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Innovative Surgical Sciences

The Rapid Journal of the German Society of Surgery

Editor-in-Chief: Jähne, Joachim

Editorial Board: Dziki, Adam / Jauch, Karl-Walter / Karpeh, Martin S. / Kitajima, Masaki / Mansfield, Paul / Pohlemann, Tim / Primrose, John / Hang-Kwang, Yang

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Masterclass - How to improve your aesthetic results in plastic surgery

1st International Summer Symposium on state of the art and upcoming innovations / 25-26 MAY 2018 | HANNOVER

Published Online: 2018-05-10 | DOI: https://doi.org/10.1515/iss-2018-3001

O 01 - Case report

Locked Cheek Lift (LCL): three dimensional cheek lift and inferior palpebral rejuvenation

M. Divaris1, *E. Sabri2

1 Private Practice, Paris, France

2 Private Practice - Cabinet medicale, Paris, France

Background: Many recent advances in face lift techniques have been made to reverse the aging process of the midface. In this study we present a new technique by which mid-face rejuvenation can be achieved in double angle vectors and allows adaption to the underlying bony structure.

The locked cheek lift (LCL) allows effective, simple and rapid lifting of the malar fat pad in two planes. Correction of the curvature of the face and reduction of the height of lid cheek junction distance can be achieved without an incision at the lower eyelid.

Methods: 115 patients (77 females, 38 male) have been operated using the LCL technique by a single surgeon, age ranging between 37 to 71-years-old (average = 51). Follow up was performed by the same team for a year postoperatively. The facial expression and lid cheek distance have been evaluated during this period.

Results: After a year from the operation, the lid cheek distance correction has been found to be maintained in 95.7 % of the cases, with stable position of the ascended malar fat pad. The postoperative edema and ecchymosis were limited.

Conclusion: LCL is an effective, simple and rapid surgical technique which is capable of correcting the cheek gravitational migration, reduce the lid cheek distance (LCD), maintain ascended stable malar fat pad for long time with a short recovery period and minimal risk of complications.

O 02 - Case report

A novel subcutaneous pedicled propeller flap method to repair defects of the lateral mid-cheek region

*I. Juhasz1

1University of Debrecen Clinical Center, Burns Unit, Dept. Dermatology, Debrecen, Hungary

Introduction: Appearance of tumors over the cheekbone is quite common due to extensive UV exposure of this region. Removal of these lesions with margin control (Mohs micrographic surgery, etc.) usually leaves large defects on a cosmetically very important area, in close proximity to the lower eyelid.

Objectives: There are numerous options to reconstruct such a defect. Most of the methods require the mobilization of large healthy tissue (Imre’s flap, large rotation flaps), or are cosmetically inadequate (free grafting). One surgical gem is proposed in the presentation.

Materials and Methods: A new subcutaneous pedicled “propeller” flap method was developed. Usually the skin on the facial plane lateral to the zygomatic arc is loose enough to allow preparation of a flap. The horizontally oriented flap then can easily be rotated into the defect. Technically a subcutaneous pedicled flap with an asymmetric (propeller) design can be made with a curved fusiform shape that fits into the cosmetic unit. Its final shape is adjusted to the requirements, defined by the special location.

Results: In our clinical experience with 25 patients the described flap was viable, the 180 rotation of the pedicle did not compromise blood supply, and the occasional initial bulkiness of the pivot point disappeared over the time. Ectropion was never observed, due to the facial lift created by the closure of the donor site.

Conclusion: The described flap is a suitable, minimally invasive tool for reconstructions in the lateral mid-cheek region area. The donor site closure creates an additional factor that reduces the risk of lower eyelid ectropion. This method has successfully made it into our daily routine for closure in this cosmetically important region.

O 09 - Case report

Reconstruction of the moustache using a thin, free hair bearing flap

*N. Dellmann1, G. Udrescu1, S. Bushart1, P. Kirchhoff1, L. Wellkamp1, A. Ring1

1St. Rochus Hospital Castrop Rauxel, Plastic Surgery, Castrop-Rauxel, Germany

Introduction: The reconstruction of dog bite injuries in the perioral region can easily be achieved using local flaps or full thickness skin grafts. However, in some cultures a descent moustache is very important for men which forbids the use of distorting local flaps.

