2020, and 2021 were retrospectively reviewed., Results:  Significant differences were found between the pandemic period (2020) and the non-pandemic periods (2019-2021) in benign bone and soft tissue lesions, resection surgeries, and soft tissue tumors, which were more prevalent in the non-pandemic periods. However, there was no significant decrease in biopsy procedures. Conclusion :  During the pandemic period, the biopsy procedure appears to be feasible for bone and soft tissue lesions without the need for anesthesia., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2023, Toksöz Yıldırım et al.)

Reconstructive strategies after orbital exenteration range from the use of skin grafts to tissue flaps, depending on the classification of the defect, patient's goals, and tolerance for surgery. We present a case of a 68-year-old, medically complex patient who underwent orbital exenteration, radiation therapy, and reconstruction with a bilaminate dermal substitute. Despite the placement in an irradiated area without periosteum, the bilaminate dermal substitute graft demonstrated acceptable integration and provided an adequate base for subsequent split thickness skin grafting, sparing a medically fragile patient from a morbid operation. This case highlights the advantages of a less invasive reconstructive modality when managing a patient with multiple comorbidities and a significant chance of cancer recurrence., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Frozen shoulder (FS) is an elusive condition that affects patients' mental and emotional quality of their lives. Corticosteroid injection technique is one of the first-line treatment methods in the treatment of FS. Ultrasound (USG) guidance allows visualization of the shoulder anatomy and improves the accuracy of the injection site. This study describes an USG-guided injection technique for FS treatment. The aim of this technique was to affect glenohumeral joint and capsule, subacromial space, the long head of biceps tendon sheath, and the coracohumeral ligament. For this purpose, four different sites were injected by USG guidance. Patients with FS can be effectively treated through this technique that is detailed in this article., (© 2022 The Authors.)

Background and Objectives : Tenosynovial giant cell tumors (TSGCTs) are benign soft tissue tumors that are divided into localized- and diffuse-type tumors, according to the World Health Organization classification of soft tissue tumours. The diffuse-type TSGCT sometimes behave aggressively and poses treatment challenges especially in patients with neurovascular involvement. Symptomatic patients who are not good candidates for surgery due to high morbidity risk may benefit from medical therapy. Objectives : Drugs that target programmed death ligand 1 (PD-L1) are among a new generation of medical therapy options, which, recently, have been explored and have displayed promising results in various cancer types; therefore, we aimed to investigate the PD-L1 status of TSGCTs as a possible therapeutic target. Materials and Methods : We assessed the PD-L1 status of 20 patients (15 men and 5 women, median age = 39 years) that had been diagnosed with TSGCTs in a single institution, between 2018 and 2020. The patients had localized- ( n = 7) and diffuse-type ( n = 13) TSGCTs. Formalin-fixed paraffin-embedded (FFPE) blocks were retrospectively retrieved from the pathology department. An immunohistochemical analysis was performed in sections of 3 micron thickness from these blocks. Results : Seventy-five percent of our patients with TSGCTs were immunopositive to PD-L1 staining. Conclusions : Taking into consideration the high positivity rate of PD-L1 staining in TSGCTs, PD-L1 blockage may be used as a valuable medical treatment for TSGCTs; however, further studies are needed.

