Correction of the superiorly displaced nipple and areola complex (NAC) in patients who have undergone previous mastopexy or breast reduction presents as a difficult challenge. Previously described techniques are limited...Correction of the superiorly displaced nipple and areola complex (NAC) in patients who have undergone previous mastopexy or breast reduction presents as a difficult challenge. Previously described techniques are limited by restricted nipple mobility, an increased risk of vascular compromise, and potentially unfavorable aesthetic outcomes. A technique is presented that releases the superiorly malpositioned NAC from the surrounding breast flaps, keeping it attached to the underlying breast parenchyma. A vertically oriented skin incision is closed primarily, and the NAC is delivered into a new lower location situated at the apex of the breast mound. The new position of the NAC is easily accommodated as a result of the complete separation of the NAC from the surrounding breast parenchyma. The NAC maintains an adequate blood supply secondary to its remaining attachments to the underlying breast parenchyma and becomes freely mobile for delivery into a new location at any desired level. Using this strategy, an appropriate relationship between the position of the NAC and the breast mound is restored and well approximated skin closure above the NAC heals with a smooth contour with no dogear.
BACKGROUND: Facial wrinkles, characterizing cutaneous aging, involve multifactorial mechanisms such as dermal collagen fragmentation, elastin degeneration, and volume loss, which are often inadequately addressed by singl...BACKGROUND: Facial wrinkles, characterizing cutaneous aging, involve multifactorial mechanisms such as dermal collagen fragmentation, elastin degeneration, and volume loss, which are often inadequately addressed by single-modality treatments. This study aims to assess the efficacy and safety of a four-step injection strategy combining subcutaneous hyaluronic acid (HA) volume restoration, intradermal microdroplet HA, and selective botulinum toxin type A (BoNTA) for treating facial wrinkles. METHODS: In this retrospective study, 53 subjects with moderate-to-severe upper facial wrinkles (including glabellar lines, forehead lines, and crow's feet) received a standardized protocol: (1) cannulabased subcutaneous HA restoration; (2) intradermal microdroplet injection of diluted HA; (3) microdroplet diluted BoNTA along persistent rhytids; and (4) conventional BoNTA for dynamic wrinkles. Outcomes were evaluated via blinded physician assessments and patient questionnaires immediately, at 1 month, and at 12 months. RESULTS: All subjects completed follow-up. Physician ratings showed significant wrinkle improvement at 1 and 12 months (P<0.01). Patients reported high satisfaction and improved quality of life. No serious adverse events occurred; minor transient bruising resolved within two weeks, while all observed erythema resolved within one week. CONCLUSIONS: This four-step strategy, by concurrently targeting anatomical and kinetic causes of rhytids, offers a safe, effective, and durable approach to upper facial rejuvenation with high patient satisfaction.
BACKGROUND: Data is limited regarding the in-vivo behavior of fresh-frozen costal cartilage allografts (CCA). This study aims to evaluate retention and biological behavior of CCA in an immunocompetent mouse model. METHOD...BACKGROUND: Data is limited regarding the in-vivo behavior of fresh-frozen costal cartilage allografts (CCA). This study aims to evaluate retention and biological behavior of CCA in an immunocompetent mouse model. METHODS: Clinical-grade fresh-frozen CCA (MTF Profile ®) from 4 donors, subcutaneously implanted into 9 SKH-1 mice. Cartilage size and volume were evaluated at 2 and 6 weeks, and 3, 6, and 9 months, using clinical assessment, digital-caliper measures, and micro-CT scan volumetric analysis. Linear measurements, total volume, and volume of calcification were compared across time-points. After sacrifice, H&E staining was performed for comparison at 3, 6, and 9 months. RESULTS: There were no significant changes in cartilage implant length (p = 0.16), width (p = 0.21), or total volume (p = 0.9) across timepoints. Average volume of calcified cartilage increased from 1.1% to 10% of total volume (p<.001). Clinical assessment did not show evident change. Clinical assessment did not show overt changes in implant appearance. Histology demonstrated capsule formation without evidence of undue inflammatory response or resorption. CONCLUSIONS: This study evaluated the in-vivo behavior of new forms of CCA currently used in practice, with implications for clinical use in facial reconstruction. We found no significant resorption or morphologic changes in fresh-frozen CCA when implanted in an immunocompetent murine model at 9 months. Although reassuring for continued use and stability long-term, further work is needed to understand the impact of cartilage calcification.Clinical Relevance: Fresh-frozen CCA demonstrated structural stability and detail preservation with minimal to no resorption, when implanted in our immunocompetent mouse model over our 9-month study period. However, progressive calcification of the graft was also observed, which may impact superficial applications.
