Background:Differentiating dermatofibrosarcoma protuberans (DFSP) from keloids presents significant clinical challenges, particularly when skin biopsies are contraindicated. This study introduces a novel, non-invasive diagnostic method leveraging the Japan Scar Workshop Scar Scale (JSS) combined with the cosine of the angle (cosθ) to distinguish between these conditions. Methods:In this case-control study, 43 cases were retrospectively analyzed using the new evaluation method, JSS × cosθ, designed specifically for this differential diagnosis. This method applies JSS in conjunction with cosθ to assess lesion characteristics non-invasively. Results:The JSS × cosθ scores effectively differentiated between DFSP and keloids. Scores ≥16 were indicative of keloids, whereas scores <16 suggested DFSP, with these findings achieving statistical significance ( p < 0.001). Conclusion:The JSS × cosθ scoring system provides a reliable and safe diagnostic tool for distinguishing DFSP from keloids, particularly in cases where biopsy is avoided due to the risk that stimulation of the reticular dermis may lead to the development, enlargement, or worsening of keloids. This method promises to significantly impact the specific management of DFSP and keloids.
Complex dorsal hand and forearm injuries with extensor tendon and soft tissue loss are challenging to manage. Single-stage reconstruction using composite anterolateral thigh (ALT) fasciocutaneous free flaps with vascularized fascia lata may reduce the need for multiple surgeries and accelerate functional recovery, but clinical evidence is limited. We conducted a retrospective case series of nine patients with complex extensor tendon and soft tissue defects who underwent single-stage reconstruction with composite ALT flaps between 2009 and 2018. Six patients were available for long-term follow-up (average 2-3 years). Data included demographics, injury characteristics, operative details, complications, and functional outcomes assessed using Miller's criteria. One donor site hematoma resolved without sequelae. Functional assessment revealed that two patients achieved excellent and poor outcomes in wrist and finger extension, respectively, while one patient demonstrated good and fair results . Poor outcomes were associated with missed follow-up, prolonged immobilization, and concomitant skeletal injuries. All patients returned to work and reported satisfaction with their functional status. This approach offers durable soft tissue coverage, restores tendon continuity, and allows early rehabilitation with minimal donor site morbidity.
Background:Surgical approaches for zygomaticomaxillary complex (ZMC) fractures have evolved toward minimizing cutaneous incisions while maintaining adequate exposure. Conventional approaches for frontozygomatic fixation, such as lateral brow or transconjunctival incisions with lateral extension, may result in visible scarring or periocular complications. Building on previous transconjunctival techniques, we applied an independent upper eyelid transconjunctival incision as a non-cutaneous approach for frontozygomatic fixation in selected ZMC tripod fractures. Methods:This retrospective comparative study included 27 patients with unilateral ZMC tripod fractures, of whom 12 underwent non-scar fixation using an upper eyelid transconjunctival approach, and 15 underwent fixation through preexisting periorbital traumatic lacerations. The surgical strategy consisted of initial reduction and fixation via an intraoral approach, followed by selective additional fixation of the frontozygomatic region when residual step deformity or instability was present. Preoperative and 6-month postoperative computed tomography and three-dimensional photogrammetry were used to evaluate bony and soft tissue intermalar height differences. Results:Preoperative intermalar height differences were comparable between groups. At 6 months postoperatively, both groups showed marked improvement, with bony differences of -0.2 ± 1.2 mm and -0.4 ± 0.4 mm, and soft tissue differences of 0.0 ± 0.6 mm and -0.2 ± 0.7 mm in the non-scar and control groups, respectively, with no clinically meaningful between-group differences. No clinically significant approach-related ophthalmic complications were observed. Conclusions:The upper eyelid transconjunctival approach is a reliable non-cutaneous option for frontozygomatic fixation in selected ZMC tripod fractures, providing adequate exposure and stable fixation without visible scarring.