Purpose: This report presents the medial pillar island flap technique of oncoplastic breast reconstruction of central defects that involve the nipple-areola complex., Methods: The procedure was performed in patients who presented with inferior pole redundancy using a vertical mammaplasty pattern. The flap was designed utilizing the territory of the lower pole as an island flap pedicled by the internal mammary artery perforators surrounded by the soft tissue of the medial pillar., Results: Eight patients underwent the procedure with a mean age of 57.6 years. Median breast cup size was D (range: from C to DDD). The mean body mass index was 37.3 kg/m 2 (range: from 32.1 to 41.5). The size of the defect ranged from 64 to 150 cm 3 (mean, 97.2). Concomitant opposite breast vertical reduction was performed in 6 cases. Flap survival was uneventful. Nipple reconstruction was performed 6 months after radiation treatment in 4 patients. No major complications were encountered. Two patients developed minor wound breakdown after nipple reconstruction., Conclusions: The medial pillar island flap is presented as a safe and reliable option for the reconstruction of central partial mastectomy defects in patients with macromastia or breast ptosis. Internal mammary system provides predictable and robust flap viability while complete separation from the inframammary fold allows for unrestricted mobility. The procedure is designed with vertical scar mammaplasty, which results in a smooth contour to the lower pole. The flap allows for nipple reconstruction using well-vascularized skin paddle. The technique is offered as an alternative oncoplasty option for neoareolar reconstruction., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest or funding. The institutional review board of our academic center approved this study., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Pyoderma gangrenosum (PG) is a rare, neutrophilic dermatosis which is characterized by painful, necrotic ulcer with violaceous border that heals with cribriform scar. Although the etiopathogenesis of PG is not known exactly, it can be triggered by many factors such as genetics, autoimmune, pathergy phenomenon, drugs, and paraneoplastic. It is frequently associated with autoimmune pathogenesis such as inflammatory bowel disease and rheumatologic disease. It can also be associated with hematological or solid organ malignancies, and then, it is called paraneoplastic PG. The association of PG with myasthenia gravis and thymoma has not been previously reported. In our case, these three diseases with a common paraneoplastic pathogenesis were seen together and the coexistence of the three diseases is rare. Treatment of PG should be decided according to the severity, spread of the lesions, concomitant disease, medical condition, and tolerance of the patient. The purpose of treatment is to control the lesions and related diseases for a long time with minimal side effects. Mycophenolate mofetil treatment was used safely and successfully for both generalized MG and PG in our case., (© 2020 Wiley Periodicals LLC.)

This report presents a case description of sternalis muscle which is an accessory muscle of anterior thoracic wall. A 56-year-old woman underwent mastectomy for breast cancer along with free flap reconstruction, revealing the presence of aberrant sternalis muscle. It was divided transversely during partial rib resection to expose internal mammary vessels. The case proceeded with successful flap transfer. Clinical implications of this anatomic variation is discussed. The authors conclude that plastic surgeons should be aware of this muscular anomaly., (Copyright © 2020. Published by Elsevier Ltd.)

Complete scalp avulsion is a devastating injury resulting in permanent disfigurement. Replantation is the procedure of choice whenever possible. This report describes a successful case of microsurgical reattachment of complete scalp avulsion of temporoparietal segment in a 72-year-old female patient after her hair was tangled in the hoof crack of a horse when the animal slipped on ice and fell on a cold New England night. The amputated segment could be recovered from under snow only after 4 hours following the incident. The procedure involved microvascular anastomoses of superficial temporal artery and vein. The recovery was uneventful, with complete survival of the replant, including the severely crushed segment. There was no need for any transfusion. Long term follow up revealed excellent aesthetic outcome with complete hair growth. This report presents a case experience of successful scalp replantation even after the amputated part was exposed to freezing conditions for 4 hours.

