Chronic lower extremity (LE) wounds, especially in diabetic patients with peripheral neuropathy, are a leading cause of nontraumatic amputation. These wounds often result from underlying biomechanical deformity and alter...Chronic lower extremity (LE) wounds, especially in diabetic patients with peripheral neuropathy, are a leading cause of nontraumatic amputation. These wounds often result from underlying biomechanical deformity and altered gait mechanics in the insensate foot. This primer outlines key biomechanical principles for plastic surgeons involved in limb salvage, emphasizing the importance of early recognition, deformity classification and considerations, and comprehensive vascular assessment prior to intervention. A multidisciplinary, biomechanically informed approach, integrating vascular, podiatric, and plastic surgical expertise, is critical for effective wound management. Surgical strategies may be guided by wound location and associated deformity. For example, tibiotalocalcaneal (TTC) fusion addresses plantar hindfoot wounds linked to ankle dorsiflexion instability, while Achilles tendon lengthening (TAL) treats forefoot wounds caused by plantarflexion contracture. Varus or valgus deformities of the lateral or medial foot may require tendon transfers or joint fusion, and Charcot neuroarthropathy often necessitates osteotomy and/or arthrodesis. Hallux and lesser toe wounds, commonly due to digital contractures, are treated with tendon transfers, arthroplasty, or fusion. In some cases, transmetatarsal amputation offers both structural and functional balance and preserves ambulatory function. Ultimately, successful limb preservation hinges on early biomechanical correction, vascular optimization, infection control, and durable soft tissue reconstruction. This integrated approach enhances healing, reduces recurrence, and improves long-term mobility and quality of life in this high-risk population.
BACKGROUND: Prior studies have reported higher hematoma rates in male facelift patients, often attributed to thicker skin, more robust subcutaneous vasculature, elevated baseline blood pressure, and greater incidence of...BACKGROUND: Prior studies have reported higher hematoma rates in male facelift patients, often attributed to thicker skin, more robust subcutaneous vasculature, elevated baseline blood pressure, and greater incidence of alcohol and tobacco use. This study aimed to evaluate postoperative hematoma rate and overall outcomes between matched male and female facelift patients treated by a single surgeon using standardized hematoma prevention protocols. METHODS: A retrospective analysis was performed on consecutive patients who underwent facelift surgery from 2014 to 2024. Male and female patients were matched by age, BMI, primary vs. secondary status, local tranexamic acid (TXA) use, and comorbidities (hypertension, diabetes, smoking). Operative characteristics and postoperative complication profiles were compared. RESULTS: 541 patients were included (34 male, 507 female). Minor hematoma occurred in 0% of males versus 2.0% of females (P=1), with no hematomas requiring operative evacuation. Males had longer operative times (456 vs 407 minutes, P<0.001) and higher EBL (≥100 cc 34.8% vs 2.9%, P<0.001). Propensity matching yielded 68 patients (34 male, 34 female). In the matched cohort, males again had longer operative time (457 vs 422 minutes, P<0.001) and higher EBL (≥100 cc 34.8% vs 6.9%, P=0.02). There remained no difference in hematoma rate between gender (0% vs 2.9%, P=1) and overall complications were similar. CONCLUSIONS: Despite increased operative time and EBL, male patients experienced similar hematoma rates compared to matched female counterparts. These findings suggest that, with modern surgical protocols, historical disparities in male facelift patient outcomes can be meaningfully reduced.