Objectives: The goal is to reconstruct the moustache region without distortion of the perioral area using a hair-growing flap.

Patients and Methods: The patient suffered a dog bite injury of the perioral region and was first reconstructed using a local flap. (Picture #1) However, he demanded a descent moustache which was of outstanding importance for him. The method of choice was a free hair bearing cutaneous temporoparietal fascia flap including the temporalis vessels similar to the method of Juri who described this flap as a pedicled one. (Picture #2) Recipient vessels are found in the angularis region. The direction of hear growth must be taken into consideration.

Results: The very thin cutaneous hair-bearing flap managed to reconstruct the perioral region without distortion. The patient was happy with the result. The picture (Picture #3) shows an early result after the operation with still active scars und swelling, but neat growth of hair and symmetric borders of the beard.

Conclusion: The free cutaneous hair bearing temporo-parietal fascia flap is a versatile method for reconstruction of the moustache with a minimal donor site morbidity.

P 1 - Poster

Optimization of periorbicular aesthetic reconstructions

*H. Haffner1, K. Berger1

1HeumarktClinic Privatpraxis, Köln, Germany

Introduction: The term periorbital reconstruction means more than a common blepharoplasty. Aesthetic reconstructions should work also as a rejuvenation in older age but shouldn’t cause an older or unnatural look even in younger age.

Objectives: To outline new perspectives in today’s aesthetic facial reconstructions, to show new trends for changing of the facial aesthetic.

Materials and Methods: Methods of lifting and volume restoration were applied in synergy, as follow: the orbicular muscle augmentation blepharoplasty, the orbicular transpositions browlift, the endoscopic pretrichal forehead and brow lift, the whole face volume restoration and facial feminisation.

Results: More effectiveness and less invasivity using the new methods. The combination of volume restoration with lifting is always better, as a using one of the methods alone. The authors minimal scar pretrichal brow and forehead -lift seems to have advantages against all other kinds of brow lift. Post blepharoplasty hollowing can be prevented by orbicularis and fat augmentation blepharoplasty. The safe transconjuctival lower lid blepharoplasty seems to replace the common way using skin incision especially in combination with canthopexy and laser skin treatment.

Conclusion: The presentation reveals, that many new trends developed in the orbicular and periorbicular facial plastic surgery in the last years, which need further presentations and discussion. The editors calls plastic surgeons to participate in the presentation of new methods in the eyelid and peri-orbicular surgery to be an author in the upcoming special issue of the Journal Plastic Aesthetic Research. This special call is a promotion for all experts or even for young plastic surgeons for a free publication in the new trends of eyelid and periorbicular rejuvenation.

O 04 - Case report

Autologous fat grafting: a possible first line option in breast reconstruction

*D. Cruz1, S. Stenske1, I. Röder1, C. Varnava1, D. Tsvetkova1, M. Kanakidou1, N. Münstermann1

1Fachklinik Hornheide, Plastic Surgery, Münster, Germany

Introduction: Some degree of breast asymmetry is almost inherent in normal female breasts. However, when the difference in shape and size of the breast and nipple-areolar complex is considerable, it may cause a great psychosocial impact over the young female. Surgical correction is then the only option.

Objectives: Autologous fat grafting has long been used to treat soft tissue defects with very distinct results but still remains a second line option in breast reconstruction. Hence, we present a paradigmatic case of an extreme developmental breast asymmetry in a young female that required a combination of different surgical techniques, including lipofilling.

Case: A 34-year-old female arrived to our unit asking for a correction of a high degree developmental breast asymmetry with a combination of left breast hypoplasia and simultaneous right breast ptosis (Fig.1). After careful assessment, a left side tissue expander was placed in the lower pole through a periareolar incision, followed by several fillings to a maximum volume of 220ml. Five months later, a total of 130ml of autologous fat was injected for the first time over the superior breast poles. The expander was then removed and two further autologous fat injections of 100ml and 150ml were performed. One year after the initial surgery, the patient underwent a right-side Lejour vertical breast reduction with simultaneous nipple-areolar complex reduction, as well as two further left side lipofillings.

Results: A 2-month postoperative view (Fig.2) The patient evaluated the result as “very good”. According to our experience, the outcome is aesthetically pleasing and shows a marked improvement in terms of symmetry of volume, shape and ptosis of both breasts.

