BACKGROUND: Due to the variability in the technique and risk of complications for Intramuscular fat grafting, there is a need for a standardized approach. We are introducing a new scoring system, designed to guide surgeo...BACKGROUND: Due to the variability in the technique and risk of complications for Intramuscular fat grafting, there is a need for a standardized approach. We are introducing a new scoring system, designed to guide surgeons in performing intramuscular fat grafting safely and effectively. METHODS: We conducted a retrospective review of patient records from January 2020 to December 2024. The inclusion criteria encompassed all patients who underwent fat grafting as part of High-Definition Liposuction (HDL). Complications were analyzed based on their occurrence. The GRAFT Scoring system was developed through inter-rater agreement among four evaluators, followed by the creation of a postoperative evaluation protocol for fat grafting, incorporating ultrasound imaging. RESULTS: A total of 1,284 muscle groups from 651 consecutive patients were analyzed. Of these, 511 cases were women, while 140 cases were men. Median age of the cohort was 37 years (IQR 11, 18-59 years), with a median BMI of 24.2 kg/m² (IQR 3.8, 17.7-33.3 kg/m²). Muscles were classified into four categories-Low Risk, Moderate Risk, High Risk, and Prohibited-based on the scoring system. The protocol for postoperative adipose graft evaluation was based on the reported complications and the overall aesthetic outcomes. CONCLUSION: GRAFT Score provides a structured, user-friendly method to classify muscles for intramuscular fat grafting, emphasizing safety and precision. By simplifying risk categories, this system facilitates decision-making, reduces complications, and enhances patient outcomes. A standardized protocol for postoperative fat grafting evaluation is a promising tool to standardize future studies.
OBJECTIVE: This study assessed the long-term outcome of secondary gingivoperiosteoplasty (GPP) and alveolar bone grafting (ABG) in unilateral and bilateral alveolar cleft groups during mixed dentition. METHODS: This retr...OBJECTIVE: This study assessed the long-term outcome of secondary gingivoperiosteoplasty (GPP) and alveolar bone grafting (ABG) in unilateral and bilateral alveolar cleft groups during mixed dentition. METHODS: This retrospective study included patients with complete unilateral and bilateral alveolar clefts who underwent either secondary GPP or secondary ABG from 2014 to 2020, with a minimum follow-up of five years. The outcomes were measured using Bergland and Witherow's scales in both occlusal and cone-beam computed tomography (CBCT) scans. RESULTS: A total of one hundred patients participated in the study, which included 126 sites. The GPP comprised 57 patients (38 with unilateral and 19 with bilateral), while the ABG included 43 patients (36 with unilateral and 7 with bilateral). When comparing outcomes between treatment groups, no statistically significant difference was observed in the success rates in the unilateral groups (p = 0.755). However, a statistically significant difference was identified between the GPP and ABG groups in bilateral cases (p = 0.006). CONCLUSION: Secondary gingivoperiosteoplasty provides reliable long-term outcomes in selected patients with alveolar clefts, especially in unilateral cases. Both GPP and secondary alveolar bone grafting are effective when appropriately indicated, though direct comparisons between the techniques should be interpreted cautiously, given differences in case selection.
BACKGROUND: Free nipple grafting (FNG) has been long reported as a viable alternative for aesthetic results and patient satisfaction in the setting of reduction mammaplasty in severe macromastia. This study demonstrates...BACKGROUND: Free nipple grafting (FNG) has been long reported as a viable alternative for aesthetic results and patient satisfaction in the setting of reduction mammaplasty in severe macromastia. This study demonstrates that FNG concepts used for reduction mammaplasty can be applied to autologous reconstruction following mastectomies in patients who do not qualify for traditional nipple sparing mastectomies. METHODS: A retrospective chart review was performed at two institutions for patients who underwent immediate autologous breast reconstruction with simultaneous FNG by the senior author (K.M.P.). Patient information collected included age, gender, BMI, and follow-up time. Recorded outcomes included nipple survival, depigmentation, revision and post-surgical complications. RESULTS: A total of 45 patients underwent a total of 73 nipple grafts. The population mean age, BMI and follow-up were 52.7 years, 28.8 kg/m 2 and 359.81 days respectively. 39 patients (60 breasts) underwent autologous breast reconstruction using deep inferior epigastric perforator (DIEP) flap (18 unilateral, 42 bilateral). 1 patient underwent right-sided DIEP with contralateral TRAM flap, and 1 patient underwent bilateral pedicled latissimus dorsi flaps.100% of nipple grafts survived with no NAC graft or breast flap loss. 15 patients experienced minor postoperative complications including 7 patients with partial thickness graft necrosis. 3 patients with 4 FNGs demonstrated depigmentation. 4 patients requested additional revision. CONCLUSIONS: FNG offers a viable alternative alongside reconstruction as it preserves a natural NAC appearance compared to nipple reconstruction with or without tattooing. While FNG limitations persist, it remains a safe and cosmetically beneficial option for patients with limited nipple preservation choices.