Background: Use of latissimus flap in prosthetic breast reconstruction after mastectomy is an established approach, particularly in patients who have failed breast-conserving therapy. This study presents a comparison of the prepectoral and the subpectoral approach for two-stage prosthetic breast reconstruction with a latissimus flap., Methods: A retrospective review of outcomes and complications was completed between the prepectoral group (n = 33 patients, 50 reconstructed breasts) and the subpectoral group (n = 22 patients, 36 reconstructed breasts)., Results: The demographics were similar between the prepectoral and subpectoral groups in terms of mean age (52.4 vs. 52.5 years, p = 0.97), smoking history (15.1% vs. 13.6%; p = 1.00), radiation history (75.8% vs. 91.0%; p = 0.28), and mean length of follow-up (479 vs. 680 days; p = 0.07). The body mass index was significantly higher in the prepectoral group (27.6 vs. 25.2 kg/m 2 ; p = 0.03). Complications were similar between the groups in terms of hematoma (9.1% vs. 0.0%, p = 0.26), infection resulting in implant failure (9.1% vs. 4.5%, p = 0.64), thromboembolic events (3.0% vs. 4.5%, p = 1.0), donor site seroma (66.7% vs. 40.9%, p = 0.09), breast seroma (18.2% vs. 27.3%, p = 0.51), capsular contracture (9.1% vs. 4.5%, p = 0.64), animation deformity (39.4% vs. 50.0%, p = 0.58), and reoperation (24.2% vs. 22.8%, p = 1.00). Patient satisfaction scores were also similar between the groups (4.33 ± 1.08 vs. 4.14 ± 1.13, p = 0.52)., Conclusions: The prepectoral approach for two-stage immediate prosthetic reconstruction with a latissimus flap has similar outcomes and complications to those of the subpectoral approach, yet obviating the need for any pectoralis major muscle dissection., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest or funding. The institutional review board of our academic center approved this study., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Breast deformity is common following lumpectomy. Use of ptotic lower pole tissue for restoration of volume in the upper pole is quite appealing since it allows for a concomitant lift. This study presents the medial pillar island flap technique of oncoplastic breast reconstruction of upper pole defects., Methods: Vascular anatomy of the lower pole of the breast was investigated with cadaver study. The medial pillar island flap was designed utilizing the territory of the inferior pole of the breast as an island flap pedicled medially by the internal mammary artery perforators surrounded by the soft tissue of the medial pillar. It was transposed to the upper pole lumpectomy defect as an independent flap from superomedial pedicle which was utilized for nipple transposition., Results: The dominant internal mammary artery perforator supplying the medial pillar island flap was consistently found in the fourth interspace at a mean distance of 8.5 cm (range, 8 to 10) from the sternal midline. Thirty patients underwent the procedure, with a mean age of 61 years and mean body mass index of 28.9. The average size of the defect was 170 cm(3) (range, 48 to 295 cm(3)). The majority of the patients (n = 28) underwent opposite breast symmetry surgery as well. The average follow up was 12 months. Complication rate was 23.3%. Reoperation rate was 16.7%. There was no evidence of flap compromise or nipple areola complex necrosis. Patient satisfaction was high, with a mean score of 4.1 (range, 2 to 5) out of 5., Conclusions: The medial pillar island flap has reliable vascularity based on the internal mammary artery system. The flap carries lower pole breast tissue as confined by the medial and lateral pillars of a vertical mastopexy design, offering unrestricted arc of rotation for effective reconstruction of upper pole lumpectomy defects as it is completely dissected from the chest wall and the inframammary fold. The two flap design, along with superomedial pedicle, accomplishes versatility for flap inset. The technique was proven to result in safe outcomes without major complications.

Complete avulsion of the nose is a devastating injury that may result in permanent disfigurement. Microvascular reattachment is technically difficult due to small size of the injured vessels, associated avulsion or crush injury, and relative inability to achieve venous anastomosis. This report describes a successful case of microsurgical replantation of the distal third of the nose in a 47-year-old patient after a dog bite injury with the use of a superficial temporal vein graft for arterial repair and leeching for venous outflow. The recovery was uneventful with total survival of the replant noted except for marginal skin necrosis, which healed by secondary intention. There was no need for any transfusion. The authors found that use of the superficial temporal vein for arterial revascularization was efficient and convenient as it was in the same surgical field, offering a favorable donor site scar in the preauricular sulcus. Microsurgical replantation should be attempted whenever feasible in cases of complete nose amputation.

Background: Prior studies have examined the relationship between obesity and adverse outcomes after reduction mammaplasty, suggesting a correlation between increasing body mass index (BMI) and postoperative complications. However, there is little data published regarding such correlation with respect to short-scar technique., Methods: A total of 236 patients underwent short-scar mammaplasty with a superomedial pedicle from 2008 to 2014. The procedure was performed by a single surgeon at an academic medical center. Adverse outcomes included delayed healing, major wounds, nipple necrosis, fat necrosis, seroma, hematoma, infection, revision, and dog ear deformities. Univariate and multivariate logistic regression analyses were used to calculate crude and adjusted odds ratios for the association of BMI category with the development of any adverse outcome., Results: Patients were grouped by the following BMI categories: <25 kg/m 2 (n = 27), 25 to <30 kg/m 2 (n = 71), 30 to <35 kg/m 2 (n = 73), 35 to <40 kg/m 2 (n = 45), and >40 kg/m 2 (n = 20). The mean follow-up period was 260 days. The total complication rate in each group was 22.2%, 23.9%, 27.4%, 33.3%, and 45.0%, respectively. Although the proportion of patients experiencing at least 1 adverse outcome increased across the ascending BMI categories ( P trend = .145), there was no statistically significant difference between the groups., Conclusion: This study of 236 patients who underwent short-scar reduction mammaplasty found a positive trend in the incidence of adverse outcomes as BMI increased. However, this was not statistically significant., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Traumatic facial soft tissue injury often creates both aesthetic and functional deficits. In complete lip avulsions, microvascular replantation is a reconstructive option that has the potential to fulfill both of these goals. However, lip replantations remain rare and there are few reports in the literature. The authors aim to present a clinical report of a young male who sustained a human bite injury and underwent microvascular replantation of a completely avulsed lower lip and to review the literature and management of these complex injuries.