Conclusion: Despite some unpredictable survival of fat grafts, we show that it can be a reliable filler, along with its easy accessibility to correct even the most severe deformities. It can lead to a more natural breast appearance than implant alone, without its well-known associated risks.

O 05 - Case report

Incorporating the patient’s aesthetic wishes and expectations in plastic reconstructive surgery of the breast

*M. Busche1

1Leverkusen Hospital, Department of Plastic and Aesthetic Surgery and Burns, Leverkusen, Germany

Question: While most women have high expectations regarding the result of breast reconstruction, some ask for aesthetic changes exceeding the reconstructive character of the procedure. To what extent can these wishes be realized in a responsible manner? Which biomechanical principles should be respected and which techniques should be used to perform the reconstruction with simultaneous aesthetic changes as safely as possible?

Methods: We present cases of breast reconstruction in young women with breast cancer or mamma asymmetry, asking for simultaneous breast augmentation or lifting and evaluate the performed procedures, the underlying biomechanical principles and the required steps to achieve the desired results.

Results: In two patients with mamma carcinoma and an extremely thin skin envelope following nipple-sparing double mastectomy, we reconstructed both sides with sub-pectoral implants and an acellular dermal matrix (ADM). To achieve a significant breast augmentation in the first patient, implant size was chosen to both augment the patient’s breasts, but also to avoid stretching forces on the skin. In a second patient, we reshaped and lifted the breasts with an ADM without reducing the excessive skin to protect perfusion of the thin skin envelope. Based on the shrinking capacity of the skin, we achieved a good final result. In a third patient, we corrected the mamma asymmetry, augmented the breasts and reshaped the belly and thighs in two lipofilling procedures.

Conclusion: When respecting the biomechanical principles in breast reconstruction, it is possible to incorporate the patient’s aesthetic wishes. In patients with thin subcutaneous skin envelopes, the use of an ADM is highly recommended and reduction of a thin skin envelope is not always necessary. Lipofilling is a useful tool in mamma asymmetry and can be combined with the patient’s wish for long-term breast augmentation and body shaping improvements.

O 06 - Case report

A safe and simple salvage procedure after a desastreous course of a breast reconstruction in breast cancer

*U. Tanzella1, K. Ueberreiter1

1Parkklinik Birkenwerder, Birkenwerder, Germany

Question: After extensive reconstructions applying flaps and/or implants following a mamma carcinoma, we repeatedly see patients asking for simple and safe methods of reconstruction, which are accompanied by minimal scars and low risk of complications in the postoperative course. We present a case of a bilateral mastectomy, which occured as a result of a sum of complications during the reconstruction procedure. We show, how we solved the problem with simple and safe surgical procedures.

Method: The following patient suffered from bilateral breast cancer. She underwent a bilateral subcutaneous mastectomy and immediate breast reconstruction with implants. Subsequently she developed a persistent seroma and skin necrosis. The implants had to be removed and the skin defect was covered with local skin flaps. Disorders of wound healing and infections of the tissue led to a complete loss of both breasts. (Figure)

With this finding the patient presented in our clinic.

The following procedures led to a reconstructed breast:

  • Fat transplantations (five times)

  • Abdominal advancement and expander implantation (once)

  • Let offs of the expanders and fat transplantations (twice)

Results: With the methods described above we achieved a good result. We could create an appropriate volume, a stable inframammary fold, and a good symmetry. The patient was satisfied with the simplicity of the interventions.

Conclusion: There is a way of safe and simple surgery as salvage procedures after a desastreous situation of a complicated breast reconstruction.

P 2 - Poster

Optimization of breast reconstruction results using the TMG flap: evaluation of several refinements addressing flap design, shaping techniques and reduction of donor site morbidity

*S. Nickl1, J. Nedomansky1, C. Radtke1, W. Haslik1, K. Schrögendorfer1

1Medical University of Vienna , Division of Plastic and Reconstructive Surgery , Vienna, Austria

Question: The transverse myocutaneous gracilis flap is a widely used alternative to abdominal flaps in autologous breast reconstruction. However, secondary procedures for aesthetic refinement are frequently necessary. Herein, we present our experience with an optimized approach in TMG breast reconstruction to enhance aesthetic outcome and to reduce the need for secondary refinements.

