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Summary: For V-shaped nasal bones, the authors consider that ostectomy of the dorsal keystone area can be avoided, and this has led to the development of a new preservation technique: the spare roof technique B (or Ferreira-Ishida technique), where the bony cap is preserved. It includes six main steps, as follows. Step 1, draw on the surface of the skin the desired dorsal brow-tip aesthetic lines, the pyriform aperture, the rhinion, and the amount of triangular bone that has to be taken out to allow pushing-down the bony cap, and the transversal line in the beginning of the nasal hump. Step 2, release the upper lateral cartilages from the dorsal septum ("high septal strip"). Step 3, take out the amount of dorsal septum necessary to dehump. Step 4, perform the paramedian high parallel osteotomies exactly below the marked brow-tip dorsal aesthetic lines. Then, perform the second group of lower osteotomies, until the E-point, to achieve a triangular shape of bone in each side of the bony cap. Perform the ostectomy of the mentioned triangular areas. Release the lateral keystone area. Perform partial ultrasonic ostectomy endonasally, below the nasal bones, to promote the weakening of the transverse fracture line, in the sagittal plane just above the E-point. Push-down gently the rectangular bony cap with a Luc nasal forceps (19 cm) in a greenstick fashion. Perform lateral traditional osteotomies from high to low to high to narrow the bony bridge as much as is needed. Step 5, perform a regular L-shape Cottle septoplasty (if necessary). Step 6, suture the cartilaginous middle vault (upper lateral cartilages) to the dorsal aspect of the remaining septum., Competing Interests: Disclosure:The authors declare that they have no conflicts of interest to report., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Background: Classic nasal hump reduction based on partial resection of the cartilage and bones in the nose may lead to dorsum deformities such as an inverted-V deformity, irregularities, and an open roof. Techniques that preserve the nasal dorsum (namely the push-down and let-down) avoid these problems, but may not always be indicated for very large, broad, or deviated noses, whereas cartilaginous push-down is also indicated for large and deviated humps. Because only the cartilaginous portion of the hump is preserved in the cartilaginous push-down, a rough area may remain where the bony portion is resected., Objectives: The aim of this study was to develop a variation of the cartilaginous push-down technique which includes a bony cap to preserve the smoothness of the keystone area during nasal hump treatment., Methods: Forty-eight consecutive patients with indication for nasal hump treatment who underwent cartilaginous push-down procedures with bony cap preservation between August 2018 and October 2019 were studied., Results: We observed related complications in 2 patients (4.2%); in 1 patient (2.1%) the bony cap was lost during the rasping of the nasal bones and the surgery was altered to utilize only the cartilaginous push-down. Another patient (2.1%) experienced a mild hump recurrence during the early weeks following the procedure. All of the remaining patients had their nasal humps treated adequately., Conclusions: The nasal hump was adequately corrected in most of the study patients (95.8%). Preserving the bony cap while performing the cartilaginous push-down may prevent complications related to the osseous resection of the keystone area., (© 2020 The Aesthetic Society.)

Athelia is a very rare entity that is defined by the absence of the nipple-areola complex. It can affect either sex and is mostly part of syndromes including other congenital or ectodermal anomalies, such as limb-mammary syndrome, scalp-ear-nipple syndrome, or ectodermal dysplasias. Here, we report on three children from two branches of an extended consanguineous Israeli Arab family, a girl and two boys, who presented with a spectrum of nipple anomalies ranging from unilateral hypothelia to bilateral athelia but no other consistently associated anomalies except a characteristic eyebrow shape. Using homozygosity mapping after single nucleotide polymorphism (SNP) array genotyping and candidate gene sequencing we identified a homozygous frameshift mutation in PTPRF as the likely cause of nipple anomalies in this family. PTPRF encodes a receptor-type protein phosphatase that localizes to adherens junctions and may be involved in the regulation of epithelial cell-cell contacts, peptide growth factor signaling, and the canonical Wnt pathway. Together with previous reports on female mutant Ptprf mice, which have a lactation defect, and disruption of one allele of PTPRF by a balanced translocation in a woman with amastia, our results indicate a key role for PTPRF in the development of the nipple-areola region.