Background:The omentum is a vascularized, immune-active tissue with regenerative potential, particularly when activated by intraperitoneal stimuli. Its secreted factors may promote lymphangiogenesis, offering a novel approach to lymphedema treatment. Methods:The omentum was activated in mice using an intraperitoneal polydextran slurry. Gene expression was evaluated over time to assess inflammatory and lymphatic markers. Culture supernatants from the activated omentum were collected, and vascular endothelial growth factor-C ( VEGF-C ) levels were measured. Therapeutic potential was tested in a mouse hindlimb lymphedema model through local application of the supernatant. Histological analysis assessed skin thickness, lymphatic vessel density, and macrophage infiltration. Results:Activation of the omentum induced early upregulation of hypoxia-inducible factor-1 α ( HIF-1α ) and angiopoietin-2 ( Ang2 ), followed by increased expression of Forkhead Box C2 ( Foxc2 ) and Prospero homeobox-1 ( Prox1 ) by day 7, indicating lymphatic maturation. VEGF-C levels in the supernatant were significantly elevated. In the lymphedema model, treated mice exhibited reduced peak edema, faster resolution, and increased skin thickness and lymphatic vessel density compared with controls. Histological analysis revealed enhanced lymphangiogenesis and reduced macrophage infiltration. Downregulation of lymphatic vessel endothelial hyaluronan receptor 1 ( Lyve1 ) and Neuropilin-1 ( NRP1 ) suggested a predominance of tissue remodeling over structural maintenance. Conclusions:Activated omental tissue secretes potent bioactive factors that promote lymphangiogenesis and tissue regeneration. These findings indicate the potential of activated omentum for functional characterization and possible applications in regenerative medicine. Further investigation in chronic and clinical models is warranted to advance its translational potential.
Supermicrosurgery, defined as the anastomosis of vessels smaller than 0.8 mm, represents a significant evolution in the field of reconstructive microsurgery. This review explores its technical foundations, clinical applications, and future directions, with a particular focus on lower extremity reconstruction. By utilizing perforator-to-perforator anastomosis and thin flap techniques, supermicrosurgery allows for reduced donor morbidity, minimized risk to major vessels, and improved aesthetic and functional outcomes. The integration of high-frequency ultrasonography and advanced microsurgical tools has enhanced preoperative planning and intraoperative precision. Despite a steep learning curve, supermicrosurgery is increasingly applied in oncologic, traumatic, ischemic, and diabetic foot reconstructions. Continued innovation in imaging, instrumentation, and robotic assistance suggests a promising future for this subspecialty.
Background:Lymphedema affects over 250 million people worldwide and is increasingly managed with physiologic procedures such as lymphovenous bypass (LVB) and vascularized lymph node transfer (VLNT). These supermicrosurgical techniques require advanced training, are ergonomically demanding, and can be limited in anatomically constrained regions. Robotic surgical systems offer high-resolution visualization, motion scaling, tremor reduction, and improved ergonomics, making them promising adjuncts for lymphatic supermicrosurgery. However, evidence on safety, feasibility, and outcomes remains limited. Methods:A systematic review was conducted in accordance with PRISMA guidelines using PubMed, Cochrane Library, and Embase from inception through December 2024. Eligible studies included human clinical reports of robotic-assisted peripheral lymphatic reconstruction. Extracted data included demographics, operative details, outcomes, and study quality. Results:Seven studies involving 134 patients and 221 anastomoses were included, of which 78% (172) were performed robotically. The Symani system was most frequently used. Robotic procedures comprised 59.9% LVBs and 32% VLNTs or other free flaps. Across studies, mean anastomotic time was longer with robotic assistance (25.7 minutes) compared with manual techniques (11 minutes); however, three studies demonstrated significant time reduction with experience, ultimately approaching manual times. When reported, clinical outcomes, including limb volume reduction and quality-of-life measures, were comparable between robotic and manual groups. Advantages included tremor elimination and improved ergonomics, while challenges included cost, setup time, and lack of haptic feedback. Conclusions:Robotic-assisted lymphatic supermicrosurgery is safe and feasible, with outcomes comparable to conventional surgery. Continued refinement, cost reduction, and standardized outcome reporting will determine its role in expanding therapeutic and preventive lymphatic reconstruction.