BACKGROUND: We investigated the association between Chiari-I-Malformation (CM1) and all types of lambdoid-involved craniosynostosis, aiming to distinguish the impact of suture fusion from underlying diagnosis. METHODS: W...BACKGROUND: We investigated the association between Chiari-I-Malformation (CM1) and all types of lambdoid-involved craniosynostosis, aiming to distinguish the impact of suture fusion from underlying diagnosis. METHODS: We conducted a retrospective cohort study of lambdoid craniosynostosis patients born between 2000 and 2024. Patients were classified as clinically non-syndromic or syndromic, the later subdivided into 'known craniosynostosis syndromes' (e.g., Crouzon/Pfeiffer, Apert), 'syndromic other' (e.g., ZIC1, HUWE-1), and clinically syndromic (without known mutation). RESULTS: Of 2341 patients with craniosynostosis, 133 had lambdoid involvement: 22 had isolated unilambdoid synostosis (11 non-syndromic, 11 syndromic), 4 had isolated bilambdoid synostosis (all syndromic), and 107 had multisuture synostosis (13 non-syndromic, 94 syndromic). All but 17 underwent early vault expansion; foramen magnum decompression was not routinely performed.CM1 occurred in 2/22 (9%) with isolated unilambdoid synostosis, 9/23 (39%) with multisuture synostosis with unilambdoid involvement, and 38/88 (43%) with bilambdoid involvement.Among multisuture cases, CM1 developed in 6/10 clinically syndromic, 6/12 'syndromic other', 6/13 non-syndromic, and 29/69 (42%) known craniosynostosis syndromes (including 23/49 (47%) Crouzon/Pfeiffer).Ultimately, 12/49 (24%) CM1-patients received CM1-associated surgery (2 clinically syndromic, 8 Crouzon/Pfeiffer, 2 'syndromic other'). CONCLUSIONS: Baseline MRI for CM1 screening appears not indicated in unisutural unilambdoid synostosis, regardless of syndromic diagnosis. Baseline MRI seems indicated for all multisuture cases with lambdoid involvement. Follow-up imaging may be limited to symptomatic patients, provided routine consultation with counseling on warning signs is done. The need for CM1-associated surgery appears more related to the underlying diagnosis than to the lambdoid fusion's impact on skull growth alone.
Infragluteal deformities are a challenging complication following liposuction, particularly when injury occurs to the fibrous osteocutaneous bands of the gluteal crease. Various surgical solutions have been proposed, inc...Infragluteal deformities are a challenging complication following liposuction, particularly when injury occurs to the fibrous osteocutaneous bands of the gluteal crease. Various surgical solutions have been proposed, including autologous fat grafting, skin-lifting procedures, and flap reconstructions, yet a consistent, scar-free, and minimally invasive technique remains elusive. In this report, we present a new modified net suture technique, inspired by the hemostatic net used in aesthetic facial surgery, as a promising treatment for post-liposuction infragluteal deformities. After aggressive power-assisted liposuction to detach mispositioned adhesions within the gluteal crease, we apply a transcutaneous continuous-running suture using non-absorbable nylon, fixed along the newly established crease. The suture is laid loosely to preserve skin perfusion, cushioned by an ointment dressing, and supported with external compression. The technique is completed in approximately 15 minutes, with suture removal on postoperative day 4. In our experience, this approach leads to aesthetically satisfactory outcomes, restores gluteal symmetry, and avoids the formation of additional scars. Our technique is simple, cost-effective, and preserves lymphatic and vascular integrity. This manuscript describes our methodology, rationale, and early clinical observations supporting this low-risk intervention.