Background: In microsurgical breast reconstruction, an adequate selection of recipient vessels is crucial for a successful outcome. Although the internal mammary (IM) vessels offer an attractive option, the internal mammary perforator (IMP) vessels are becoming a reliable alternative. The purpose of this study is to investigate the external diameters, lumen area, and atherosclerotic lesions changes of the IMP, IM, and deep inferior epigastric (DIE) vessels through quantitative and qualitative histomorphometric analysis., Methods: Ninety-six vessels of bilateral IM, IMP, and DIE vessels from 16 fresh female cadavers were evaluated. Mean age was 54.06 ± 5.7 years. External diameters, lumen area, and degenerative changes of the tunica intimae and media were analyzed by qualitative histomorphometric analysis., Results: Seventy-one vessels (20 IM, 31 IMP, and 20 DIE vessels) were included in the final histological analysis. A statistically lower external diameters and lumen area were presented by the IMP. The DIE vessels showed a lower incidence (10%) of moderate and severe intimal layer degenerative changes (P = 0.0589). The IMP and DIE vessels showed a lower incidence (9.4 and 25%, respectively) of major media layer degenerative changes (P = 0.0001). No major arterial degenerative lesions were observed in the IMP arteries., Conclusion: Although the IMP external diameters and lumen area were lower than the IM, the results of this study indicated that the tunica media layer in the IMP is less damaged than the other recipient vessels. The results of the comparative histological study permitted to describe additional advantages and disadvantages of using IMP as a recipient vessel for free flap breast reconstruction., (© 2013 Wiley Periodicals, Inc.)

The supraclavicular island flap has been widely used in head and neck reconstruction, providing an alternative to the traditional techniques like regional or free flaps, mainly because of its thin skin island tissue and reliable vascularity. Head and neck patients who require large reconstructions usually present poor clinical and healing conditions. An early experience using this flap for late-stage head and neck tumour treatment is reported. Forty-seven supraclavicular artery flaps were used to treat head and neck oncologic defects after cutaneous, intraoral and pharyngeal tumour resections. Dissection time, complications, donor and reconstructed area outcomes were assessed. The mean time for harvesting the flaps was 50 min by the senior author. All donor sites were closed primarily. Three cases of laryngopharyngectomy reconstruction developed a small controlled (salivary) leak that was resolved with conservative measures. Small or no strictures were detected on radiologic swallowing examinations and all patients regained normal swallowing function. Five patients developed donor site dehiscence. These wounds were treated with regular dressing until healing was complete. There were four distal flap necroses in this series. These necroses were debrided and closed primarily. The supraclavicular flap is pliable for head and neck oncologic reconstruction in late-stage patients. High-risk patients and modified radical neck dissection are not contraindications for its use. The absence of the need to isolate the pedicle offers quick and reliable harvesting. The arc of rotation on the base of the neck provides adequate length for pharyngeal, oral lining and to reconstruct the middle and superior third of the face., (Copyright © 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. All rights reserved.)

Background: Protrusion of the abdominal wall secondary to abdominoplasty may occur in patients with weakness of the aponeurotic structures. The anterior layer of the rectus abdominis muscle consists of fibers that are transverse rather than vertical. Based on this anatomical feature, vertical sutures are suggested for the correction of diastasis recti, since they include a greater amount of fascial fibers and thus would be more resistant to tensile strength than horizontal ones., Methods: The anterior layers of the rectus abdominis muscles of 15 fresh cadavers were dissected. Two vertical lines were marked on each side of the linea alba, corresponding to the site where plication is usually performed in abdominoplasties. Three abdominal levels were evaluated: the supraumbilical, umbilical, and infraumbilical levels. A simple suture was placed in the vertical direction in one group and in the horizontal direction in the other group, at each of the three levels previously described. These sutures were connected to a dynamometer, which was pulled medially toward the linea alba until rupture of the aponeurosis occurred., Results: The mean strength required to rupture the aponeurotic structures in which the vertical sutures had been placed was greater than for the horizontal ones (p < 0.0001)., Conclusion: The vertical suture of the rectus abdominis sheaths was stronger than the horizontal suture because of the more transversal arrangement of its aponeurotic fibers. Thus, routine use of the vertical suture in plications of the aponeurosis of the rectus abdominis muscles is suggested.