Primary thinning of bulky flaps in high-body mass index patients remain a significant challenge in reconstructive microsurgery. Aggressive defatting risks compromising the linking vessels between the subdermal and supraf...Primary thinning of bulky flaps in high-body mass index patients remain a significant challenge in reconstructive microsurgery. Aggressive defatting risks compromising the linking vessels between the subdermal and suprafascial plexuses, leading to flap marginal necrosis. Consequently, one-stage thinning of large, fatty flaps is generally discouraged. A new three-step technique was applied in eight consecutive patients undergoing free flap transplantations between August and October 2025. The procedure consisted of: suprafascial flap elevation; radial fasciotomy (incision of the superficial fascia) around perforators; and manual extrusion of fat granules, performable before or after pedicle division. Flaps were thinned to a target fat layer thickness of <0.5 cm. Operative time for flap thinning, intraoperative vasospasm (>5 minutes), and postoperative complications were assessed. All eight flaps were successfully thinned to an ultra-thin state (<0.5 cm) within 20 minutes. No vascular branches required sacrifice during manual extrusion. No lasting vasospasm or postoperative complications (e.g., vascular compromise, partial necrosis, or skin ecchymosis) occurred. All flaps survived completely. This novel approach enables safe, efficient, single-stage flap thinning while preserving sensation, even in obese patients. It represents a significant advance that merits further validation through larger comparative studies. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
BACKGROUND: Endoscopic CTR (ECTR) accounts for a growing proportion of surgeries over open CTR (OCTR). In a cost-conscious healthcare environment, it is important to characterize the drivers of high-cost care, since OCTR...BACKGROUND: Endoscopic CTR (ECTR) accounts for a growing proportion of surgeries over open CTR (OCTR). In a cost-conscious healthcare environment, it is important to characterize the drivers of high-cost care, since OCTR can be performed with similar outcomes but less costs. We investigated whether regional surgeon competition affects the type of CTR. METHODS: : Using MarketScan claims data from 2018 to 2022, we calculated the Herfindahl-Hirschman Index, a measure of market competition. Multivariable regression was used to identify factors affecting the type of CTR performed, costs, and complications. RESULTS: There were 41,593 OCTR (71.9%) and 16,274 ECTR (28.1%) identified. Competitive markets were associated with 12% higher odds of performing ECTR, leading to an increase of $37.68 in patient out-of-pocket costs and $347.45 in total healthcare costs. Regional surgeon competition was not associated with differences in complications after CTR. CONCLUSIONS: Surgeons in competitive markets have greater odds of performing ECTR over OCTR, which are more costly. Surgeons should recognize the potential influence of non-medical factors in the management of carpal tunnel syndrome. The selective performance of ECTR through shared decision-making can be considered.
