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Iatrogenic jowling can be an unintended consequence of facial feminization surgery. Reduction of the mandible and chin without overlying changes to the soft tissue can lead to a redundant and deflated soft-tissue envelope, requiring a face lift to address jowling, cervicofacial laxity, and/or lower facial rhytids. Prospective quality-of-life outcomes data support this hypothesis, as patients who underwent mandible contouring with or without angle osteotomies were significantly more likely to express interest in face lift following facial feminization surgery on univariable analysis (90.0 percent versus 10.0 percent, p = 0.038). Patients with inherent skin laxity are at particularly high risk, such as those with advancing age, extrinsic skin damage (e.g., sun exposure, cigarette smoke), and history of massive weight loss. Before facial feminization surgery, the authors recommend comprehensive patient counseling that includes a discussion of the possible future need for a face lift, preferably around 1 year after facial feminization surgery. When performing a face lift after facial feminization surgery, technical considerations include those related to sequelae of prior facial surgery, anatomical differences between cismale and cisfemale facial soft tissue, and the mechanism of jowling after facial feminization surgery versus normal facial aging. The authors believe that these considerations can set more realistic expectations for facial feminization surgery patients, improve surgeons' ability to skillfully execute this procedure, and ultimately contribute to ongoing quality-of-life improvements in facial feminization surgery patients.

To report on the immediate postoperative alignment of distal tibia fractures (within 10 cm of the tibial plafond) treated with infrapatellar intramedullary nailing (IMN) using the tibial traction triangle (TTT).We performed a retrospective cohort study at a Level-I academic trauma center, with eighty-one skeletally mature patients with closed distal tibia fractures treated over a 10-year period with closed infrapatellar intramedullary nailing, without fibula fixation, using the TTT. The primary outcome measure is primary malalignment ≥5°.Primary malalignment occurred in 4 (4.9%) patients, all in the coronal plane. Mean coronal plane alignment was 1.72° valgus (range 3° varus to 8° valgus). No sagittal malalignment occurred. The fibula was intact in 5 (6.2%) cases. No patients underwent fibula fixation or blocking screw placement. Intra-articular extension occurred in 28 (34.6%) cases. Mean fracture distance from the plafond was 5.98 cm. Thirty-one patients had a fracture within 5 cm of the plafond, where malalignment was noted in 2 (6.5%) patients.This is the first analysis of a large cohort of patients with distal tibia fractures treated with the TTT. Use of this device leads to a very low rate of primary malalignment with infrapatellar nailing, even in extremely distal fractures. We recommend consideration of this device as one more adjunct to help treat these difficult fractures successfully.

Background Scalp reconstruction has evolved over time. Given the large surface area, location, and high likelihood of sun exposure, the scalp is particularly prone to sun damage and skin cancer. Resection of scalp cancers often leaves a large defect that can be challenging for reconstruction. The authors present objective data and recommendations based on more than 10 years of consecutive scalp reconstructions performed by the senior author (J.F.T.). In addition, the authors describe each method of reconstruction and delineate an algorithm based on the senior author's approach and the cases assessed. Methods The authors conducted a retrospective review of patients who underwent scalp reconstruction after Mohs cancer excision over a 10-year period. Each case was evaluated for key patient characteristics, defect location, defect size, defect composition, reconstructive modality, and complications. Results The senior author (J.F.T.) performed 913 scalp reconstruction procedures. Defects most commonly involved the forehead or vertex of the scalp, with a wide range of sizes. A significant majority of the patients' defects were repaired with the use of adjacent tissue transfer or Integra dermal regeneration templates. There were 94 complications (12.5 percent) noted, ranging from graft loss to cancer recurrence. Conclusions Reconstruction of scalp defects after Mohs cancer excision presents the plastic surgeon with numerous patient and defect preoperative variables to consider. Each defect should be evaluated, and a plan based on composition of the defect and the needs of the patient should be developed. Scalp reconstruction is safe to perform in an outpatient setting, even in elderly patients. Clinical question/level of evidence Therapeutic, IV.

