Cranioplasty

Calvarial defects are commonly encountered after neurosurgical procedures, trauma, and ablative procedures of advanced head neck cancers. The goals of cranioplasty are to provide a protective barrier for the intracranial contents, to restore form, and prevent syndrome of the trephined. Autologous and alloplastic techniques are available, each with their advantages and drawbacks. A multitude of materials are available for cranioplasty, and proper timing of reconstruction with attention to the overlying skin envelope is important in minimizing complications.

The Facial Aging Process From the “Inside Out”

The normal course of aging alters the harmonious, symmetrical, and balanced facial features found in youth, not only impacting physical attractiveness but also influencing self-esteem and causing miscommunication of affect based on facial miscues. This evidence-based paper aims to provide a comprehensive overview of the latest research on the etiology and progression of facial aging by explaining the aging process from the “inside out”; that is, from the bony platform to the skin envelope. A general overview of the changes occurring within each of the main layers of the facial anatomy are presented, including remodeling of the facial skeleton, atrophy or repositioning of fat pads, changes in muscle tone and thickness, and weakening and thinning of the skin. This is followed by an in-depth analysis of specific aging regions by facial thirds (upper, middle, and lower thirds). This review may help aesthetic physicians in the interpretation of the aging process and in prioritizing and rationalizing treatment decisions to establish harmonious facial balance in younger patients or to restore balance lost with age in older patients.

Optimizing Aesthetic Outcomes in Breast Reconstruction After Nipple-Sparing Mastectomy

Nipple-sparing mastectomy (NSM) has been associated with improved quality of life and patient satisfaction with similar oncologic outcomes compared with traditional mastectomy techniques. By conserving the nipple-areola complex and the majority of the breast skin envelope, NSM allows for improved aesthetic outcomes after breast reconstruction. However, the technique is also associated with a steep learning curve that must be considered to achieve optimal outcomes. It is important that the plastic surgeon functions in concert with the extirpative breast surgeon to optimize outcomes because the reconstruction is ultimately dependent on the quality of the overlying mastectomy flaps. Various other factors influence the complex interplay between aesthetic and reconstructive outcomes in NSM, including preoperative evaluation, specific implant- and autologous-based considerations, as well as techniques to optimize and correct nipple-areola complex position. Management strategies for complications necessary to salvage a successful reconstruction are also reviewed. Lastly, techniques to expand indications for NSM and maximize nipple viability as well as preshape the breast are discussed. Through thoughtful preoperative planning and intraoperative technique, ideal aesthetic results in NSM may be achieved.

How to Maximize Aesthetics in Autologous Breast Reconstruction

With continuous technical and functional advances in the field of breast reconstruction, there is now a greater focus on the artistry and aesthetic aspects of autologous reconstruction. Whereas once surgeons were most concerned with flap survival and vessel patency, they are now dedicated to reconstructing a similarly or even more aesthetically pleasing breast than before tumor resection. We discuss the approach to shaping the breast through the footprint, conus, and skin envelope. We then discuss how donor site aesthetics can be optimized through flap design, scar management, and umbilical positioning. Each patient has a different perception of their ideal breast appearance, and through conversation and counseling, realistic goals can be set to reach optimal aesthetic outcomes in breast reconstruction.

Optimizing the Mastectomy Flap to Improve Aesthetic Outcomes

The aesthetics of breast reconstruction inherently rely on both the ablative and reconstructive procedures. Mastectomy flap quality remains one of the most critical factors in determining the success of a reconstruction and its aesthetic outcome. Maintaining the segmental perfusion to the nipple and skin envelope during mastectomy requires preserving the subcutaneous tissue superficial to the breast capsule. Because this layer of tissue varies in thickness among different patients and within each breast, anatomic dissection along the appropriate planes is required rather than a “one-size-fits-all” mentality. A team-based approach between the breast surgeon and plastic surgeon will optimize both the ablative and reconstructive procedures while engaging in a process of shared decision-making with the patient. Preoperative clinical analysis and utilization of imaging to assess individual breast anatomy will help guide mastectomies as well as decisions on reconstructive modalities. Critical assessment of mastectomy flaps is paramount and requires flexibility to adapt reconstructive paradigms intraoperatively to minimize the risk of complications and provide the best aesthetic result.