Reconstructing the dorsum in revision rhinoplasty remains a complex challenge. Traditional methods such as solid rib grafts and diced cartilage fascia (DCF) grafts present significant limitations, including warping, disp...Reconstructing the dorsum in revision rhinoplasty remains a complex challenge. Traditional methods such as solid rib grafts and diced cartilage fascia (DCF) grafts present significant limitations, including warping, displacement, and insufficient dorsal definition. First devised in 2017, the SPLF (sandwich of perichondrium-lamina-fascia) graft has now become well-established in the senior author's practice as a refined, versatile, and customizable approach for dorsal reconstruction. This construct integrates seamlessly with native tissues, providing smooth contours, well-defined dorsal aesthetic lines (DAL) and consistent long-term results. Unlike conventional grafting techniques, the SPLF graft allows intraoperative adaptability, offering real-time customization of height, contour and lateral continuity through a multilayered design. In recent years, the SPLF graft as originally described has been progressively refined through variations in lamination thickness, shape and extensions, as well as the implementation of additional laminations and the innovative use of "rib plaster" for enhanced customization. These refinements have further legitimized its role as a cornerstone in revision rhinoplasty, providing surgeons with a predictable, stable and natural-looking solution for dorsal augmentation. Level of evidence: V.
BACKGROUND: Endoscopic brow lift surgery is increasingly performed, yet there are concerns about potential increase in forehead height and hairline position postoperatively. We believe one of the main factors in determin...BACKGROUND: Endoscopic brow lift surgery is increasingly performed, yet there are concerns about potential increase in forehead height and hairline position postoperatively. We believe one of the main factors in determining forehead height is the effect of frontalis muscle contraction. This study aims to investigate perceived changes in forehead dimensions following endoscopic brow lift surgery by using a closed-eye model that effectively eliminates frontalis muscle contraction and utilizing an artificial intelligence technique for precise measurement to assess whether forehead is indeed enlarged after this procedure. METHODS: A total of 35 patients who underwent endoscopic brow lift surgery were analyzed using the SPIGA model for facial landmark detection. Preoperative and postoperative measurements of forehead height and brow position were taken in both open and closed-eye states. Statistical analyses were conducted to compare these measurements. RESULTS: Significant increases in forehead height were observed postoperatively in the open-eye state (P＜0.001). However, no significant changes in forehead height were noted in the closed-eye state (P>0.05), indicating that the forehead itself does not elongate postoperatively. The perceived increase in forehead size is attributed to the comparison of contracted preoperative states with relaxed postoperative states. CONCLUSIONS: Endoscopic brow lift surgery does not inherently cause an increase in forehead size. The perception of elongation is likely due to the relaxation of the frontalis muscle post-surgery. The integration of AI in measuring facial changes offers a promising avenue for future research.CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
BACKGROUND: Achieving adequate analgesia in patients undergoing vaginoplasty facilitates early ambulation, reduces postoperative morbidity and increases patient satisfaction. This study evaluated the use of intraoperativ...BACKGROUND: Achieving adequate analgesia in patients undergoing vaginoplasty facilitates early ambulation, reduces postoperative morbidity and increases patient satisfaction. This study evaluated the use of intraoperative nerve blocks (transverse abdominis plane [TAP] block and perineal block) in reducing postoperative pain and decreasing opioid use in robotic-assisted peritoneal flap vaginoplasty. METHODS: A prospective cohort study of 150 consecutive adult patients undergoing robotic peritoneal flap vaginoplasty performed by the senior authors was conducted at a single institution from December 2023 to October 2024. 75 consecutive patients who did not receive a block and 75 consecutive patients who did receive blocks were included based upon power analysis calculations with assumptions yielding 99% power. Demographic data as well as multimodal analgesic use was compared between groups with respect to use during the preoperative, intraoperative, and post anesthesia phases of care, as well as on each day of inpatient admission. RESULTS: Groups did not differ significantly in baseline characteristics. Block-treated patients demonstrated a significantly reduced total opioid requirement throughout their hospital stay, inclusive of intraoperative and perioperative dosing, as measured in total morphine milligram equivalents (MME) (median 675 versus 26 MME; p < 0.001). Block-treated patients required almost no oxycodone or hydromorphone after surgery with a median oxycodone dose of 0 mg compared with 33 mg in controls (p < 0.001); their total median hydromorphone dose was 0.4 mg versus 1.2 mg (p < 0.001). CONCLUSIONS: The block intervention achieved a dramatic reduction in total postoperative opioid use (oral and intravenous) throughout the hospital stay.