Methods: We retrospectively analyzed 37 immediate or delayed reconstructions with transverse myocutaneous gracilis flaps in 34 women. Four patients (five flaps) constituted the conventional group (non-optimized approach). Thirty patients (32 flaps; modified group) underwent an optimized procedure consisting of modified flap harvesting and shaping techniques and methods utilized to reduce denting after rib resection and to diminish donor site morbidity.

Results: Statistically significant fewer secondary procedures (0.6±0.9 versus 4.8±2.2; p<0.001) and fewer trips to the operating room (0.4±0.7 versus 2.3±1.0 times; p=0.001) for aesthetic refinement were needed in the modified group as compared to the conventional group. In the modified group, four patients (13.3%) required refinement of the reconstructed breast, seven patients (23.3%) underwent mastopexy/mammoplasty or lipofilling of the contralateral breast, and four patients (13.3%) required refinement of the contralateral thigh. Total flap loss did not occur in any patient. Revision surgery was needed once.

Conclusion: Compared to the conventional group, enhanced aesthetic results with consecutive reduction of secondary refinements could be achieved when using our modified flap harvesting and shaping techniques, as well as our methods for reducing contour deformities after rib resection and for overcoming donor site morbidities.

P 3 - Poster

Venous superdrainage in DIEP breast reconstruction: the impact of superficial inferior epigastric vein dissection on abdominal seroma formation

*J. Nedomansky1, S. Nickl1, C. Radtke1, W. Haslik1, K. Schrögendorfer1

1Medical Universtity of Vienna, Department for Plastic and Reconstructive Surgery, Vienna, Austria

Question: Abdominal seroma formation after DIEP breast reconstruction is a common donor site complication. Additional dissection of one or both of the superficial inferior epigastric veins (SIEVs) in DIEP flap breast reconstruction allows an additional anastomosis for venous superdrainage if venous congestion occurs. However, generally, SIEV dissection involves greater invasiveness into the inguinal region, which can traumatize lymphatic tissue and lead to lymph accumulation. The aim of this study was to evaluate the impact of SIEV dissection on postoperative abdominal seroma incidence.

Methods: A series of 100 consecutive cases performed by the Department for Plastic and Reconstructive Surgery at the Medical University of Vienna from 2001-2016 was analyzed. Patients were divided into three groups: unilateral, bilateral, and no SIEV dissection. Abdominal seroma rates, length of hospital stay, abdominal drainage duration, and drainage fluid volumes were compared retrospectively.

Results: Seromas were observed in 11.5% of patients without SIEV dissection, 17.2% of patients with unilateral SIEV dissection (p = 0.45 vs. no SIEV), and 40% of patients with bilateral SIEV dissection (p = 0.02 vs. no SIEV). The SIEV was anastomosed to salvage a congested DIEP flap twice. All seromas that developed could be treated with, on average, two fine-needle aspirations without any complications.

Conclusion: Bilateral, but not unilateral, SIEV dissection increased abdominal seroma rates significantly. Venous congestion was observed rarely, but when it did occur, it endangered flap viability. Because an additional anastomosis of the SIEV can salvage a flap, unilateral SIEV dissection should be performed when raising a DIEP flap.

O 07 - Case report

Sub-Muscular Safe (SMS) technique for buttock augmentation with gluteal implants

*F. Petit1, E. Sabri1

1Cabinet Médical Esthétique, Plastic Surgery, Paris, France

Introduction: Buttock augmentation is a growing request in the current plastic surgery practice. Gluteal implants provide the best results, but the procedure still faces strong resistance from patients, as well as surgeons, due to unpredictable results and possible complications.

Materials and Methods: In this prospective study, we evaluate 90 patients (male = 6, female = 84), average age 34-year-old (range = 20-64), in which we applied the same “SMS” (for Sub-Muscular Safe) technique for buttock augmentation with gluteal implants. The gluteal implants are inserted through a 3-4 cm incision in the intergluteal cease, and positionned in a virtual avascular pocket, under (not into) the gluteus maximus muscle. This procedure is routinely performed as a day case procedure.