Background: The use of synthetic mesh for abdominal wall closure after removal of the rectus abdominis is established but not standardised. This study compares two forms of mesh fixation: a simple suture, which fixes the mesh to the edges of the defect on the anterior rectus abdominis fascia; and total fixation, which incorporates the fasciae of the internal oblique, external oblique and transverse muscles in the suture, anchoring the mesh in the position of the removed muscle., Method: A total of 16 fresh cadavers were dissected. Two sutures were compared: simple and total. Three different sites were analysed: 5 cm above, 5 cm below and at the level of the umbilicus. The two sutures compared were tested in each region using a standardised technique. All sutures were performed with nylon 0, perpendicular to the linea alba. Each suture was secured to a dynamometer, which was pulled perpendicularly towards the midline until the rupture of the aponeurosis. 'Rupture resistance' was measured in kilogram force. The mean among the groups was compared using the paired Student's t-test to a significance level of 1% (p<0.01)., Results: The mean rupture resistance of the total suture was 160% higher than that of the simple suture., Conclusion: The total suture includes the external oblique, internal oblique and transverse fasciae, which are multi-directional, and creates a much higher resistance when compared with the simple suture. Total suture may reduce the incidence of bulging and hernias of the abdominal wall after harvesting the rectus abdominis muscle, but comparative clinical studies are necessary., (Copyright © 2010 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Background: Treatment of excessive gingival display usually involves procedures such as Le Fort impaction or maxillary gingivectomies. The authors propose an alternative technique that reduces the muscular function of the elevator of the upper lip muscle and repositioning of the upper lip., Methods: Fourteen female patients with excessive gingival exposure were operated on between February of 2008 and March of 2009. They were filmed before and at least 6 months after the procedure. They were asked to perform their fullest smile, and the maximum gingival exposures were measured and analyzed using ImageJ software. Patients were operated on under local anesthesia. Their gingival mucosa was freed from the maxilla using a periosteum elevator. Skin and subcutaneous tissue were dissected bluntly from the underlying musculature of the upper lip. A frenuloplasty was performed to lengthen the upper lip. Both levator labii superioris muscles were dissected and divided., Results: The postoperative course was uneventful in all of the patients. The mean gingival exposure before surgery was 5.22 +/- 1.48 mm; 6 months after surgery, it was 1.91 +/- 1.50 mm. The mean gingival exposure reduction was 3.31 +/- 1.05 mm (p < 0.001), ranging from 1.59 to 4.83 mm., Conclusion: This study shows that the proposed technique was efficient in reducing the amount of exposed gum during smile in all patients in this series.

The cartilaginous structures of the nose play an important role in nasal esthetics and function. The handling of these structures has always been very treacherous, and long-term follow-up quite often has shown unexpected results. Based on Gibson's studies, we propose the use of abrasion treatment of the nasal cartilages with the burr power drill. This device can produce controlled weakening on determined regions of the nasal cartilages. If this weakening is done on just one side, the cartilage will bend to the opposite side. On the septal cartilage, this method can be used to straighten it by abrasion on its concave portion. To correct the alar cartilages, the burring is done either to enhance curvatures or to change the conformation of the alar cartilage itself. This method was used in 67 patients with satisfactory results, permitting corrections of septal deviations with very little resections of the septal cartilages and corrections of various tip deformities, with almost no resections at all of the alar cartilages.

Background: To report a new technique with less morbidity for coverage of trochanteric defects, an anatomical and clinical study was performed., Methods: Twenty-four fresh cadavers were dissected. The following parameters were measured: origin, location, number, and length of the perforating vessels. In addition, a clinical study was performed on 21 patients with trochanteric pressure sores., Results: The anatomical study of 24 fresh cadavers revealed the constant presence of perforator pedicles anterior to the greater trochanter, which provides an adequate arc of rotation arc for flap harvest without sacrificing the underlying muscles. The mean length of the pedicles was 9.59 +/- 2.16 cm. This flap is nourished by perforator vessels arising from the ascending branch of the lateral circumflex femoral artery, which arises from the deep femoral artery and runs through the intermuscular septum, tensor fasciae latae, and rectus femoralis muscles. In this study, flaps were raised based on perforators located preoperatively using a unidirectional Doppler probe. Good results were obtained with primary closure of the donor site, with only two donor-site dehiscences., Conclusions: This flap is an alternative to myocutaneous flaps, as it preserves local musculature without functional sequelae in patients who walk. It also preserves the local musculature in the event of recurrence, as is usually seen in paralytic patients with pressure sores.

The absence of nipple-areola complex is a rare entity and is always associated with other anomalies. This paper described a case of bilateral athelia without other alterations. The atrophy of the dense mesenchyme due to absence of parathyroid hormone-related protein produced in epithelium may lead to nipple involution. Further cases should be studied to corroborate this theory.