BACKGROUND: Carboxytherapy refers to the use of CO2 gas for several therapeutic purposes. CO2 has numerous physiological effects, most notably promoting the Bohr effect causing a decrease in hemoglobin affinity for oxyge...BACKGROUND: Carboxytherapy refers to the use of CO2 gas for several therapeutic purposes. CO2 has numerous physiological effects, most notably promoting the Bohr effect causing a decrease in hemoglobin affinity for oxygen and thereby increasing oxygen delivery to the treated area. Carboxytherapy historically was applied in a percutaneous manner, however recent advancements have made topical forms available. Over the last several decades, practitioners have utilized carboxytherapy for aesthetic purposes. The purpose of this article is to review the applications of carboxytherapy in aesthetic surgery and medicine. METHODS: A comprehensive review of the literature was performed using a number of search terms related to carboxytherapy. Articles were reviewed and selected by two independent reviewers. Due to the heterogeneity of the articles, a narrative review was performed. RESULTS: Ultimately, 32 articles were selected for review. The articles focused on periorbital rejuvenation, facial rejuvenation, lipolysis, and transcutaneous applications. The available research suggests that transcutaneous carboxytherapy can address periorbital hyperpigmentation. Additionally, it can potentially reduce fine lines and wrinkles in the face and lead to mild lipolysis in the treated area. Finally, topical carboxytherapy gel shows early promise for improving local healing and tissue oxygenation. CONCLUSIONS: Carboxytherapy shows potential as a therapy in aesthetic surgery and medicine, particularly for periorbital hyperpigmentation, facial wrinkles, and lipolysis. Additionally, the topical form is of potential great interest to plastic surgeons as an adjunct for tissue healing and oxygenation after surgical and non-surgical treatments. Further research is needed to support these findings and provide comprehensive clinical guidelines.
In Asian rhinoplasty, silicone implants are widely used for dorsal augmentation, but prefabricated implants often fail to reflect individual anatomy and asymmetry, leading to implant malposition or contour irregularity....In Asian rhinoplasty, silicone implants are widely used for dorsal augmentation, but prefabricated implants often fail to reflect individual anatomy and asymmetry, leading to implant malposition or contour irregularity. This study evaluated whether a 3D-printed customized implant provides more precise dorsal correction than conventional prefabricated implants. We compared outcomes of silicone augmentation rhinoplasty for mild dorsal deviation or hump. Photographs were analyzed for dorsal deviation, hump angle, and dorsal irregularity. Customized implants achieved greater improvement in dorsal deviation and hump angle than prefabricated implants. Overall, 3D-printed customized implants provided more precise correction of mild dorsal deformities, suggesting improved anatomical conformity and dorsal contour stability.
BACKGROUND: Hematoma remains a major complication following breast surgery. While tranexamic acid (TXA) efficacy is established in reduction mammaplasty, its utility across other breast procedures remains unclear. METHOD...BACKGROUND: Hematoma remains a major complication following breast surgery. While tranexamic acid (TXA) efficacy is established in reduction mammaplasty, its utility across other breast procedures remains unclear. METHODS: This retrospective cohort study included 5,202 consecutive procedures (2019-2025) performed by multiple surgeons at a single private hospital: primary augmentation (n=3,738), reduction mammaplasty (n=943), explantation with mastopexy (n=358), and explantation alone (n=163). TXA administration was at surgeon discretion. Inverse Probability of Treatment Weighting controlled for temporal adoption bias and confounders. Primary outcome was hematoma requiring surgical intervention within 30 days; isolated ecchymosis without palpable collection was not classified as hematoma. RESULTS: TXA adoption increased from 7.0% (2019) to 93.0% (2025). After achieving covariate balance (all SMD <0.2), procedure-specific effects emerged. In reduction mammaplasty, TXA significantly reduced hematoma (2.2% vs 7.2%; adjusted OR 0.28, 95% CI 0.14-0.58, p<0.001; NNT=20). Explantation with mastopexy showed similar benefit (1.6% vs 6.0%; OR 0.42, 95% CI 0.20-0.88, p<0.001). Primary augmentation demonstrated no statistically detectable difference (1.2% vs 1.2%; OR 0.94, 95% CI 0.36-2.42, p=0.905), regardless of implant plane. No thromboembolic events occurred. Surgical site infection showed a nominally significant difference (OR 0.47, p=0.02) but should be considered exploratory given small event counts and absence of a plausible biological mechanism. Seroma and wound dehiscence showed no significant differences. CONCLUSIONS: TXA efficacy is procedure-dependent. It provides significant protection in reduction mammaplasty and mastopexy involving extensive parenchymal dissection, but shows no statistically detectable benefit in primary augmentation. These findings support procedure-specific practice guidance rather than universal prophylaxis.