BACKGROUND: Tendon adhesion after repair remains a major postoperative complication that limits motion and impairs functional recovery. Although various anti-adhesion materials have been investigated, many compromise ten...BACKGROUND: Tendon adhesion after repair remains a major postoperative complication that limits motion and impairs functional recovery. Although various anti-adhesion materials have been investigated, many compromise tendon healing and strength. A novel bioadhesive sealant derived from hydrophobically modified Alaska pollock gelatin (hm-ApGltn) has demonstrated anti-adhesion effect and biocompatibility in previous studies. This study aimed to evaluate the efficacy of an hm-ApGltn sheet in preventing tendon adhesion and preserving tendon healing strength in a rat Achilles tendon partial defect model. METHODS: Fifty-two Wistar rats were randomly assigned to the ApGltn group (n = 26) or the control group (n = 26). After creation of an Achilles tendon defect model, the ApGltn group received circumferential application of an hm-ApGltn sheet around the tendon. Biomechanical traction testing was performed at 2 and 4 weeks to evaluate adhesion strength and tendon tensile strength. Histological assessments were conducted using Masson's trichrome staining. RESULTS: At both 2 and 4 weeks, the ApGltn group showed significantly lower failure loads for adhesion detachment than the control group, indicating reduced adhesion formation. No significant differences in tendon tensile strength were found between the ApGltn and control groups at either time point. Histological examination demonstrated significantly improved adhesion quality in the ApGltn group, with residual hm-ApGltn material observed up to 4 weeks postoperatively. CONCLUSIONS: The hm-ApGltn sheet effectively prevented peritendinous adhesion without impairing tendon healing strength in a rat Achilles tendon partial defect model. This biocompatible sealant represents a promising material for adhesion prevention in tendon repair.Clinical Relevance Statement: This study demonstrates that an ApGltn sealant effectively prevents postoperative tendon adhesion without impairing tendon healing or tensile strength.These findings suggest that ApGltn may serve as a safe and biocompatible barrier material for clinical use in tendon repair surgery.
BACKGROUND: Traditional measures of success in lower limb reconstruction have focused on flap survival, often overlooking aesthetic and patient-reported outcomes. However, postoperative dissatisfaction with contour, colo...BACKGROUND: Traditional measures of success in lower limb reconstruction have focused on flap survival, often overlooking aesthetic and patient-reported outcomes. However, postoperative dissatisfaction with contour, colour, and donor site appearance remains common. This study aimed (1) to retrospectively assess aesthetic outcomes and revision rates after lower limb reconstruction and (2) to evaluate patient-reported aesthetic satisfaction using a dedicated questionnaire. METHODS: A single-surgeon cohort of 73 patients who underwent lower limb reconstruction was analysed. Demographics, reconstruction type and aesthetic revision procedures were reviewed. Patients were grouped as free flaps (n=44) or local perforator flaps (n=29). A 20-item aesthetic questionnaire, divided equally between donor and recipient domains, was administered at 12 months postoperatively. Responses were recorded on a 5-point Likert scale and analysed. RESULTS: Thirteen patients (17.8%) underwent secondary aesthetic refinement, most commonly liposuction, with a higher revision rate after free flaps (24.1%) than local flaps (11.9%; p=0.04). Among 44 respondents, donor site satisfaction was significantly greater in the local flap group for contour (p=0.0021), scar appearance (p=0.0004), skin colour (p=0.008) and comfort when clothed (p=0.02). Recipient site scores showed no significant differences. Several patients who had not expressed dissatisfaction during follow-up reported concerns when completing the questionnaire, suggesting the presence of previously unexpressed aesthetic concerns. CONCLUSIONS: In this exploratory study, aesthetic satisfaction after lower limb reconstruction appeared to be influenced by donor site-related factors, with local perforator flaps showing higher donor-site satisfaction scores than free flaps. Systematic use of aesthetic-focused patient-reported outcome measures may help identify unvoiced concerns and support shared decision-making. These findings support the importance of integrating aesthetic considerations into contemporary lower limb reconstruction.