Background:Conventional detergent-based decellularization can disrupt the extracellular matrix (ECM) structure and denature proteins. Supercritical carbon dioxide (scCO 2 ) processing offers a simplified manufacturing process (<2 hours), minimal protein denaturation, and excellent ECM preservation. This study aimed to evaluate the clinical outcomes of scCO 2 processing acellular dermal matrix (ADM) compared with conventional detergent-processed ADM. Methods:This prospective observational study enrolled patients undergoing immediate implant-based breast reconstruction with scCO 2 -processed ADM ( n = 50) and compared outcomes with a retrospective cohort receiving conventional detergent-processed human ADM ( n = 50). Patient demographics, comorbidities, and treatment variables were collected. Postoperative complications and BREAST-Q-assessed patient-reported outcomes were analyzed. Results:The groups were comparable in age (45.0 ± 10.4 years vs. 46.8 ± 9.4 years, p = 0.362), body mass index (median: 21.5 kg/m 2 vs. 22.7 kg/m 2 , p = 0.558), comorbidities, and oncologic characteristics. Rates of skin necrosis (2% vs. 0%), nipple-areolar complex necrosis (2% vs. 2%), hematoma (4% vs. 4%), seroma (6% vs. 0%), infection (6% vs. 0%), capsular contracture (8% vs. 12%), implant failure (0% vs. 0%), implant change (2% vs. 2%), and reoperation (2% vs. 2%) did not differ significantly between groups. BREAST-Q questionnaires revealed no significant differences in patient-reported outcomes. Conclusion:scCO 2 -processed ADM demonstrated safety and patient-reported outcomes equivalent to established detergent-based ADMs. Given its eco-friendly, protein-preserving manufacturing process, scCO 2 -processed ADM represents a safe and effective alternative for implant-based breast reconstruction. Long-term follow-up studies are warranted.
Effective soft tissue coverage is essential for minimizing complications in large cranial defects. This case report describes the successful application of a chimeric serratus anterior fascia-latissimus dorsi (SAFLD) flap for single-stage coverage of a large cranial defect. This technique is compared to the current literature. A 69-year-old female with a history of glioblastoma and a rapidly growing scalp squamous cell carcinoma underwent en bloc resection and single-stage reconstruction. After cranioplasty, a large defect was covered with an SAFLD flap, ensuring multilayered vascularized soft tissue coverage. Recovery was uneventful, and a 1-year follow-up demonstrated good cranial morphology. This case demonstrates the successful application of a chimeric free flap for dual-layer coverage in cranial reconstruction, potentially reducing complications associated with single-stage repairs and improving patient outcomes. A literature review demonstrating various case applications of this flap is also presented.
Academic engagement in plastic and reconstructive surgery (PRS) has grown substantially, marked by an increasing number of professional societies, annual meetings, and peer-reviewed journals. While this growth has facilitated innovation, collaboration, and knowledge sharing, it has also introduced financial burdens. These costs may limit access to academic involvement, especially for early-career surgeons and those without institutional funding. Despite the implications these financial barriers pose for equity, academic engagement, and innovation within the field, the cumulative cost of academic involvement in PRS remains poorly quantified. A cross-sectional review was conducted to assess the financial costs of academic engagement in PRS in the United States. Between January and April 2025, data were collected from official websites of national and subspecialty PRS societies, journals, continuing medical education (CME) platforms, and board-certifying bodies. Annual dues, meeting fees, CME costs, journal subscription, publishing fees, and board-related expenses were compiled. A comparative analysis with five other surgical subspecialties was conducted. Thirty-two major PRS societies were identified. Membership dues ranged from $150 to $1,299. Meeting registration was $250 to $1,495. Journal subscription costs ranged from $44.90 to $1,518, and open-access (OA) article processing charges (APCs) from $700 to $5,334. PRS-board certification costs averaged $9,045. CME cost-per-credit reached up to $600. Among the six surgical specialties in the United States that were included in the comparative analysis, PRS ranked second in baseline academic engagement (BAE) costs after Neurosurgery, averaging $10,109. Academic engagement in PRS carries significant financial burdens that may limit access. Addressing these barriers is essential to maintaining equity and innovation.