Giant basal cell carcinoma (GBCC) is defined as a tumor ≥5 cm in diameter. GBCC of scalp usually requires extended resection of soft tissues, calvarium, and dura. In this study, we present 5 patients with GBCC of head, who underwent a single-stage combined scalp, calvarium, and dural reconstruction. Herein, we aim to discuss reconstruction methods, cerebrospinal fluid (CSF) leakage, duration of hospital stay, and tumor recurrency. Peroperative and postoperative follow-ups, defect areas, and performed calvarium reconstruction methods of 5 patients, who underwent complex scalp and calvarium reconstruction after GBCC between year 2010 and 2017, were retrospectively maintained. We studied reconstruction methods, CSF leakage, duration of hospital stay, and tumor recurrency. All patients undergone single-stage reconstruction. Avarge duration of hospital stay was 15 days. Titanium mesh was used in 3 patients and methyl methacrylate was used in 2 patients for calvarium reconstruction. CSF leakage was seen in patients who underwent calvarium reconstruction with titanium mesh. Tumor recurrence occured next to calvarium in 1 patient who undergone calvarium reconstruction with methyl methacrylate. CSF leakage and duration of hospital stay may induce morbidity of this oncoplastic procedure. The fact of longer hospital stay of patients reconstructed with titanium mesh might be a new data presented in this study. These parameters can be related with the method of calvarium reconstruction.

It is generally claimed that short-scar mammaplasty is limited to small-to-medium reductions. Its use in patients with severe macromastia has been associated with a high rate of complications. This report presents our experience of reduction mammaplasty greater than 1000 g per breast using a short-scar technique. The procedure is based on the following: a) modified breast marking method with conservative placement of the nipple-areola complex, determined not only by the level of the inframammary fold but also degree of upper pole volume loss; b) use of liposuction for contouring the inferior pole; c) vertical design dermoglandular resection; d) superomedial pedicle; and e) skin closure without undermining or gathering. A total of 69 patients were identified (n = 138 breasts). Mean age was 38.0 years with average BMI of 36.4 kg/m. Mean weight of breast removed was 1333.8 g (range, 1002-3275). New nipple position was determined to be inferior to the inframammary fold at a mean distance of 4.6 cm, as predicted by the degree of flatness of upper pole. Complications included delayed healing (7.2%), fat necrosis (10.1%), infection (5.8%), hematoma (2.9%), and seroma (1.5%). There were no instances of nipple-areola complex necrosis. Revision of dog-ears was necessary in 7 patients (10.1%). The authors conclude that in using a modified short-scar mammaplasty approach in cases of severe macromastia, the outcomes can be improved with reduced scar burden, pleasing breast shape, and a low complication rate.

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 <30 had 10 complications compared with patients with BMI ≥30 had 15 complications., Conclusions: There are many benefits of fleur-de-lis over traditional panniculectomy, even for medical necessity cases. There is limited undermining of tissue which minimizes/eliminates skin necrosis. Our experience with primarily fleur-de-lis panniculectomies shows a complication rate lower than most published data. Fleur-de-lis potentially creates a better symptom correction and cosmetic outcome by resecting maximal skin in both vertical and horizontal directions. These findings must be balanced against a potentially longer operation.