BACKGROUND: Wise pattern mastectomy has emerged as a popular alternative to transverse pattern mastectomy for patients with moderate-to-severe breast ptosis and macromastia. However, there is a knowledge gap regarding re...BACKGROUND: Wise pattern mastectomy has emerged as a popular alternative to transverse pattern mastectomy for patients with moderate-to-severe breast ptosis and macromastia. However, there is a knowledge gap regarding reconstructive outcomes. In this study, we compared complication and revision rates among patients with breast ptosis undergoing Wise pattern versus transverse pattern skin-sparing mastectomy with immediate two-stage implant-based breast reconstruction. METHODS: In this single-center retrospective cohort study, female patients with Regnault grade II or III breast ptosis who underwent skin-sparing mastectomy with immediate tissue expander placement from 2019-2023 were included. Bivariate analyses were conducted to compare Wise pattern and transverse pattern mastectomy cohorts. Multivariable analyses were performed to evaluate complication and revision rates. RESULTS: A total of 200 patients met the inclusion criteria, with 125 and 75 patients in the transverse pattern and Wise pattern groups, respectively. In multivariable analysis, Wise pattern mastectomy was not associated with minor complications and was associated with decreased odds of major complications (OR 0.285, 95% CI 0.120-0.679, p=0.005). Moreover, Wise pattern mastectomy was associated with decreased odds of undergoing breast revision (OR = 0.247, 95% CI 0.117-0.523, p<0.001) and decreased odds of a higher number of total revisions on ordinal logistic regression (OR = 0.231, 95% CI 0.110-0.487, p<0.001). CONCLUSIONS: For patients with moderate-to-severe breast ptosis undergoing immediate two-stage implant-based breast reconstruction, Wise pattern mastectomy was associated a similar complication profile and reduced revision burden compared with transverse pattern mastectomy. Prospective multicenter studies incorporating patient-reported outcome measures are warranted.
Complete release of the retaining ligaments during deep plane face and neck lift is essential for durable rejuvenation. This step demands particular caution to avoid nerve injury, however, as branches of the facial nerve...Complete release of the retaining ligaments during deep plane face and neck lift is essential for durable rejuvenation. This step demands particular caution to avoid nerve injury, however, as branches of the facial nerve course in close proximity to the retaining ligaments. During ligament release, surgeons currently rely on uncodified visual and tactile clues or separate neuromonitoring equipment which introduces an instrument change between identification and division. We describe a three-sign sequential identification framework in which the LigaSure vessel sealing system (Medtronic, Minneapolis, MN) serves as both the diagnostic probe and the division instrument, eliminating the need for an instrument change during ligament release in deep plane facelift. First, the Visual Assessment Test evaluates fiber direction and tissue character. Second, the LigaSure Tweak Test distinguishes excitable nerve from nonresponsive ligamentous tissue. Third, the Skin Tethering Test applies gentle traction to confirm a ligament's dermal insertion through visible skin dimpling. A structure is divided only when all three signs align with a ligamentous identity. This framework synthesizes individually described anatomic identification clues into a structured, reproducible, and teachable approach for what is described as the most challenging step of deep plane facelift.
Lip adhesion procedures have proven useful in facilitating definitive cleft lip repair in wide cleft lip defects. This article and video vignette depict the indications, benefits, and operative technique of lip adhesion...Lip adhesion procedures have proven useful in facilitating definitive cleft lip repair in wide cleft lip defects. This article and video vignette depict the indications, benefits, and operative technique of lip adhesion by the senior author to serve as a surgical guide for cleft lip management.
BACKGROUND: The Poly Implant Prothèse (PIP) scandal in 2010 led to the first-ever international recall, revealing shortcomings in electronic patient records (EPRs) to effectively trace patients with PIP implants. In resp...BACKGROUND: The Poly Implant Prothèse (PIP) scandal in 2010 led to the first-ever international recall, revealing shortcomings in electronic patient records (EPRs) to effectively trace patients with PIP implants. In response, the Dutch Breast Implant Registry (DBIR) was established. This study aimed to investigate the track-and-trace ability of DBIR in a test recall setting. METHODS: All patients in DBIR who received a breast implant between 2015 and 2019 in one of the pilot hospitals were included. A test recall scenario was drafted and translated to implant specifications as stated in the DBIR dataset. A third trusted party extracted patients per pilot hospital whose implants fell within the recall scenario. Subsequently, DBIR-data were compared to EPR-data. The number of traced implants with solely EPR versus traced with EPR and data from DBIR were compared. RESULTS: In total, 1113 implants (726 patients) matched the recall scenarios. Significantly more implants could be traced with additional DBIR-data than with EPRs alone (n=1011 [90.8%; 95% CI, 89.1%-92.5%] versus n=915 [80.9%; 95% CI, 78.6%-83.2%], respectively). Due to incorrectly registered patient identifiers or missing implant data in EPRs and DBIR, 102 implants were untraceable. CONCLUSION: This first-ever test recall study proved that adding DBIR-data to EPRs allows for tracing more implants and patients. Our study emphasizes the importance of complete and correct data registration in implant registries, so that patients can be informed in a timely and reliable way in case of an actual recall.