A variety of useful recipient sites exist for breast reconstruction with free flaps, and correct selection remains a significant decision for the surgeon. Among the main pedicles, the disadvantages of the internal mammary vessels are the necessity of costal cartilage resection and the impairment of future cardiac bypass. This study was designed to reduce morbidity and to seek alternative recipient vessels. In the anatomical part of the study, 32 parasternal regions from 16 fresh cadavers were used. The locations and components of internal mammary perforator branches were measured and a histomorphometric analysis was performed. In the clinical part of the study, 36 patients underwent 38 deep inferior epigastric perforator (DIEP) flap and two superior gluteal artery perforator flap breast reconstructions (31 immediate and four bilateral). The recipient vessels were evaluated. In the anatomical study, there were 22 perforating vessels, with 14 (63.6 percent) on the second intercostal space and 11 (50 percent) with one artery and vein. The average (+/-SD) internal and external perforator artery diameters were 598.48 +/- 176.68 microm and 848.97 +/- 276.68 microm, respectively. In the clinical study, 13 successful anastomoses (32.5 percent) were performed at the internal mammary perforator branches (second and third intercostal spaces) with 12 DIEP flaps and one superior gluteal artery perforator flap (all performed as immediate reconstructions). One case of intraoperative vein thrombosis and one case of pedicle avulsion during flap molding were observed. The anatomic and clinical studies demonstrated that the internal mammary perforator branch as a recipient site is a further refinement to free flap breast reconstruction. However, it is neither a reproducible technique nor potentially applicable in all patients. Preoperative planning between the general surgeon and the plastic surgeon is crucial to preserve the main perforator branches during mastectomy. The procedure was not demonstrable in late reconstructions. The main advantages of internal mammary perforator branches used as recipient sites are sparing of the internal mammary vessels for a possible future cardiac surgery, prevention of thoracic deformities, and reduction of the operative time by limited dissection. Despite this, limited surgical exposure, caliber incompatibility, and technical difficulties have to be considered as the main restrictions.

Free flaps based on perforator vessels, and in particular the deep inferior epigastric perforator (DIEP) flap, are currently being applied in abdominal reconstruction. However, one of the main disadvantages is the operative complexity. Through anatomical study and clinical experience with the DIEP flap in breast reconstruction, the intramuscular path of the perforator vessels was comparatively studied, to establish the main anatomical parameters that favor procedure planning. Thirty DIEP flaps from 15 fresh cadavers were used. The number, location, and intramuscular course of the perforator vessels were determined. In addition, an initial clinical study was performed in 31 patients using 35 DIEP flaps in breast reconstruction. The number, location, and the intramuscular course of the perforators were assessed. In the cadaver study, 191 perforator vessels were detected (6.4 vessels per flap). Thirty-four percent were located in the lateral row, and the rectilinear course was observed in 79.2 percent of these vessels. In the medial row, only 18.2 percent of the perforator vessels presented this configuration (p = 0.001). Thirty-one patients underwent DIEP flap breast reconstruction, with 26 immediate and four bilateral reconstructions. In 22 of 35 flaps (62.9 percent), two perforators were used. In 25 flaps (71.4 percent), the lateral row perforators with a rectilinear course were observed. Mean operative time was 7 hours and 37 minutes. Two total flap losses and two partial necroses were observed. The majority of the lateral row perforators presented a rectilinear intramuscular course, which was shorter than that of the medial row perforators. This anatomical characteristic favors dissection with reduced operative time and vascular lesion morbidity, resulting in an important anatomical parameter for DIEP flap harvesting.

The principle of free flaps based on perforator vessels and the development of deep inferior epigastric perforator flap (DIEP) is currently used in reconstructive microsurgery. Clinical experience and research have shown that perforator flaps provide numerous advantages over the conventional myocutaneous flaps and combine muscle preservation and sequel minimization at the donor site. Clinical use of autogenous tissue or perforator flaps in aesthetic breast surgery or augmentation mammaplasty is not a common practice. The authors indicate the use of the DIEP flap to correct severe hypomastia after bilateral breast augmentation with silicon implants, followed by infection and implant extrusion. Using the DIEP flap is a new option for patients who have had complications from breast augmentation with implants or severe hypomastia and have excess tissue in the lower abdomen. Additional studies and clinical research are necessary to evaluate the real benefits as compared to silicone implants, such as operative time, the recovery period and financial implications.

Classically, nasal hump reduction is based on the partial resection of the cartilages and bones of the nose, as it was described by Joseph almost a century ago. The cartilaginous portion of the hump consists of a single unity formed by the two upper lateral cartilages and the septal cartilage. During hump reduction in the classic rhinoplasty, this structure is slashed in three pieces, which is the main cause of irregularities, shadows, and pinchings over the long-term results. Late follow-ups of the classical hump removal often show an inverted V-shaped shadow on the dorsum secondary to the destruction of the osseous-cartilaginous transition. The angle and relation between the septal and upper lateral cartilages are reduced, which may compromise the functional aspect. The destruction of the unique anatomy of the cartilaginous hump is one of the main causes of this functional and aesthetic sequela. Here, we present a technique that preserves the cartilaginous framework of the nasal hump by lowering it through the resection of a strip of septum, avoiding the problems described above.