In the era of supermicrosurgery, clinicians need more precise imaging modalities to know the exact microvascular and lymphatic anatomy of the patient. The goal of this review is to answer the research question "What are the state-of-the-art medical imaging modalities supporting supermicrosurgery?"This study is a scoping review and case report.Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are well-known current standard imaging modalities in flap surgery. In lymphatic surgery, lymphoscintigraphy is the gold standard. (Ultra)high-frequency ultrasound (UHFUS) has taken a major role in preoperative planning of flap surgery and lymphatic surgery. Practical guidelines on the use of UHFUS in flap planning and lymphatic surgery are described in this review article. Indocyanine green angiography and near-infrared fluorescent lymphography have also become key elements in modern flap surgery and lymphatic surgery. Moreover, contrast-enhanced magnetic resonance lymphography produces high-resolution imaging of superficial as well as deep lymphatic vessels. Laser tomography and photoacoustic imaging are promising experimental imaging techniques in lymphatic surgery.This review article describes and compares possible imaging modalities for preoperative planning and intraoperative guidance with the aims of enhancing surgical outcomes, reducing operative time, and preventing complications in supermicrosurgery. Moreover, a case report is described in order to illustrate the practical imaging work-up in daily practice.
Background While surgical site infection (SSI) is a major complication of implant-based breast reconstruction, delayed infections remain underrecognized despite their clinical significance. This study aimed to identify the risk factors of delayed infection and compare the clinical outcomes of acute and delayed SSI after tissue expander insertion. Methods Patients who underwent immediate tissue expander-based breast reconstruction between March 2016 and February 2021 were reviewed. Acute SSI (<30 days) and delayed SSI (>60 days) were analyzed and compared with the no-infection group. Results Among 146 breasts (140 patients), 26 SSIs occurred; 50% ( n = 13) were delayed. Multivariable analysis identified wound complication as the sole independent risk factor for delayed SSI. Compared with acute SSI, delayed infection was associated with a significantly longer interval from symptom onset to diagnosis (4.15 vs. 0.33 days, p = 0.0181) and a lower salvage rate (31% vs. 83%), showing borderline significance ( p = 0.057). Conclusion Delayed SSI is not rare after expander-based breast reconstruction. Because salvage is challenging due to diagnostic delay, surgeons and patients should remain vigilant, particularly when risk factors for delayed infection of the tissue expander remain.
Background:Patients undergoing breast cancer surgery and reconstruction seek information using online patient education materials (OPEMs). The National Institutes of Health (NIH) and American Medical Association (AMA) recommend a sixth-grade reading level for OPEMs. In recent years, Chat Generative Pre-Trained Transformer (ChatGPT), a large language model (LLM), has shown potential utility in patient education. This study compares the readability and content quality of OPEMs on breast cancer surgery and reconstruction with ChatGPT-generated materials. Methods:Google searches were conducted in January 2025 to identify relevant OPEMs for breast cancer surgery and reconstruction. For each search term, ChatGPT 4.0 was prompted to generate patient education guides using two approaches: (1) Standard prompting and (2) simplified prompting to align with NIH/AHA recommendations ("write the guide like I am in sixth grade"). Readability and content quality metrics were assessed. Results:Ninety-nine OPEMs and 60 ChatGPT responses (30 standard, 30 simplified) were analyzed. Median Flesch-Kincaid Grade Level (FKGL) was 10.8 for OPEMs, 10.0 for standard ChatGPT responses, and 5.8 for simplified ChatGPT responses. OPEMs and standard ChatGPT responses significantly exceeded NIH/AMA recommendations ( p < 0.001). Simplified ChatGPT responses aligned with the sixth-grade level and were significantly easier to read than OPEMs and standard ChatGPT responses ( p < 0.001). DISCERN scores did not significantly differ between OPEMs and standard/simplified ChatGPT responses. Conclusion:OPEMs on breast cancer surgery and reconstruction exceed recommended readability levels. ChatGPT, when prompted to simplify, produced materials consistent with NIH/AMA guidelines while maintaining content quality. Using ChatGPT for patient education may enhance accessibility and patient comprehension of health information.