PURPOSE: The aim of this study is to identify the anatomical location of the emergence point of the zygomaticotemporal nerve (EP) in the lateral orbital margin with reference to the marginal tubercle of zygomatic bone (M...PURPOSE: The aim of this study is to identify the anatomical location of the emergence point of the zygomaticotemporal nerve (EP) in the lateral orbital margin with reference to the marginal tubercle of zygomatic bone (MT), and to determine whether the MT can serve as a consistent landmark for zygomaticotemporal nerve (ZTN) block procedures. METHODS: Thirty-six hemifaces from 20 cadavers were dissected. The spatial relationships of the EP with the MT and the lateral canthus (LC) were the main outcomes. Facial proportions were recorded as covariates. Cross-sectional relationships of the ZTN with the middle temporal vein (MTV) and the frontal branch of the facial nerve (FN) in fascial planes were also examined. RESULTS: The EP was consistently identified near the lateral orbital margin, located 4.5±1.6 mm superior to the MT and 17.6±2.7 mm lateral and 9.5±2.9 mm superior to the LC. The vertical distance to the MTV was 7.3±2.3 mm, with both structures positioned within the same fascial plane. In contrast, the FN coursed through a more-superficial layer. Correlation analyses indicated that while the facial proportions affected the absolute location of the ZTN, they did not alter its spatial relationship to the MT. CONCLUSION: The MT serves as a consistent palpable landmark for locating the EP, facilitating more-accurate regional nerve blocks for anesthesia, postoperative pain control, and neuralgia treatment. When the MT is not palpable, the LC can serve as an alternative landmark. Understanding their spatial relationships with surrounding structures-including the MTV and FN-may help prevent vascular injury and inadvertent FN blockade.Levels of Evidence: Basic science and clinical study.
BACKGROUND: The deep inferior epigastric perforator (DIEP) flap is a common breast reconstruction technique. As a microvascular procedure, it carries a risk of complications requiring careful patient selection. While hig...BACKGROUND: The deep inferior epigastric perforator (DIEP) flap is a common breast reconstruction technique. As a microvascular procedure, it carries a risk of complications requiring careful patient selection. While high body mass index (BMI) is a recognized risk factor for complications, the role of muscle mass and more detailed body composition remains unclear. This study aimed to investigate the impact of low muscle mass and high BMI on complications in patients undergoing DIEP breast reconstruction. METHODS: We retrospectively studied patients who underwent DIEP breast reconstruction at our tertiary center during the years 20182021. Preoperative CT scans were used to calculate skeletal muscle index (SMI). Patients were classified into four phenotype categories based on SMI (cut-off: 38.5 cm 2/m 2) and BMI (cut-off: 25 kg/m 2). Complication rates were evaluated and compared between phenotypes. RESULTS: Altogether 204 patients were included, of which 29 (14.2%) met the criteria for sarcopenic overweight (SMI < 38.5 cm 2/m 2 & BMI > 25 kg/m 2). Complications occurred in 37 (18.1%) patients. Sarcopenic overweight associated with higher rates of early flap (p = 0.009) and overall (p = 0.034) complications compared to other phenotypes. In multivariable analysis, sarcopenic overweight was the only significant factor associated with overall complications (OR 8.66, 95% CI: 1.68-44.62, p = 0.010). Neither sarcopenia nor overweight alone were independent risk factors for complications. CONCLUSIONS: In this study, sarcopenic overweight was associated with an eightfold increased risk of complications following DIEP breast reconstruction. Body composition, rather than mere BMI, should be considered when evaluating patients for breast reconstruction.