Mastopexy

Mastopexy and mastopexy-augmentation are commonly performed surgeries to lift ptotic breasts while improving breast shape and volume. Factors that cause breast ptosis include aging, hormonal changes, and weight loss. Common surgical approaches for mastopexy utilize the periareolar, vertical, and wise techniques. All of these techniques incorporate parenchymal rearrangement in addition to skin envelope resection in order to achieve the patient’s aesthetic goals. A plastic surgeon should carefully select the appropriate mastopexy technique based on a patient’s preoperative grade of ptosis, breast shape/volume, and aesthetic goals. Many of these mastopexy techniques can be combined with implant augmentation, either as a single or two-stage procedure in appropriate patients with volume concerns. Revisions tend to be more common after implant-augmentations and may be necessary based on patient concerns and surgeon discretion. This review contains 5 figures, 5 tables, and 14 references Keywords: mastopexy, mastopexy-augmentation, breast lift, breast ptosis, vertical mastopexy, periareolar mastopexy, wise pattern mastopexy, breast surgery

Oncoplastic Approach to Giant Benign Breast Tumors Presenting as Unilateral Macromastia

Benign breast tumors attaining large size constitute an important cause of unilateral macromastia. Their usual treatment involves enucleation or excision with a margin based on pathology and waiting for spontaneous retraction of skin envelope. In very large tumors, this will leave the residual breast deflated and unaesthetic, with spontaneous skin retraction giving unpredictable results. Application of the principles of oncoplastic surgery are helpful in this situation. Here, we present two cases of benign giant tumors—a giant fibroadenoma and a giant lipoma—managed by reduction mammaplasty approach to restore the breast symmetry and aesthetics.

Composite Cartilage-osseous-mucosal Nasoseptal Flap for Reconstruction after Near Total Rhinectomy

Background: Reconstruction of full thickness nasal defects usually requires different donor sites for the external skin envelope, structural elements, and internal nasal lining. In this paper we present a novel single site method for dual inner lining and skeleton repair for full thickness nasal defects with a composite nasoseptal flap and extended pedicle dissection. Methods: A 72-year-old male presented with a T4b melanoma involving the nasal dorsum and left upper lateral cartilage. Following full thickness resection, reconstruction was performed with a nasoseptal flap (NSF) with attached septal cartilage and vomer in conjunction with a paramedian forehead flap. Extended pedicle dissection into the pterygopalatine fossa allowed the NSF to fully cover the defect. Results: The nasal defect was fully corrected. There was no evidence of flap compromise or nasal valve stenosis at 1 month, 2 month, and 1 year follow-up visits. Conclusions: We present here the first successful application of a composite cartilage-osseous-mucosal NSF for multilayered nasal reconstruction. In appropriate patients, this technique may obviate the need for flaps or grafts from extranasal sources, limiting donor site morbidity.

No-Scar Breast Reduction Utilizing Power-Assisted Liposuction Mammaplasty, Loops, and Lipofilling

Background In the context of continuous interest to develop and refine minimally invasive procedures, recent publications reported a scarless approach in breast lifting. Objectives The authors describe a power-assisted lipomodeling technique combined with surgical loops to achieve breast reduction and reshaping with minimal scars. Methods Between 2014 and 2018, a total of 94 patients underwent breast reduction by combined liposuction and loops. Following infiltration of the breasts, liposuction of the outer quadrants and the lower pole was achieved to reduce the breast footprint and the lateral and inferior heaviness of the breast. After multiaxial multiplanar tunnelization, three types of loops were taken around the breast to suspend and elevate the breast skin envelope and parenchyma. Each loop was guided through a 3 mm, three-hole cannula passed through skin stab incisions. The first loop was designed to reduce the breast footprint and enhance the breast projection, whereas the second loop is designed to achieve breast conus remodeling and can be performed three to five times. The third loop was passed circumferentially around the areola and then cephalad along the breast axis and pulled until the desired NAC elevation was reached. Each loop was pulled to achieve the desired breast projection and shape. Results The authors achieved breast reduction with a mean nipple elevation of 7.3 cm, and 88% of patients were satisfied with their breast shape. The total complication rate was 1%, including mild cellulitis in one breast, treated efficiently with oral antibiotics. Conclusions The proposed technique is a novel, simple, and safe alternative to achieve breast reduction and reshaping without a scar.