Recurrent ptosis, loss of upper pole fullness, and postoperative asymmetry remain persistent challenges in mastopexy surgery. Most conventional techniques primarily rely on a vertical support vector, which may be insufficient to resist long-term gravitational descent and asymmetric settling. To address these limitations, we describe a modified mastopexy technique using transsternal dermal cable grafts to provide additional horizontal vector support and improve breast stability. The technique was performed in 75 women undergoing inverted-T scar central mound mastopexy. Transsternal dermal grafts were designed as a dual-vector suspension system connecting the medial breast pillars across the presternal region, reinforcing medial fullness, projection, and symmetric breast positioning. The grafts function as an internal balancing mechanism, analogous to a libra, while preserving breast mobility and contour. Clinical follow-up demonstrated stable breast shape, improved upper pole fullness, enhanced projection, and satisfactory symmetry over time. Minor wound-healing problems and hypertrophic scarring occurred in a limited number of patients, whereas nipple-areola sensation was preserved in all patients. This technique introduces a structurally reinforced dual-vector mastopexy concept that combines vertical reshaping with horizontal stabilization. Transsternal cable grafts may help reduce recurrent ptosis and asymmetric breast settling while improving long-term breast contour and projection.
BACKGROUND:The LIMB-Q is a validated patient-reported outcome instrument developed for lower extremity trauma patients. It is composed of 16 independently functioning scales. Normative values for the LIMB-Q scales have not been established, limiting data interpretation. METHODS:A cross-sectional study was conducted using participants recruited through an online research community. Eligible individuals were residents of the United States or Canada, fluent in English, aged 18 ≥ years, and had no prior history of lower extremity injury or infection resulting in fracture, surgery, amputation, or flap reconstruction. Participants provided demographic information and completed the LIMB-Q scales for Lower Limb Physical Function, Lower Limb Symptoms, Psychological, Sexual, and Work. Data analysis, including bivariate analyses, was performed. RESULTS:The LIMB-Q scales were completed by 1,137 individuals. Fifty-three percent identified as female. The median age was 34 years (interquartile range, 27-43), with 6% of participants aged ≥ 60 years. Sixty-five percent were Caucasian, and 77% had worked within the past three months. Mean ± standard deviation LIMB-Q scores were as follows: Lower Limb Function (83 ± 14), Lower Limb Symptoms (86 ± 13), Psychological (85 ± 16), Work (92 ± 16), and Sexual (69 ± 25). Scores for Physical Function and Symptoms scales were higher for individuals < 60 years old compared to those ≥ 60 years (84 vs. 74 and 87 vs. 82, respectively, both p < 0.001). CONCLUSION:These are the first published normative scores for the LIMB-Q and will provide a clinical reference point for the interpretation of LIMB-Q data.
Background: Triple-jaw surgery, defined as concurrent Le Fort I osteotomy, bilateral sagittal split osteotomy, and genioplasty, is traditionally performed inpatient with overnight admission. As complex care shifts toward ambulatory surgery centers (ASCs), the safety and feasibility of same-day discharge after complex orthognathic surgery warrant evaluation. We hypothesized that triple-jaw surgery with adjunctive procedures can be performed safely in an outpatient setting. Methods: A retrospective review was performed of patients undergoing triple-jaw orthognathic surgery with at least 2 adjunctive procedures by a single surgeon at an ASC over an 18-month period. Primary outcomes included airway compromise, bleeding, hospital transfer, inpatient conversion, and admission. Secondary outcomes included nausea, vomiting, infection, hardware failure, 30-day emergency department visits, and revision surgery. Outcomes were compared with published inpatient cohorts. Results: 177 patients were included. Mean age was 29.5 years, and 52.0% were female. Mean operative time was 200 ± 41.8 minutes, 83.6% received liposomal bupivacaine, and mean recovery time was 123.3 ± 38.8 minutes. Adjunctive procedures included autologous fat grafting, bone grafting, submental liposuction, dental extractions, and facial bone implants. No patients required hospital transfer, admission, or inpatient conversion. Vomiting occurred in 1.1%, hemorrhage in 0%, and infection in 1.1%. Hardware failure, airway compromise, return to the operating room for infection, and revision surgery were 0%. Several postoperative outcomes were significantly lower than published inpatient cohorts. Conclusions: In a selected single-surgeon cohort, triple-jaw surgery with adjunctive procedures was feasible and safe with same-day discharge. ASC-based orthognathic surgery may represent an alternative to conventional hospital-based care.