Results: All patients went back home the same day, after a postop recovery time of 4 to 7 hours. All patients were seen in the medical office postoperatively, in a regular scheduled way for follow-up (follow-up range from 6 months to 3 years). The patients rate of satisfaction is high, with a minimal rate of complication and a short recovery period.

Discussion: With the SMS technique, the implant is located under/behind the gluteus maximus muscle, thus it remains fully covered, and is not visible nor palpable. The muscle acts as a shield for the implant. The SMS technique is a fast, reliable and safe technique for buttocks augmentation with gluteal implants. Complications and uneven results are very rare. The patients’ satisfaction rate is high, due to a fast recovery, with no positionning restrictions, and with stable cosmetic results over time.

Conclusion: The SMS technique is a safe technique of inserting gluteal implants with minimal risk of complications and maximal rate of patients’ satisfaction. We highly recommend it as the gold-standard in buttock surgery with implants, such as buttock augmentation, or buttock uplift and bodylift with gluteal volume restoration.

O 08 - Case report

Avoidance and treatment of persistent lymphorrhea in thigh lift operations

*N. Dellmann1, G. Udrescu1, S. Bushart1, P. Kirchhoff1, L. Wellkamp1, A. Ring1

1St. Rochus Hospital Castrop Rauxel, Plastic Surgery, Castrop-Rauxel, Germany

Introduction: The upcoming higher demand in thigh lift operations both in weight loss and aesthetic patients requires a reduction or treatment of one of the most annoying and persistent complications: lymphorrhea, often mistaken as a “seroma”.

Objectives: The goal was to reduce and treat the complication of lymphorrhea.

Patients and Methods: The ICG fluorescence angiography in the area to be resected shows the presence of strong lymphatic vessels (picture #1). Instead of an excision of skin and fat, and thus lymphatic vessels, the liposuction allows us enough tissue debulking with preservation of lymphatic vessels. A simple skin excision above the liposuctioned area enables us to lift the medial thigh’s skin system. The picture (see picture #2) shows the intact lymphatics, veins and nerves.

The second case shows the treatment of disrupted and persistent leaking lymphatic vessels with thorough resection of the lymphocele (see picture #3), lympho-venous anastomosis and the following stop of lymphatic leakage.

Results: The combination of a hockey-stick incision and liposuction in thigh lift helps to gain an optimal result without lymphorrhea, “seroma”, nerve damage and no delayed wound healing.

The reconstruction of the lymphatic drainage drys out the lymphorrhea.

Conclusion: Liposuction assisted resection helps in avoiding lymphatic complications, but further follow up for long term results is required, as it is not always possible to peg up the deep Scarpa fascia. Lymphoceles should not be mistaken as a “seroma” and require a reconstruction of the lymphatic pathway to dry out.

O 10 - Case report

Circumferential degloving injury of the lower limb - optimizing aesthetic results of skin grafts

*B. Antoszewski1, A. Kasielska-Trojan1

1Medical University of Lodz, Plastic, Reconstructive and Aesthetic Surgery Clinic, Institute of Surgery, Lodz, Poland

Introduction: Degloving injury includes detachment of the skin and subcutaneous tissue from the underlying fascia and muscles. Usually it affects extremities and causes major problems during treatment, often in plastic surgery departments. Due to the range of tissue damage, high infection rate and massive blood loss, such treatment is time-consuming and the functional and aesthetic results are often poor. Objectives: To present the course and results of treatment of a patient after circumferential degloving injury of the lower limb.

Materials and Methods: In this case report we described a complex treatment of a patient after circumferential degloving injury of the lower limb.

Results: Complex treatment included surgical procedures (necrectomies, skin grafts) and additional therapies (hyperbaric chamber, negative pressure therapy). Finally, a good functional and aesthetic effect was obtained.

Conclusion: Circumferential degloving injury represent a unique challenge for reconstructive surgeons. Application of additional non-invasive therapies may help to optimize aesthetic effects of skin grafts in such patients.

About the article

Published Online: 2018-05-10

Citation Information: Innovative Surgical Sciences, Volume 3, Issue s2, Pages s1–s14, ISSN (Online) 2364-7485, DOI: https://doi.org/10.1515/iss-2018-3001.

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© The Author(s) 2018, published by De Gruyter, Berlin/Boston. This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 License. BY-NC-ND 4.0

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