INTRODUCTION: Hand injuries impose financial burdens that can delay care and impact outcomes. However, there is a lack of information about the impact of different patient, injury, and health system factors that drive pa...INTRODUCTION: Hand injuries impose financial burdens that can delay care and impact outcomes. However, there is a lack of information about the impact of different patient, injury, and health system factors that drive patient out-of-pocket (OOP) expenses. METHODS: We performed a retrospective study (2016-2023) examining patients with surgically treated hand trauma. Patients were separated into two cohorts based on their treatment hospital (public safety-net and private community hospital). OOP expenses at 3-, 6-, and 12-months post-operatively were collected. Generalized linear models examined the effects of patient characteristics on cumulative 12-month OOP expenses. RESULTS: There were 819 patients treated at the public safety-net hospital and 313 patients at the private community hospital. At the public safety-net hospital, 72% of patients were enrolled in the Financial Assistance Program while 20% were enrolled in commercial insurance. At the private community hospital, 74% of patients had commercial insurance and 26% had Medicare/Medicaid. Twelve-month OOP expenses at private community hospital were 37% of the expenses compared to the public safety-net hospital (95% CI: 0.29-0.46). Patients with commercial insurance had higher predicted 12-month OOP expenses at both hospital systems (safety-net: $2,835, 95% CI: $2161-$3720; private: $1,036, 95% CI: $790-$1361) compared to Medicare/Medicaid (safety-net: $1,590, 95% CI: $1160-$2180; private: $352, 95% CI: $258-$483). CONCLUSION: OOP expenses after surgical intervention for hand trauma were associated with insurance coverage and hospital setting, rather than patient or injury specific factors. These findings highlight the need for policies that promote price transparency and protect patients from financial burden after hand trauma.
BACKGROUND: Trapeziectomy with Ligament Reconstruction and Tendon Interposition (LRTI) is a key treatment for thumb carpometacarpal (CMC-1) osteoarthritis (OA). Despite proven effectiveness, concerns remain about the nee...BACKGROUND: Trapeziectomy with Ligament Reconstruction and Tendon Interposition (LRTI) is a key treatment for thumb carpometacarpal (CMC-1) osteoarthritis (OA). Despite proven effectiveness, concerns remain about the need for revision surgery and its impact on long-term outcomes. Current literature lacks data on long-term rates of additional surgery. Therefore, this study evaluates long-term outcomes of trapeziectomy with LRTI in CMC-1 OA, focusing on revision rate. METHODS: This multicenter prospective cohort study included patients who underwent trapeziectomy with LRTI (Weilby-sling, Burton-Pellegrini, or APL-sling) for CMC-1 OA between December 2011 and October 2021. The primary outcome was the rate of additional surgery beyond one year following LRTI, focusing on revision surgery. Secondary outcomes included prognostic factors for revision surgery, and long-term patient-reported outcomes (PROMs). Additionally, the impact of revision surgery on PROMS was assessed. RESULTS: A total of 1369 patients were included, with a median follow-up of 7.8 years (range 3.1 to 13.0 years), of which 13% (95% Confidence Interval (CI): 11.3% to 14.9%) underwent additional surgery beyond one year. Revision surgery was required in 2.6% (95% CI: 1.7% to 3.5%). The APL-sling technique and younger age were associated with higher revision rates. PROMs improved significantly between 12 months and long-term follow-up, with revision surgery being associated with worse outcomes. CONCLUSIONS: Long-term follow-up revealed a 13% additional surgery rate, with 2.6% requiring revision surgery. We suggest that the APL-sling should be approached with caution. In younger patients, alternative treatments should be considered to postpone LRTI surgery and reduce revision risk.Level of evidence: Therapeutic, II.