BACKGROUND: Many African American patients who undergo rhinoplasty prefer to maintain their ethnic characteristics rather than aim toward Euro-Western ideals. Effective communication of these preferences is paramount dur...BACKGROUND: Many African American patients who undergo rhinoplasty prefer to maintain their ethnic characteristics rather than aim toward Euro-Western ideals. Effective communication of these preferences is paramount during the preoperative consultation for these unique cases. The aim of this study is to investigate whether recent advances in Artificial Intelligence (AI) 3D morphing, with the ability to plan rhinoplasty based on patient preferences, offer improved outcomes. METHODS: Rhinoplasty patients who emphasized ethnic considerations (based on a validated survey) underwent either preoperative 1) Deep Surface AI Morphing or 2) No morphing to communicate their preferences (n=392). Surveys were used to record patient-reported aesthetic outcomes and to record psychosocial indicators. Perioperative complications, long term stability (1-year), need for revisions, were compared (Student's t-test). RESULTS: 'AI Morphing' vs. 'No Morphing' cohorts operated on sequentially, had equal numbers (n=392), with similar: demographics, operative techniques, and complications (2% vs. 3%), but AI Morphing revisions were less (8% vs. 19%). Operative techniques included variations in upper vault narrowing, dorsal onlay grafts, spreader grafts, septal extension grafts, tip grafts, alar base resection, lateral wall osteotomy, and the use of cadaveric grafts. 'AI Morphing' patients had greater improvement in aesthetic scores (3.2+0.4 vs. 2.0+0.3) and in psychosocial indicators: Anxiety (-8.4 vs. -5.2), Depression (-7.8 vs. -1.3), and Meaning and Purpose (+4.9 vs. +1.9). CONCLUSIONS: Rhinoplasty nasal reshaping using AI Morphing and cadaveric cartilage improves patient satisfaction scores and psychosocial outcomes.
BACKGROUND: Traditionally, autologous breast reconstruction with perforator free flaps utilizes a skin paddle to allow for clinical monitoring of the flap once transferred to the breast. With the advent of alternative fl...BACKGROUND: Traditionally, autologous breast reconstruction with perforator free flaps utilizes a skin paddle to allow for clinical monitoring of the flap once transferred to the breast. With the advent of alternative flap monitoring techniques, such as implantable dopplers, one may also completely deepithelialize and bury the flap in the native breast envelope, with no external component for monitoring. As buried flaps are not amenable to conventional monitoring, there is concern of flap failure going unnoticed for an extended period, drastically decreasing the chances of flap salvage. METHODS: A retrospective chart review was performed for all deep inferior epigastric perforator flap breast reconstructions done by the three senior authors from November 2017 to December 2021. Postoperative complications were compared between the buried and nonburied flap cohorts with total flap loss being the primary outcome. A propensity score matched model was created to help control confounding factors. RESULTS: A total of 404 DIEP flaps were included, with 299 in the non-buried group and 105 in the buried group. There was no statistically significant difference in total flap loss between the two groups (2.7% non-buried vs. 1.0% buried; p = 0.457). The non-buried group had a significantly higher 30-day readmission rate (9.0% vs. 1.0%; p = 0.003). Among patients undergoing nipple-sparing mastectomy, flap loss was significantly higher in the non-buried group (7.1% vs. 0%; p = 0.033), and breast dehiscence was more common in the buried group (5.8% vs. 0%; p = 0.038). However, these differences were no longer statistically significant after propensity score matching. In the matched cohort (n = 94), complication rates, including flap loss, takeback, infection, and readmission, were similar between buried and non-buried flaps. CONCLUSION: Completely buried flaps for autologous breast reconstruction demonstrated similar complication rates to flaps with a skin paddle, which opens the possibility of single-stage breast reconstructions.