BACKGROUND:Dynamic reanimation with functioning free muscle transplantation (FFMT) is the standard of care for long-standing and developmental facial paralysis. Donor nerve selection is pivotal, but no consensus exists on preferred strategies. METHODS:An international, web-based survey was distributed to attending microsurgeons performing FFMT for long-standing facial paralysis. The questionnaire collected demographic data and preferences across ten standardized clinical scenarios. Descriptive statistics summarized responses. RESULTS:A total of 107 experts from 34 countries responded. The gracilis was the preferred donor muscle (92.5%). Donor nerve choice varied with age: for patients <60 years, cross-facial nerve grafts (CFNG) were most common (44.9%), whereas for patients ≥60 years, the masseteric nerve predominated (60.7%). Dual innervation was used by 17-20% of respondents, though optimal configuration varied. In bilateral congenital paralysis, 91.6% favored the masseteric nerve, while unilateral developmental cases showed more evenly distributed preferences among CFNG (35.5%), masseteric (34.6%), and dual innervation (26.2%). Surgeons prioritized either maximal excursion (42.1%) or spontaneous smile (39.3%). Reported CFNG limitations included limited excursion, insufficient axons, and the need for a two-stage procedure. Adjunctive strategies included sensory supercharging (21.5%), electrical stimulation (14.0%), and vascularized nerve grafts (7.5%). CONCLUSIONS:This global survey highlights current preferences in donor nerve selection for FFMT. CFNG is favored in younger patients for spontaneity, while the masseteric nerve is preferred in older individuals for reliability. Dual innervation is increasingly adopted but heterogeneous. These findings underscore the need for comparative outcome studies and consensus-building in free functioning muscle transplantation for facial reanimation.
Implant-based breast reconstruction often presents a binary choice: immediate direct-to-implant (DTI) reconstruction or two-stage tissue expander-based reconstruction. Here, we present outcomes of the Staged Approach For Early Direct-to-Implant DTI (SAFE-DTI) protocol in which permanent implants are placed one to three weeks post-mastectomy. Patients undergoing SAFE-DTI were those otherwise eligible for immediate DTI reconstruction in whom (1) there was elevated risk of post-mastectomy flap necrosis, (2) uncertainty regarding their pathologic diagnosis, or (3) logistic challenges between the oncologic and reconstructive surgeon. We reviewed a cohort of 19 patients (32 breasts) who underwent SAFE-DTI at our institution between 2021 and 2025. Most patients underwent nipple-sparing mastectomy (96.9%) followed by SAFE-DTI with a median implant volume of 398cc (IQR 264cc-445cc). The overall complication rate was 18.8%, including infection (6.3%, two breasts in one patient), hematoma (3.1%, one breast) and partial nipple-areolar complex necrosis (9.4%, three breasts, all initially noted prior to implant placement). Four patients (8 breasts, 25% of total) underwent revision within 6 months which consisted primarily of autologous fat grafting for aesthetic optimization. For planned cases, SAFE-DTI leverages the delay phenomenon for improved tissue perfusion, allows confirmation of final pathology, and overcomes logistical scheduling challenges. In salvage cases, it enables the avoidance of tissue expanders when intraoperative tissue perfusion is a concern and immediate DTI is aborted. SAFE-DTI represents a practical technique to mitigate common barriers to immediate DTI reconstruction while preserving its benefits for appropriately selected patients.