BACKGROUND: Raynaud's phenomenon (RP) encompasses vasospastic disorders that can progress to digital ischemia, ulceration, and tissue loss. Despite multiple therapeutic options, variability in diagnostic evaluation and p...BACKGROUND: Raynaud's phenomenon (RP) encompasses vasospastic disorders that can progress to digital ischemia, ulceration, and tissue loss. Despite multiple therapeutic options, variability in diagnostic evaluation and procedural indications can delay appropriate treatment. This review summarizes current evidence on RP and presents a structured diagnostic pathway and treatment algorithm for patients with vasospastic disease and digital ischemia. METHODS: A review of contemporary literature on the epidemiology, pathophysiology, diagnostic studies and therapeutic interventions for RP was collected. Additionally, we describe our institution's algorithm which integrates noninvasive vascular diagnostics, catheter angiography with vasodilation challenges and a stepwise approach to procedure selection based on patterns of vasospasm and occlusion. RESULTS: Primary RP is a vasospastic disorder whereas secondary RP involves vasospasm and fixed occlusive disease. Noninvasive studies help assess wound healing potential and abnormal results will lead to an interventional radiology consultation for catheter angiography. Angiography defines the level of disease, responsiveness to vasodilators and suitability for intervention. Interventions include chemical and mechanical sympathectomy which is most suitable in patients with vasospastic disease and less effective in secondary RP. Patients with segmental occlusions and patent distal targets or with secondary RP will benefit from open arterial bypass or arterial reconstruction. Patients with disease isolated to the proper digital arteries are not amenable to targeted surgical interventions due to the risk of worsening ischemia. CONCLUSIONS: A structured, physiology-guided diagnostic and treatment algorithm can improve the precision of RP management. Integrating noninvasive testing with angiography allows tailored use of sympathectomy and reconstruction in these patients.
BACKGROUND: Diabetic foot ulcers (DFUs) frequently lead to infections, amputations, and reduced quality of life, and limb salvage through flap reconstruction plays a crucial role in treatment. However, challenges arise i...BACKGROUND: Diabetic foot ulcers (DFUs) frequently lead to infections, amputations, and reduced quality of life, and limb salvage through flap reconstruction plays a crucial role in treatment. However, challenges arise in cases requiring soft tissue to cover the metatarsal head or dead space above the amputation stump. This study aims to assess the importance and effectiveness of mini free flap reconstruction for small DFUs to prevent further amputations and preserve foot length. METHODS: A retrospective review was conducted of patients with DFUs who underwent mini free flap reconstruction. Preoperative evaluation included computed tomography angiography and high-frequency ultrasonography to assess recipient vessel status and guide flap design. Mini free flaps were harvested and anastomosed to recipient vessels selected from smaller distal arteries rather than major vessels. RESULTS: A total of 20 patients underwent mini free flap reconstruction. The average wound size was 6.8 cm 2 . The mini flap types included superficial circumflex iliac artery perforator, superficial inferior epigastric artery, anterior tibial artery, and peroneal artery perforator flaps, with an average pedicle length of 6.9 cm and an average artery diameter of 1.4 mm. Recipient vessels used included the dorsal metatarsal artery, arcuate artery, medial and lateral tarsal arteries, and digital artery, with an average diameter of 1.5 mm. CONCLUSIONS: Mini free flap reconstruction is an effective solution for small DFUs, offering a reliable method for foot salvage. By using advanced imaging techniques for precise vessel and flap selection, this approach ensures optimal flap survival and improves quality of life by avoiding unnecessary amputations.