Periorbital aging is driven by early, compartment-specific volume loss that is accentuated by the region's thin, soft tissue and complex retaining ligament network. This article presents a structured, anatomy-based appro...Periorbital aging is driven by early, compartment-specific volume loss that is accentuated by the region's thin, soft tissue and complex retaining ligament network. This article presents a structured, anatomy-based approach to periorbital fat grafting that targets five key anatomic regions: the tear trough, medial superior orbital rim, lateral brow, temple, and lateral canthal region. This technique provides a reproducible framework for safe and natural periorbital rejuvenation, either as a standalone procedure or in conjunction with blepharoplasty, browlift, and facelift surgeries.
BACKGROUND: . Autologous fat transfer (AFT) is a well-established technique for cosmetic breast augmentation and reconstructive breast procedures. Historically, however, graft retention has been highly variable. The Vial...BACKGROUND: . Autologous fat transfer (AFT) is a well-established technique for cosmetic breast augmentation and reconstructive breast procedures. Historically, however, graft retention has been highly variable. The Viality™ system (Tiger Aesthetics Medical, Conshohocken, PA) is an FDA-cleared, in-line fat processing device designed to concentrate viable adipocytes, improving retention. METHODS: . In this prospective, 14-center study (NCT05258305), 190 patients underwent AFT for cosmetic (n=85) or reconstructive (n=105) breast procedures. Harvested fat was processed with Viality and AuraClens™ surfactant wash. Volumetric analysis, based on 3D imaging, was performed at baseline and 1, 3, 6, and 12 months. Percentage retention and impact of patient factors on retention at 12 months were assessed. RESULTS: . Mean (95% CI) retention was 86.6% (85.4 to 87.7) at month 1, 83.1% (81.8 to 84.4) at month 3, 84.1% (82.8 to 85.5) at month 6, and 84.8% (83.2 to 86.5) at month 12. Mean retention was significantly greater at all timepoints than the historical benchmark of 70% (P <.0001) with no significant changes in retention over time. Similar trends were observed for reconstruction and cosmetic cohorts. Retention was affected by fat transfer volume (P<.0001), weight change (P<.0001), and graft-to-recipient breast volume ratio (P=.0187). CONCLUSIONS: . Early graft steady state, sustained high-percentage volume retention, and consistent results suggest that the Viality system is an effective, predictable modality for processing fat for cosmetic and reconstructive breast surgery, setting a new standard for sustained volume retention.
BACKGROUND: Autologous breast reconstruction using the Deep Inferior Epigastric Perforator (DIEP) flap is recognized as the gold standard in post-mastectomy reconstruction. Beyond restoring breast volume, DIEP flap techn...BACKGROUND: Autologous breast reconstruction using the Deep Inferior Epigastric Perforator (DIEP) flap is recognized as the gold standard in post-mastectomy reconstruction. Beyond restoring breast volume, DIEP flap techniques may also contribute to overall body aesthetics and psychological recovery, especially when combined with abdominal contouring and contralateral symmetrisation procedures. This paper aimed to evaluate clinical, aesthetic, and psychological outcomes of immediate DIEP flap breast reconstruction, with a specific focus on global body image, satisfaction, and Appearance Investment (AI), exploring the concept of a "DIEP Mommy Makeover" approach. METHODS: A retrospective cohort study was conducted on 73 patients undergoing immediate DIEP flap reconstruction between 2019 and June 2024. Outcomes were assessed using validated tools: BREAST-Q (breast satisfaction), BODY-Q (body and abdominal satisfaction), and ASI-R (Appearance Investment) at baseline, 6 and 12 months. Multivariable regression analyses identified predictors of outcomes. RESULTS: Significant improvements were observed across all BREAST-Q and BODY-Q domains at 12 months (p < 0.001). AI scores increased from 41.2 ± 11.8 to 61.3 ± 13.2 (p < 0.001). Combined contouring procedures and NAC reconstruction were strong positive predictors, while complications, radiotherapy, and higher BMI negatively influenced outcomes. CONCLUSION: Immediate DIEP flap breast reconstruction, when integrated with aesthetic procedures, offers holistic benefits beyond oncologic restoration. The "DIEP Mommy Makeover" approach enhances patient satisfaction with body image and self-perception, underscoring the importance of aesthetic considerations in reconstructive planning to support both physical and psychological recovery.