Background:Lateral low-to-low osteotomies in rhinoplasty raise safety concerns regarding Webster's triangle and airway patency. This study aimed to measure the distance between the osteotomy line and the anterior inferior nasal turbinate and evaluate its relationship with other nasal characteristics. Methods:We retrospectively analyzed CT scans from 81 East Asian patients (January-December 2020). This study used a virtual simulation to measure the distance between a projected lateral low-to-low osteotomy line and the anterior inferior nasal turbinate on CT scans, along with nasal bone length/thickness, pyriform aperture width, and rhinion-nasomaxillary suture distance. Linear regression and Spearman correlation assessed parameter associations. Results:The 81 patients (mean age 46.7 years) showed an average distance of 7.1 ± 3.2 mm (right) and 6.5 ± 3.0 mm (left) between the osteotomy line and the inferior nasal turbinate. A significant negative correlation ( r = -0.35, p < 0.001) was found between rhinion-nasomaxillary suture distance and this osteotomy-turbinate distance. No correlation was seen with nasal bone length or pyriform aperture width. Measurements demonstrated good intrarater reliability (intraclass correlation coefficient [ICC] = 0.98). Conclusions:The lateral low-to-low osteotomy line does not intersect the anterior nasal turbinate, indicating it can be safely performed without concern for Webster's triangle. However, caution is advised for patients with higher nasal dorsum projection (shorter rhinion-nasomaxillary suture distance). This study offers valuable insights into East Asian nasal characteristics for rhinoplasty.
Trigeminal trophic syndrome (TTS) is a rare neurocutaneous disorder defined by trigeminal anesthesia, facial paresthesia, and crescentic ulceration of the nasal ala. We describe an 86-year-old woman with long-standing trigeminal neuralgia who developed a suspicious ulcerated lesion on the left nasal ala. Although the initial biopsy showed atypical squamous cells suggestive of squamous cell carcinoma, the combined histopathologic, radiologic, and clinical findings supported a diagnosis of TTS. This case underscores the need to distinguish TTS from malignancy, particularly in elderly patients with neurologic comorbidities. Early recognition may prevent unnecessary invasive procedures and improve outcomes.
Protein-losing enteropathy (PLE) is a rare disorder characterized by abnormal protein loss through the gastrointestinal tract, often leading to hypoalbuminemia and malnutrition. This case report describes the successful surgical management of chronic lower limb lymphedema and PLE in a 7-year-old male with a thrombospondin type 1 domain-containing 1 (THSD1) mutation, unresponsive to conventional therapies. Despite aggressive nutritional support, including albumin infusions, the patient experienced persistent hypoalbuminemia and ongoing protein loss. Imaging revealed significant lymphatic dysfunction, prompting lymphovenous bypass and lymph node-vein anastomosis (LNVA). Postoperatively, serum albumin levels improved from 1.5 to 3.2 g/dL, limb circumference decreased, and alpha-1 antitrypsin levels normalized. However, a 3-year follow-up revealed a relapse of hypoalbuminemia following an upper respiratory infection, underscoring the need for additional interventions in growing pediatric patients. This case strengthens the potential of lymphatic surgery in addressing PLE-related lymphatic dysfunction when medical treatments fail and emphasizes the need for further research to confirm the efficacy of this approach.