BACKGROUND: The rise of artificial intelligence (AI) and large language models in academic writing has raised concerns regarding research integrity and authorship transparency. This study evaluated the prevalence of AI-g...BACKGROUND: The rise of artificial intelligence (AI) and large language models in academic writing has raised concerns regarding research integrity and authorship transparency. This study evaluated the prevalence of AI-generated content in plastic surgery publications following the release of ChatGPT. METHODS: We conducted a cross-sectional study of 1,627 manuscripts published in 10 major plastic surgery journals between January 2024 and May 2025. ZeroGPT was used to quantify AI-generated content. A baseline threshold for substantial AI involvement (22.5%) was established using 300 pre-ChatGPT manuscripts (2010-2011). Outcomes included the proportion of manuscripts exceeding this threshold, average AI content, and associations with publication year, journal, and evidence level. RESULTS: Overall, 21.5% of 2024-2025 articles exceeded the threshold for substantial AI involvement. The median proportion of AI-generated text rose from 7.4% in 2024 to 12.2% in 2025, while the percentage of manuscripts with substantial involvement increased from 17% to 29%. AI involvement varied widely across journals (0-41%). In multivariable analysis, 2025 publication year (OR 1.86, p<0.001) and certain journals were independently associated with substantial AI involvement. Higher evidence level studies demonstrated greater AI involvement, with Level 4 studies showing significantly lower odds than Level 1 (OR 0.47, p=0.001). CONCLUSION: More than one in five recent plastic surgery manuscripts contain substantial AI involvement, with marked variation across journals and evidence levels. These findings highlight the need for standardized editorial guidelines governing AI use to maintain research integrity and transparency in plastic surgery literature.
BACKGROUND: The objectives of this study were to determine if financial considerations affect reconstructive decision-making, and conversely if reconstructive choice affects downstream financial burden. METHODS: We condu...BACKGROUND: The objectives of this study were to determine if financial considerations affect reconstructive decision-making, and conversely if reconstructive choice affects downstream financial burden. METHODS: We conducted mixed-methods study with a convergent design. Patients undergoing mastectomy with or without reconstruction were administered the Comprehensive Score for Financial Toxicity (COST) questionnaire before and after surgical treatment, where COST ≤20 indicated financial toxicity (FT). Multivariable regression models were used to identify predictors of FT and changes in COST score. Additionally, we conducted semi-structured interviews with patients who screened positive for FT to comprehensively capture experiences with financial burden. RESULTS: There were 1,029 patients with a COST score prior to mastectomy, with a 30.6% rate of FT. Significant predictors of FT included age (OR 0.97), race (Asian OR 2.12, Black OR 2.66, compared to White), marital status (divorced/separated OR 2.70, single OR 2.43, compared to partnered), and neighborhood-level socioeconomic deprivation (OR 1.15) (p<0.02). Receipt of reconstruction was not significantly associated with baseline FT, nor were type and timing among those who underwent reconstruction (N=739). Additionally, receipt, type, and/or timing of reconstruction were not significantly associated with a change in COST score (full cohort N=446, reconstruction cohort N=297). Interviews yielded 3 themes: prioritizing outcomes over financial implications, difficulties navigating and maintaining insurance coverage, and a need for greater transparency and access to financial resources. CONCLUSION: Bidirectional relationships between FT and receipt, type, and timing of reconstruction did not reach statistical significance. Additional patient-centric financial navigation and price transparency are warranted to mitigate financial burden.
BACKGROUND: The impact of socioeconomic status on completion of cleft lip and palate (CLP) care is poorly understood. We examined the association between socioeconomic factors and both completion and timing of LeFort I a...BACKGROUND: The impact of socioeconomic status on completion of cleft lip and palate (CLP) care is poorly understood. We examined the association between socioeconomic factors and both completion and timing of LeFort I advancement, one of the final surgeries in the cleft care pathway. METHODS: We conducted a multi-institutional retrospective study of CLP patients > 18 years of age recommended for LeFort I advancement between 1991-2024. Addresses were geocoded and linked to four socioeconomic indices: Social Vulnerability Index, Vizient Vulnerability Index, Child Opportunity Index, and Area Deprivation Index. Multi-variable logistic regression models evaluated associations between socioeconomic indices and surgical completion. Multi-variable linear regression models assessed associations between scores and age at surgery among patients who completed LeFort I advancement surgery, adjusting for clinical severity, insurance, travel distance, distraction osteogenesis, and program engagement duration. RESULTS: Of the 184 CLP patients [median age at review 29.1 (IQR 20.4;32.3) years], 127 (69%) underwent LeFort I advancement and 57 (31%) did not complete surgery. Patients who did not undergo surgery demonstrated consistently greater vulnerability or lower opportunity across indices. Household composition vulnerability independently predicted foregoing surgery (adjusted OR 4.6-14.7 depending on geospatial scale, p<0.05). Among patients who underwent LeFort I, socioeconomic vulnerability was associated with older age at surgery. Transportation vulnerability, in particular, was found to independently delay surgery by 1.4-8.7 years per unit increase depending on index and geospatial scale, while greater neighborhood wealth was associated with earlier surgery. CONCLUSIONS: Socioeconomic disadvantage influences both completion and timing of LeFort I advancement.