BACKGROUND: Reconstruction of nasal defects can prove challenging for plastic surgeons, requiring consideration of both aesthetics and function. While many reconstructive techniques exist, the study of biologic agents in...BACKGROUND: Reconstruction of nasal defects can prove challenging for plastic surgeons, requiring consideration of both aesthetics and function. While many reconstructive techniques exist, the study of biologic agents in nasal reconstruction remains limited. METHODS: We conducted a retrospective review of patients who underwent nasal reconstruction using a biologic wound healing agent (Integra or ACell) from 2013 to 2023 performed by the senior author (J.F.T.). Data was collected and analyzed regarding patient demographics, defect characteristics, reconstructive modality, revisions, and complications. RESULTS: A total of 138 patients underwent nasal reconstruction using Integra or ACell. The ala was the most commonly affected subunit (25.4 percent), and the mean defect size was 6.9 cm 2. ACell was the most common biologic used for reconstruction (73.2 percent). The overall complication rate was 6.5 percent (n = 9), ranging from scar retraction to biologic loss. There were no statistically significant differences in complication rates among patients over 75 years of age, those with a history of cigarette smoking, or those on anticoagulation. Additionally, defect size and location did not significantly impact complication rates. CONCLUSIONS: Nasal reconstruction requires consideration of numerous patient and defect variables. Compared to a multi-staged reconstructive procedure, biologic agents offer a simpler, well-tolerated, and effective alternative. This study supports the reliability of biologic agents in nasal reconstruction, including in high-risk populations such as elderly patients, smokers, and those on anticoagulation therapy.
METHODS: Time-trend analysis of 5,113 consecutive free flaps (1981-2023) from a single surgeon at Chang Gung Memorial Hospital, using segmented regression and joinpoint modelling. RESULTS: 5,113 free flaps included 1,927...METHODS: Time-trend analysis of 5,113 consecutive free flaps (1981-2023) from a single surgeon at Chang Gung Memorial Hospital, using segmented regression and joinpoint modelling. RESULTS: 5,113 free flaps included 1,927 ALT, 946 fibula, 1,010 toe transfers, 469 radial, 232 latissimus dorsi and 67 gracilis. INNOVATIONS: ALT introduction was associated with explosive growth (+ 21 flaps/year; p=.003, 1996 to 1999) and rapid substitution of competing soft tissue flaps, with declines in LD, gracilis, and radial forearm. Fibula showed a much slower uptake, with joinpoint models showing moderate growth (+ 2.13 flaps/year; P<.001) until repurposing for mandible reconstruction in 1989. This subsequently correlated with increased site-specific use and tracking of oral cancer incidence (incidence rate ratio = 1.05, p <0.001). LEGISLATION: Toe transfers declined after national Safety Legislation in 1991, with a 4-year lag (-33.7, P<.001). CONCLUSIONS: Microsurgical practice evolves through both technical advances and external forces such as health policy. The contrasting trajectories of the ALT and fibula flaps highlight how innovations reshape reconstructive practice differently. External drivers such as legislation can impact on microsurgical need such as toe transfers. Together these underscore the need for long-range horizons in surgical planning, and the need for intepreting time-trends alongside epidemiological shifts and health policy.