Head and neck squamous cell carcinoma often requires total laryngectomy (TL), creating complex defects, especially in irradiated patients. The internal mammary artery perforator (IMAP) flap is a promising reconstructive option, offering reliable vascularization with minimal donor site morbidity. However, postoperative characteristics such as retention/survival and complications in irradiated patients have not been fully addressed. A retrospective analysis was conducted on seven patients undergoing IMAP flap reconstruction after TL for advanced laryngeal carcinoma. All had prior radiotherapy. The procedures were designed using the Doppler ultrasound technique, and the second intercostal space IMAP was used in most patients, except for one. Flap elevation surgical time, defect coverage, complications, and hospital stay were evaluated. Our patients were 79 ± 4.3 years old. The average surgical time for flap elevation was 61 ± 5.34 minutes. The pharynx defect size was 4.57 ± 0.53 cm 2 , achieving full coverage in all cases. The mean hospital length of stay was 4.0 ± 1.52 days. One patient developed a postoperative hematoma; no flap necrosis or fistulas occurred after 3 months of follow-up. The flap survival rate was 100%. In this work, our IMAP flap design could be considered thin and elongated; however, due to the constant blood flow of the IMAP, we observed reliable results, and no partial or total necrosis was reported. Thus, the IMAP flap is a safe and effective alternative for laryngeal defect reconstruction in irradiated patients, proving excellent viability, favorable aesthetics, reduced morbidity, and minimal complications.
Chronic compartment syndrome (CCS), though often described in athletes, can occur in patients with long-standing lymphedema due to chronic fibrotic changes in the skin, subcutaneous tissue, and deep fascia. We present a unique case of CCS in a patient with advanced secondary lymphedema of the left lower limb. She underwent multiple sittings of vascularized lymph node transfers and lymphovenous anastomoses. Her final lymph node transfer, combined with bariatric surgery, led to dramatic weight loss and a reduction in lower limb girth. Subsequently, she developed persistent exertional pain and neuropathic symptoms in the left calf, raising suspicion for CCS. Intracompartmental pressure (normal range of 0–10 mm Hg) analysis by manometry confirmed CCS with preoperative readings of 22, 25.2, 17.9, and 29.5 mm Hg in anterior, lateral, superficial, and deep compartments of the leg. Surgical decompression and debulking resulted in postdecompression pressures of 6.5, 6, 4.6, and 4.6 mm Hg, respectively, with good symptomatic relief. This case emphasizes the importance of considering CCS in chronic lymphedema with limb pain and neuropathy unexplained by surgical outcomes.
The latissimus dorsi (LD) muscle is considered one of the most reliable donor sites for autologous breast reconstruction, particularly in patients with prior oncologic treatment or comorbidities precluding microsurgical options. While its consistent anatomy typically permits straightforward surgical planning, rare anatomical anomalies can dramatically alter intraoperative decision-making. We report the case of a 69-year-old woman with a long oncologic history and multiple comorbidities who underwent delayed breast reconstruction using a pedicled LD flap, one year after radical mastectomy and axillary lymphadenectomy. Intraoperatively, the LD muscle was found to be completely absent on the left side, with no identifiable muscle belly and tendon. Immediate adaptation was required, and a serratus anterior muscle flap based on a thoracodorsal branch was used instead. Interestingly, retrospective review of a CT scan performed two years earlier for a pulmonary complaint revealed clear evidence of unilateral LD muscle absence, an oversight that underscores the importance of targeted imaging review. This case is one of only four reported in the literature, where unilateral absence of LD muscle in non-syndromic patient was encountered, and the only one intra-operative discovery during breast reconstruction. This highlights the critical need for anatomical vigilance and intraoperative adaptability in reconstructive surgery. When standard options fail, familiarity with alternative flaps and sequential planning are essential to achieving functional and aesthetic outcomes.
