Autologous fat grafting (AFG) is commonly used in breast reconstruction for volume restoration or contour correction. Our previous study demonstrated that standard decantation yields inferior volume retention compared to active wash and filtration (AWF) and low-pressure decantation (LPS). Building upon these findings, we replaced standard decantation with a new processing technique, active wash with surfactant (AWFS). This study aims to evaluate long-term volume retention among AWF, LPS, and AWFS. A prospective, randomized controlled trial was conducted at our institution between 2023 and 2025. Thirty patients were randomized in a 1:1:1 ratio to receive fat grafting processed by either AWF, LPS, or AWFS. Three-dimensional scans of the upper torso were obtained preoperatively and at 3 months postoperatively. Breast volume was measured using Autodesk Meshmixer, and volume retention was calculated as a percentage of the initial grafted volume. Differences in volume retention across groups were analyzed using one-way ANOVA. The volume of fat injected during the procedure did not differ significantly between groups: 89.0 ± 56.0cm3 for AWF, 125.8 ± 68.9cm3 for LPS, and 127.5 ± 78.7cm3 for AWFS (P=0.33). Average volume retention at 3 months was 55.3% ± 17.2% for AWF, 58.7% ± 17.8% for LPS, and 62.7% ± 15.7% for AWFS. No significant difference in volume retention was observed across groups (P=0.52). Although AWFS demonstrated the highest average volume retention, differences between techniques were not statistically significant. These findings suggest comparable long-term outcomes among the 3 processing methods.

Reconstructing upper-quadrant defects in oncoplastic breast reduction (OBR) can be challenging due to upper-pole concavity after tumor resection. To address this, we adopted a dual-component technique using 2 separate flaps: (1) a superiorly based flap for the nipple-areola complex (NAC) and (2) an inferior advancement flap from the quadrant ipsilateral to the lumpectomy defect, "mirroring" the laterality of the defect. This study evaluates outcomes using this algorithm for superior pole reconstruction in OBR. A retrospective review was conducted of OBR cases performed by a single surgeon from September 2022 to November 2024. All were performed for oncologic indications and used an inferior flap for upper-quadrant volume displacement according to the senior author's algorithm demonstrated in Figure 1. A total of 47 patients (51 breasts) underwent lumpectomy and immediate OBR. Most tumors were located in the upper outer quadrant (UOQ; 70.6%), followed by the upper inner quadrant (UIQ; 29.4%). Superomedial NAC pedicles were used for UOQ defects, and superolateral pedicles for UIQ. All UOQ defects were filled with inferolateral advancement flaps, and all UIQ defects with inferomedial flaps. Over 13.2 ± 7.5 months of follow-up, 15.7% of breasts experienced complications. One breast (2.0%) had upper-pole concavity not requiring revision. Six breasts (11.8%) underwent revision secondary to complications related to radiation (5/6) or dehiscence (1/6). The proposed dual-component mirror flap technique reliably reconstructs superior quadrant defects with low rates of contour deformity.

Implant-based reconstruction represents the most common method of breast reconstruction today. Many surgeons approach implant-based breast reconstruction in 2 stages, with the first stage being placement of a tissue expander at the time of mastectomy. Neoadjuvant chemotherapy can have systemic effects that may place patients at risk for TE/implant loss, infection, wound, and other complications. A retrospective review of all cases of TE breast reconstruction at a single institution between 2017 and 2024 was performed. A total of 210 patients, representing 319 total breasts that underwent reconstruction, met the inclusion criteria. Sixty-five patients underwent neoadjuvant chemotherapy and 145 did not. Patients were separated into neoadjuvant chemotherapy (NACT) and nonneoadjuvant chemotherapy (non-NACT) cohorts. Primary outcomes of TE loss, wound, infection, and seroma were analyzed. Regression analysis was performed, matching patients for known risk factors. The rate of all-cause TE loss in patients who underwent NACT was 18%, and 11% for patients who did not. The rate of pathologic TE loss was significantly higher at 14% in patients who underwent NACT and 7% in patients who did not undergo NACT (P=0.032). On regression analysis, neoadjuvant chemotherapy increased the rate of all-cause and pathologic TE loss by 17% (P<0.05). There were no statistically significant differences in wound, seroma, and infection. In this study, neoadjuvant chemotherapy is an independent risk factor for TE loss after immediate tissue expander-based breast reconstruction. Further analysis of adjuncts, implant factors, and specific chemotherapeutic agents is needed.