Reduction mammaplasty may be necessary even after massive weight loss. Patients typically present with unfavorable breast features such as significant loss of upper pole volume, inelastic skin, and severe ptosis. The most common approach in the United States has been the Wise-pattern inferior pedicle technique, emphasizing skin excision. This report presents the short scar vertical reduction mammaplasty approach for the bariatric patient population. It aims to demonstrate improved outcomes with less scar burden. The study included 15 women (n = 29 breast reductions) with mean age of 41.8 years. All the patients had undergone gastric bypass surgery, with mean weight loss of 109 pounds and mean body mass index of 33.3 kg/m(2). A modified superomedial pedicle vertical mammaplasty technique was used. New nipple position was placed lower than the inframammary fold in accordance with vertical lack of upper pole fullness. Suction-assisted lipectomy was used to contour the inferior pole of the breast before glandular resection. A full-thickness superomedial pedicle and median incision of the upper pole maximized pedicle safety. The mean breast resection was 605 g on the right side (range, 352-945) and 592 g on the left side (range, 360-908). Patient satisfaction was high, with pleasing and stable breast shape at long-term, and a mean patient-related aesthetic ranking of 4.3 of 5.0. No major complications were noted. It is shown that superomedial pedicle vertical reduction mammaplasty can be an alternative approach in bariatric patients, achieving long-term pleasing and stable results with significantly decreased scar burden.

Background: The adductor magnus musculocutaneous perforator flap is a medial thigh flap whose utility is often overshadowed by that of its anatomic neighbor, the gracilis flap. It has a large, reliable pedicle and associated skin paddle. Few reports have been published describing the use of this flap as a local or free tissue transfer. The purpose of this study is to revisit and further characterize the anatomy of this extremely versatile yet underutilized flap., Materials/methods: A total of 13 cadavers (n = 26 thighs) were dissected to identify the musculocutaneous perforators that supply the skin of the posteriomedial thigh. The vascular anatomy was studied using multiple modalities. Based on the anatomic data, a local V-Y advancement flap was designed. A total of 8 patients (n = 10 flaps) underwent reconstruction of locoregional defects., Results: Our anatomic studies confirmed the presence of multiple parallel musculocutaneous perforators that travel through the adductor magnus muscle and course obliquely in a posterior-inferior direction. We found that the primary perforator is reliably found approximately 8 cm distal to the groin crease and 2 cm posterior to the posterior border of the gracilis muscle. We discovered that it is consistently accompanied by a separate perforator located 2 cm distally. Minimal dissection into the muscle revealed a Y-configuration of these 2 perforators. This configuration was present in 100% of the cadaveric dissections and is supplied by the first medial branch of the profunda femoris artery. Computed tomography angiograms depicted vascular arborization of the perforators supplying the flap. Clinical experience showed that complete flap survival was achieved in all of the cases., Conclusion: The adductor magnus perforator flap is a reliable flap that offers robust blood supply, through a consistent vascular pedicle, to an extensive skin territory. Our anatomic studies revealed the consistent presence of 2 proximal perforators in the medial thigh that are linked by an intramuscular Y-configuration that provides enhanced blood supply to a local V-Y advancement flap design. The location of the skin paddle on the proximal medial thigh allows for minimal donor-site morbidity as it can be closed primarily with a V-Y advancement flap design, obviating the need for skin grafting.

Background: Precise contouring of the inframammary fold is essential in vertical mammaplasty to avoid persistent dog-ears and revision surgery. This report presents the adjunctive use of suction-assisted lipectomy to shape the inferior pole of the breast in vertical reduction mammaplasty., Methods: A total of 117 patients underwent a modified superomedial pedicle vertical breast reduction. In group I (n = 45), the lower pole shaping was achieved with direct defatting. Based on contour problems leading to revisions, group II (n = 72) comprised the later experience whereby the inferior pole and inferolateral aspect of the breast was approached with liposuction. The rest of the procedure was similar. Revisions and complications were analyzed retrospectively., Results: The demographics were similar in terms of age (38 ± 13 years versus 37 ± 12 years; p > 0.05), body mass index (31.8 ± 5.2 versus 32.1 ± 4.8; p > 0.05), and the amount of breast reduction (713 ± 341 g versus 668 ± 455 g on the right side and 704 ± 347 g versus 649 ± 450 g on the left side; p > 0.05). Group II patients required revision surgery significantly less than group I patients (22.2 percent versus 5.5 percent; p < 0.05). However, the complication rates were similar (15.6 percent versus 12.5 percent; p > 0.05)., Conclusions: In a practice setting with a broad spectrum of patient profiles, adjunctive use of liposuction in vertical breast reduction accomplishes effective contouring of the lower pole of the breast and reduces the revision rates significantly with a low complication rate. This is particularly helpful in large breasts with an ill-defined lateral border. It is emphasized that liposuction is used for contouring purposes and not for volume reduction.