Background: Preparation of Extracellular vesicles (EVs) from cell cultures is labor-intensive. Plasma-derived EVs have demonstrated proliferative effects. The aim of this study was to compare the proliferative effect of plasma EVs on Schwann cells (SC) and to assess the cost structure of EVs derived from plasma versus Adipose tissue-derived stromal cells (AdSCs). Methods: EVs isolated from rat platelet-rich plasma (PRP), platelet-poor plasma (PPP), and AdSC cell culture were assessed by quantity, size, and phenotypic markers. Both plasma-EVs in three dosages were added to primary rat SC cultures. As controls, SCs were incubated in standard growth medium, PRP, PPP or EVs derived from AdSCs and the proliferation rate, SC length-to-width ratio and increase in confluency was determined. Furthermore, the cost structure and working hours associated with EV preparation were calculated. Results: EVs derived from AdSCs, PPP and PRP were about the same size with a significantly higher concentration of EVs found in plasma. After the addition of PRP, PPP, PRP-EVs, PPP-EVs, and AdSC-EV to SC cultures, only AdSC-EVs and PRP-EVs in highest concentration reached a significantly increased proliferation. Cost and labor analysis revealed that plasma-derived EVs could be obtained more efficiently, with reduced time and expense. Conclusions: Compared to AdSC-EVs, PRP-EVs were isolated at a significantly higher concentration with lower cost and reduced labor time. Given their autologous origin, PRP-EVs may serve as a promising option to increase proliferation of Schwann cells. The results of this study deliver preliminary insights, and further studies are needed to explore their full regenerative potential.
Background: Submandibular gland (SMG) prominence can disrupt neck contour, particularly in East Asian patients with limited skeletal support and reduced soft-tissue camouflage. Although concerns regarding deep neck hemorrhage with respiratory compromise, nerve injury, sialocele, and dry mouth have limited broader adoption, selective SMG reduction may be incorporated into deep neck contouring in appropriately selected patients. Methods: We retrospectively reviewed 240 East Asian patients who underwent deep neck contouring with partial SMG resection from August 2024 to July 2025. Concomitant facelift or neck lift procedures were performed when clinically indicated for skin laxity or advanced aging changes. SMG reduction was performed through medial capsular entry and lobule-by-lobule bipolar dissection with targeted cauterization of intraglandular vessels. Thin-film fibrin sealant and low-dose botulinum toxin A were applied to the residual gland for dead-space and secretion control. Outcomes included complications, surgeon-rated Likert scores based on standardized photographs, and patient satisfaction. Results: Observed complications included hematoma in 3 patients (1.3%; reoperation, n = 1), seroma in 3 (1.3%), infection in 2 (0.8%), sialocele in 1 (0.4%), and transient lower-lip depressor dysfunction in 4 (1.7%). No permanent nerve injury or clinically evident salivary dysfunction was observed during follow-up. The single sialocele resolved with aspiration and adjunctive BTX-A injection. Standardized photographic assessment demonstrated consistent improvement in mandibular contour. Conclusions: In this retrospective East Asian cohort, lobule-based SMG reduction was associated with low observed complication rates and favorable contour improvement. Selective SMG reduction may be considered as a component of anatomy-based deep neck contouring in appropriately selected patients. Level of Evidence: Therapeutic, IV.
Background: Contemporary facial reanimation techniques increasingly aim to achieve smile spontaneity, defined by most as an unprompted smile triggered by positive emotions. This study aimed to 1) assess the rate of reporting of spontaneity outcomes and commonly used tools to elicit and assess spontaneity and 2) evaluate the published success rate in achieving spontaneity. Methods: A systematic review of the Ovid MEDLINE, Embase and Cochrane literature from January 1, 2005 to May 13, 2025 was performed. Original studies reporting on clinical outcomes with cross-facial neural input for flaccid facial paralysis were included. Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed. Results: 95 articles met inclusion criteria, including a total of 3,874 patients having undergone facial reanimation with cross-facial nerve grafting either to the native facial musculature (N=384) or for neurotization of free muscle transfer (N=3,487). The neural input was either cross-facial nerve grafting alone (N=3,268) or dual innervation with added input from an ipsilateral nerve transfer (masseteric or hypoglossal) (N=599). Less than half of studies reported spontaneity outcomes (39/95, 41.1%), with most articles only describing binary data (presence or absence of spontaneity). The presence of spontaneity was reported in 88.25% (95% CI, 77.49-96.32, I² = 93.7%, τ² = 0.11, p < 0.0001) (1,456 patients, 31 studies). Conclusions: While quantitative tools assessing smile spontaneity have been described, their use in the facial nerve outcomes literature remains limited. This study highlights the need to address barriers to widespread implementation of spontaneity assessments.