BACKGROUND: The Reverse Sural Artery Flap (RSAF) supplied by distal peroneal perforators is a versatile local flap option for distal limb coverage. We describe perforator distribution in cadaveric dissections, and our cl...BACKGROUND: The Reverse Sural Artery Flap (RSAF) supplied by distal peroneal perforators is a versatile local flap option for distal limb coverage. We describe perforator distribution in cadaveric dissections, and our clinical experience with four novel modifications (perforator skeletonization, Achilles tendon release, tunneling under the Achilles tendon, proximal peroneal artery ligation) to allow greater reach for the RSAF. METHODS: 38 cadaveric legs were dissected to study the peroneal perforators. 12 patients from 5-73 years-old underwent RSAF and the proposed modifications for a variety of defects, including the medial foot and distal forefoot. RESULTS: From the cadaveric study, terminal peroneal perforator was at a mean distance of 10.96±3.67 cm above the malleolus. Only 10.6% of distal-most perforators were within the last 20% of the fibular length, or 6.76 cm from the malleolus. Clinical series findings were comparable, with adult distances of 9.31±1.80 cm. However, the pivot point was lower, at 6.67±1.59 cm, owing to perforator skeletonization and dissection off the Achilles in all cases, tunneling under the Achilles in four, and proximal peroneal artery ligation in one. Two had subsequent <10% distal tip necrosis and one 50% superficial epidermolysis, which healed with local care. CONCLUSIONS: The terminal peroneal perforator may lie higher than the 5 cm pivot point generally recommended for the RSAF. For these cases, perforator skeletonization, dissection off and/or tunneling under the Achilles tendon, and even proximal peroneal artery ligation can allow further reach of the RSAF to reliably cover distal defects including the medial foot and forefoot.
BACKGROUND: Although the Tajima overcorrection technique is used in primary rhinoplasty procedures at our institution, we have observed a recurring asymmetry problem in patients who undergo such procedures at around the...BACKGROUND: Although the Tajima overcorrection technique is used in primary rhinoplasty procedures at our institution, we have observed a recurring asymmetry problem in patients who undergo such procedures at around the age of approximately 1. Notably, this asymmetry appears to be minor and remains stable over time. The current study is a longitudinal analysis of outcomes following primary overcorrected rhinoplasty and provides insights into the long-term trajectory of nasal morphology after treatment. METHODS: This retrospective study examined a cohort of 146 patients with a nonsyndromic unilateral cleft lip who underwent cheiloplasty with primary Tajima overcorrected rhinoplasty at the Chang Gung Memorial Hospital Craniofacial Center between 2002 and 2003. A longitudinal analysis of nostril morphology was conducted using a series of digital photographs taken at five time points: 1 (T1), 5 (T2), 10 (T3), 15 (T4), and 18 (T5) years of age. Symmetry was assessed using anthropometric measurements, including nostril height, nostril base height, nostril width, nasal width and columella angle. RESULTS: Nostril asymmetry improved over time among both patients with a complete and incomplete unilateral cleft lip. Nostril height, nostril width, nasal width and columella angle significantly varied with time (P < 0.01), whereas nostril base height remained stable. CONCLUSIONS: Achieving adequate cleft-side nasal height during primary procedures is crucial. The current results can provide valuable guidance for surgeons regarding the optimal timing for secondary rhinoplasty, particularly in cases where primary outcomes are suboptimal.