Breast contouring surgery after massive weight loss is challenging because of unfavorable features such as inelastic skin, volume depletion, loss of upper pole fullness, and significant ptosis. An approach is presented for autoaugmentation using a lateral intercostal artery perforator (LICAP) flap secured with a pectoralis muscle sling, along with mastopexy based on vertical scar principles. In a total of 8 patients (average age: 39.3 years, range: 29-57; average body mass index: 30.8 kg/m2, range: 25.7-39.1) with breast ptosis and volume depletion after a mean weight loss of 121.9 pounds (range: 80-210), LICAP flap (n = 16) was used with turnover flap design to increase breast volume under a pectoralis muscle sling. Vertical design mastopexy (n = 16) was achieved at the same time, resulting in an L-shaped final scar. All the patients were followed for at least 1 year after the surgery. Patient satisfaction was high at long-term follow-up (average: 16.8 months, range: 12-24), with stable and pleasing breast shape and a mean patient ranking for aesthetic outcome of 4.2 (of 5). None of the patients developed any flap necrosis or fat necrosis. An alternative approach is described for the combined treatment of breast ptosis and volume loss in the bariatric patient, with promising long-term results. The muscle sling seems to help prevent tissue descent, without evidence of pseudoptosis at long term. It is shown that vertical scar techniques can be successfully used even in bariatric patients.

Y-scar vertical mammaplasty is a technical modification of vertical scar breast reduction, which avoids superior areolar scarring. It has been previously shown to be particularly useful in young patients with mild macromastia and minimal or no ptosis. This case report presents a new indication for which to apply this technical approach. A 58-year-old patient presented with mild macromastia of mainly the inferior pole and pseudoptosis. Since there was no need to transpose the nipple, a Y-scar vertical mammaplasty was performed, removing tissue from the lower pole and preserving upper-pole fullness. Furthermore, superior areolar scarring was avoided. In conclusion, Y-scar vertical mammaplasty may find its use in other less commonly seen patient profiles such as this presented case of an older patient with slightly enlarged breasts and pseudoptosis.

Background: The medial pedicle is commonly employed in vertical breast reduction. With this procedure, there is concern about pedicle compression, especially in large breast reductions when a relatively large medial pedicle is rotated into a smaller sized areolar opening., Objective: The author describes a technical refinement to the vertical mammaplasty, whereby a splitting incision is made into the upper pole parenchyma that allows safe pedicle inset without any constriction by the pillar closure, while upper pole fullness is still maintained., Methods: A total of 94 patients underwent mammaplasty with the author's technique, in which a superomedial pedicle was dissected as a full-thickness flap. The excision of breast tissue was beveled (especially laterally) to treat lateral fullness, while it was maintained perpendicular to the chest wall at the areola opening to preserve upper pole fullness. A straight incision was made into the upper pole, such that the pedicle was then easily rotated to the defect, obviating the need for upper pole debulking., Results: Resection per breast ranged from 350 to 2505 g (average, 780 g). In this series, medial pedicle vertical mammaplasty was a safe and effective operation for a wide variety of breast sizes and shapes, without any nipple-areola complex necrosis. Follow-up at an average of one year demonstrated a stable and aesthetically pleasing shape in all patients., Conclusions: The median incision of the upper pole adds to the safety of vertical mammaplasty by preventing medial pedicle compression. Additionally, the aesthetic outcome is improved.

The authors present a case of free vascularized transfer of the tibial bone as an osteomyocutaneous flap based on the posterior tibial vessels. A 42-year-old man presented with severe crush injury to bilateral legs. The left tibial bone and soft tissue defect required reconstruction with an osteomyocutaneous free flap. Since the contralateral leg was traumatically amputated at the level of the ankle, a decision was made to harvest a free tibial osteomyocutaneous flap with below-knee-amputation completed. The transfer was achieved successfully with complete survival of the flap and bony union. This report describes the technical and healing aspects of such a unique transfer which may rarely be indicated.