Background: The COVID-19 pandemic has resulted in unpreceded changes to medical education. Medical students interested in urology and neurosurgery have reported concerns regarding COVID-19's effects on clinical experience and the residency application process;however, the impact amongst students interested in plastic surgery is unknown. We hypothesized that students applying into plastic surgery may experience much distress as a result of the COVID-19 pandemic. Methods: An electronic survey was developed by 3 plastic surgery residents and 2 academic plastic surgeons and later refined by 4 fourth-year medical students. Questions focused on medical education curricular changes, perceived impact on medical education, and demographics. From April-May 2020 the survey was distributed to medical students who were interested in plastic surgery. Participants were identified through plastic surgery residency program personnel and social media platforms. Results: In total, 130 of the 140 respondents reported interest in plastic surgery careers. An estimated 67% were in their clinical years or completing research year(s) before residency applications. Of the respondents, 80% believed that the COVID-19 pandemic had a negative impact on their medical education. Clinical-level students compared with preclinical-level students, and students applying to residency during the 2020-2021 match cycle compared with students not applying during the 2020-2021 match cycle were significantly more likely to perceive the COVID-19 pandemic as having a negative impact on their medical education (P = 0.04 and 0.03, respectively). Conclusion: Medical students interested in plastic surgery perceive the COVID-19 pandemic as having a negative impact on their education, likely due to a reduction in clinical exposure. © 2021 Lippincott Williams and Wilkins. All rights reserved.

The lips provide key functional and aesthetic features of the face. From social interactions and speech to swallowing and oral competence, a functional dynamic structure is required. This interaction with surrounding landmarks presents a challenge for reconstruction. There are a myriad of ways reported to reconstruct these defects; however, as the authors' practice has evolved, a more refined approach was developed to optimize results and minimize the complexity of each patient's surgery.A retrospective review from 2004 to 2018 was performed of consecutive patients who underwent lip reconstruction following Mohs cancer resection performed by a single surgeon. Each case was evaluated for key patient characteristics, defect location, defect size, defect composition, reconstructive modality, and complications. In addition, the evolution of treatment types over those 14 years was evaluated.Six hundred fifteen patients underwent lip reconstruction. Defects most commonly involved the upper lateral lip, and 247 (40 percent) involved both the skin and vermillion. A significant majority of the patient's defects were repaired using either linear closure or V-wedge excision and closure. A complication rate of 10.2 percent (n = 63) was found, ranging from oral incompetence to cancer recurrence. There was no significant difference in complication rates in patients older than 75 years, in smokers, or in patients who were on anticoagulation.The authors' techniques have evolved from more invasive advancement and rotation flaps to a more reliable linear closure method over the past 14 years. This study shows that lip reconstruction is safe in elderly patients, smokers, and patients who are on anticoagulation.Therapeutic, IV.

The ear serves many functional and aesthetic purposes, and its complex structure presents a notable challenge for reconstruction. A paucity of objective data and analysis on reconstruction of acquired ear defects remains. The goal of this study was to evaluate all ear reconstructions and the lessons learned over the past decades in treating these complicated defects in a large clinical Mohs reconstruction practice.A retrospective analysis of consecutive patients who underwent ear reconstruction after Mohs cancer excision from 2004 to 2018 performed by the senior author (J.F.T) was conducted. Data regarding patient demographics, oncologic type, treatment, defect characteristics, reconstructive modalities, number of stages, and complications were collected and analyzed.Three hundred twenty-seven patients underwent ear reconstruction. Defects most commonly involved the superior one-third of the helix and the antihelix. Approximately half of the patients' defects were reconstructed with full-thickness skin grafts, and approximately one-third of the patients' defects required flap reconstruction. There were 30 complications (9 percent), ranging from partial flap loss to cancer recurrence. There was no difference in complication rates in elderly patients compared with the younger cohort.Optimizing results when reconstructing ear defects is challenging, and there are multiple preoperative variables to consider. Ear reconstruction is safe in an outpatient setting, and age should not preclude patients from undergoing reconstruction of ear defects. The lessons learned from the past decade of ear reconstructions are demonstrated, and an algorithmic approach to treating these defects allows for a safe and reproducible method for reconstructing acquired ear defects.Therapeutic, IV.

Malalignment after intramedullary nailing of proximal and distal tibia fractures remains a significant problem. We describe the use of a novel device to ease treatment of tibia fractures that undergo intramedullary nailing. The tibial traction triangle is simple and easy to use and allows for better reductions, leading to lower rates of malalignment. A prospective series of 11 patients is presented.