BACKGROUND: Gender-affirming mastectomy has been shown to significantly improve body image, quality of life, and psychosocial functioning among transmasculine individuals in the immediate postoperative period. However, f...BACKGROUND: Gender-affirming mastectomy has been shown to significantly improve body image, quality of life, and psychosocial functioning among transmasculine individuals in the immediate postoperative period. However, few studies have examined the persistence of patient-reported outcomes over time. Thus, this study aimed to evaluate chest satisfaction and quality of life several years following gender-affirming mastectomy. METHODS: A cross-sectional patient-reported outcome measure survey study was conducted from February 2022 to July 2022 among individuals who were greater than two-years postoperative from gender-affirming mastectomy. The primary outcomes were scores on the BODY-Q Chest and Nipples scales and the Gender Congruence and Life Satisfaction (GCLS) Chest, Psychological Functioning, and Life Satisfaction subscales. RESULTS: Of the 237 patients surveyed, 152 individuals completed the survey instrument (64% response rate). Responders' median current age was 31 years old, with a median time since surgery of 3.4 years. Responders reported high satisfaction with chest and nipple appearance, reflected in median BODY-Q Chest and Nipples scores of 87/100 and 90/100, respectively. GCLS scores were similarly high, with medians of 5.0/5.0 for Chest, 4.8/5.0 for Psychological Functioning, and 3.9/5.0 for Life Satisfaction. CONCLUSIONS: Gender-affirming mastectomy is associated with high chest appearance satisfaction, psychological functioning, and life satisfaction several years after surgery. These findings affirm the persistent benefits of GAM and offer valuable evidence for patients, providers, and policymakers. Future research should include multi-center, prospective studies with extended follow-up to further evaluate the long-term effects of gender-affirming surgical interventions.
Postoperative dressings play a critical yet underappreciated role in implant-based breast reconstruction outcomes. We describe a simple, reproducible transparent film (Tegaderm™, 3M TM, St. Paul, MN) "bra" dressing for p...Postoperative dressings play a critical yet underappreciated role in implant-based breast reconstruction outcomes. We describe a simple, reproducible transparent film (Tegaderm™, 3M TM, St. Paul, MN) "bra" dressing for prepectoral breast reconstruction to stabilize the mastectomy flap, promote adherence of acellular dermal matrix, and reduce seroma and reoperation rates. The method leverages semi-occlusion, antimicrobial coverage, moisture regulation, gentle compression and structural support to optimize healing and patient comfort. Patients maintain the dressings until postoperative follow-up without external bras, reducing variability in wound care. This dressing is cost-neutral and integrates seamlessly into existing workflows, making it a practical innovation for standardizing postoperative management in prepectoral breast reconstruction.
Deep Inferior Epigastric Perforator (DIEP) flap is the most common form of autologous breast reconstruction. Enhanced recovery protocols often include transversus abdominis plane (TAP) blocks using liposomal bupivacaine,...Deep Inferior Epigastric Perforator (DIEP) flap is the most common form of autologous breast reconstruction. Enhanced recovery protocols often include transversus abdominis plane (TAP) blocks using liposomal bupivacaine, but cost limits use. Dexamethasone added to bupivacaine is a low-cost strategy to prolong block duration. We compared the efficacy of liposomal bupivacaine to bupivacaine with dexamethasone for TAP blocks in DIEP patients. A retrospective single-institution study (2018-2023) of DIEP patients receiving intraoperative, ultrasound-guided TAP blocks were identified and divided into two: Group 1 (commercially-available liposomal bupivacaine) and Group 2 (30 mL 0.25% bupivacaine + 1 mg dexamethasone). Outcomes included length of stay (LOS), total post-operative morphine milligram equivalents (MME), and Numeric Pain Rating Scale scores. Demographics were assessed and p<0.05 were considered significant. Among 178 patients (Group 1: 95; Group 2: 83), there was no difference in age, BMI>30 kg/m 2, smoking status, laterality, perforator selection, and wound complications across cohorts. Group 2 had a shorter LOS (2.88 days vs 3.49 days; p<0.001), lower total post-operative MME usage (70.6 ± 60.0 vs 104.7 ± 72.8; p<0.001), and lower pain scores (3.44 ± 1.50 vs 4.53 ± 1.57; p<0.001) on post-operative day one compared to Group 1. No differences were noted in pain scores on subsequent post-operative days (POD 2, 3, 4). TAP blocks using dexamethasone with bupivacaine added may represent a cost-effective and clinically effective alternative approach for post-operative pain management during DIEP flap breast reconstruction compared to commercially marketed liposomal bupivacaine.