Background: The heterodigital artery island flap is a popular method of reconstruction for finger defects. Postoperative venous congestion is a common problem., Methods: The authors present a technique to augment venous drainage of the flap. Briefly, the flap is harvested along with a dorsal vein that is then anastomosed to a recipient vein in an end-to-end fashion, after flap transfer and insetting. Using this technique, seven patients were operated on, ranging in age from 5 to 35 years (average age, 23 years)., Results: All flaps survived with no postoperative flap congestion, fully satisfying the reconstructive requirements. By this modification, skeletonization of the digital artery of the flap pedicle is safe if that approach is preferred, since there is no need to harvest periarterial fat for venous drainage., Conclusions: Providing good harmony with conventional methods and microsurgery, inclusion of a vein with the heterodigital artery island flap allows a more reliable and safer reconstructive choice for finger defects. Such a modification converts the unconventional venous circulation of the heterodigital artery island flap to a more physiologic one.

Considering both its unique structural and functional properties, the reconstruction of the penis is still a challenging problem in reconstructive surgery. Reconstruction may be required in many situations, including traumas, congenital abnormalities, and female-to-male transsexual surgery. Currently, the only natural reconstructive method for the penis is its microvascular reattachment in amputation cases. In all other situations, and in nonreplantable amputations, there is no alternative but to reconstruct the penis using autologous tissues to create the most similar substitute, hoping for a possible allogeneic transplantation in the future. There are many unresolved issues and unanswered questions related to functional recovery after replantation of the penis. In this study, to overcome these drawbacks and to guide and show the feasibility of allogeneic transplantation of the penis in humans in the future, we describe a penile composite tissue flap based on the internal pudendal artery and its autotransplantation in an economical animal species. Fifty adult male Sprague-Dawley rats weighing 400 to 500 g were used. In 20 rats, the vascular anatomy of the male perineal region was determined by anatomic dissections. Based on this anatomic study, the penile composite flap was created based on the internal pudendal vessels. In 10 rats, the penile flap was raised as an island flap based on its vascular pedicle and replaced in situ. In 10 rats, distant flap transfer was accomplished to determine the feasibility of the flap being transferred as a free flap and to demonstrate the viability of the flap components in a heterotopic region. For this purpose, the flap was transferred to the groin region performing anastomoses between internal pudendal vessels and superficial epigastric vessels. In the control group (n=10), while the same surgical procedure was performed, the flap was transferred to the groin region but no anastomosis was performed. The procedure required approximately 3 to 4 hours of operating time in the free flap group. Five of the animals died in the early postoperative days, while all others survived. Direct observation and microangiography were used to assess the viability of the flaps. On the basis of direct observation on the seventh postoperative day, all the pedicled flaps survived completely. In the free-flap group, all but 1 of the vascularized flaps showed complete survival, whereas all the nonvascularized flaps completely necrosed. The authors conclude that the penile flap of the rat offers the following advantages: (1) the composite tissue flap is harvested from a small animal species, (2) the flap is an exact representation of the clinical original penile composition, (3) it can be transferred as a free flap without the need for an isogeneic animal, (4) the vascular pedicle is consistent and allows for microvascular anastomoses. The flap will provide a means for future physiological studies, especially for replantation cases. The feasible autotransplantation of the penile flap with successful results will also guide researchers towards the future allogeneic transfer of the penis in humans.

Any surgical intervention that involves the manipulation of veins, large or small, carries the risk of acute venous congestion. Venous congestion is the product of an imbalance between arterial inflow and venous outflow, and results in the stasis of blood in the tissues that are normally drained by the affected veins. The resultant lack of tissue perfusion causes hypoxia, acidosis, and arterial thrombi formation, which can potentially progress to tissue necrosis and wet gangrene. In the past several decades, the use of leeches (Hirudo medicinalis) has been rediscovered as an effective method of relieving acute venous congestion. This updated review of leech therapy focuses on the use of medicinal leeches in a variety of clinical conditions characterized by acute venous congestion, and points out the experimental use of leeches in other pathological entities. A discussion of the recent scientific findings that explain the possible mechanisms of action of leech therapy is also provided.