Forefoot and heel fat pad atrophy are debilitating conditions that compromise structural integrity of the plantar soft tissues, resulting in pain and disability. This localized destruction of soft tissue integrity has been associated with increased age, diabetes, and repetitive trauma. Although autologous fat grafting has shown improvements to short-term patient pain levels and quality of life, there is limited evidence as to the long-term benefit of this treatment. This study aims to evaluate the long-term outcomes of autologous fat grafting to the foot for fat pad atrophy treatment. This was a cross-sectional long-term follow-up of patients who underwent autologous fat grafting for pedal fat pad atrophy between 2015 and 2018. Patients received grafting at presentation (interventional cohort) or after 1 year of conservative management (crossover cohort). Demographic and procedural data were collected. Patient-reported outcomes were assessed using the Manchester Foot and Disability Index (MFDI) at baseline, final in-office follow-up, and long-term follow-up (mean: 9 y). After correction of raw data outliers, statistical analyses included Fisher exact and Wilcoxon rank-sum for baseline associations, Mann-Whitney U tests for long-term between-group comparisons, and repeated-measures ANOVA for within-group changes in forefoot patients only. Heel outcomes were reported descriptively due to small sample size. Of 36 eligible patients, 25 participated (69.4% response rate; mean follow-up 9.0±1.2 y). Interventional (n=14) and crossover (n=11) cohorts showed no significant long-term differences across all domains (pain, function, appearance, work/leisure). Forefoot grafting significantly improved appearance (mean change: -2.9 to 0.8, P<0.001) but demonstrated functional decline at long-term follow-up (mean: 12.9 to 7.2, P=0.020). Heel grafting was associated with durable functional improvement (median difference, P=0.004) and trended towards pain reduction, although appearance outcomes were lower compared with forefoot patients (P=0.002). Work/leisure outcomes showed no significant long-term differences (P=0.087). Autologous foot grafting confers durable, site-specific benefits nearly a decade post-procedure. Heel grafting restores long-term function, whereas forefoot grafting primarily improves cosmesis. Importantly, timing of grafting (immediate vs. delayed) does not alter durability, underscoring the need for location-specific treatment counseling and potential repeat procedures in forefoot patients.

Secondary cleft lip deformities (SCLD) are common, diverse, and individually unique due to their multifactorial etiology and varied clinical presentation. They are the result of postoperative complications of primary cleft lip repair, such as lip dehiscence, delayed wound healing, hematoma, infection, trauma, suture abscesses, poor operative planning, and inadequate surgical technique. The broad spectrum of these deformities and the absence of a standardized stratification framework necessitated the development of a comprehensive and universally applicable classification system. This system was designed to provide a simplified, consistent approach to identifying and categorizing residual cleft deformities. By doing so, it enhances communication among cleft care providers and facilitates the planning and execution of appropriate corrective procedures. The proposed classification organizes SCLD into 5 types (type I to V) based on the anatomic structures involved: skin, mucosa, orbicularis oris muscle, nose, and premaxilla. Each type corresponds to a specific pattern of tissue involvement and is associated with a tailored surgical approach described in this chapter. A careful preoperative assessment using this classification system significantly improves surgical planning, guides anesthetic considerations, ensures more accurate time and resource allocation, and promotes effective interdisciplinary communication.

Fat grafting is widely used in reconstructive and aesthetic surgery, but outcomes can vary due to inconsistent fat survival. Cryopreservation offers a way to store excess adipose tissue, potentially reducing the need for repeated harvesting. However, the impact of cryopreservation on the viability and functionality of adipose tissue components remains unclear. This study evaluated the survival, regenerative potential, and biological contributions of cryopreserved adipose-derived stem cells (ADSCs), stromal vascular fraction (SVF), fat graft, and tissue cocktail in a rat model. Inguinal fats harvested from 48 immunocompetent male Wistar rats were processed into ADSCs, SVF, fat graft, and tissue cocktail. These components underwent a standardized cryopreservation protocol for 3 months, followed by autologous transplantation into the contralateral inguinal fat. Histological, immunohistochemical, and morphological evaluations assessed tissue viability, angiogenesis, and adipogenesis at 4 and 8 weeks to evaluate the components' behavior as grafts. ADSCs and SVF groups demonstrated superior regenerative potential, as evidenced by significant weight increase in the ADSCs-SVF group at weeks 4 and 8 (P = 0.037, Cohen's d = 1.79), indicating progressive tissue remodeling and active growth. VEGF expression was significantly elevated in the ADSCs, SVF, and ADSCs-SVF groups compared to controls (P < 0.05), with enhanced adipogenesis and angiogenesis confirmed histologically. Inflammatory response, edema, and fibrosis were significantly reduced in these groups (P < 0.001), and no necrosis was observed. In contrast, the fat graft and tissue cocktail groups exhibited severe inflammation, increased necrosis, and giant cell accumulation, despite displaying the highest VEGF and Ki67 expression (P < 0.001), suggesting prolonged and severe inflammation that can lead to dysfunction. Cryopreserved ADSCs and SVF are superior adipose-derived components for repeat fat grafting procedures. They preserve graft volume and significantly promote angiogenesis and adipogenesis while minimizing inflammation and tissue damage. These findings support their potential for enhancing long-term graft survival and tissue regeneration in clinical applications.

Gross breast asymmetry, characterized by significant differences in size or shape between breasts, poses both psychological and surgical challenges. Achieving optimal symmetry requires a tailored approach that balances patient preferences with surgical precision. This study evaluates a sequential strategy for managing breast asymmetry through a combination of augmentation and reduction techniques, enhanced by Crisalix 3D imaging software (version 2) for preoperative planning. Three patients presenting with varying degrees of breast asymmetry were included, each undergoing individualized surgical correction based on their specific anatomical characteristics. Preoperative planning involved 3D software simulation to determine implant sizes corresponding to patients' desired postoperative appearance, alongside external sizers to validate volume projections. Outcomes were assessed through clinical and photographic evaluations, a 5-point Likert scale for satisfaction, and complication rates. Across all cases, high satisfaction scores (average 4.7/5) were achieved, with notable improvements in symmetry. Minor scar hypertrophy was observed in one patient, which improved with silicone gel application. The integration of 3D imaging software significantly enhanced preoperative decision making and patient communication, allowing for more precise implant selection and improved prediction of post-operative outcomes. The sequential approach proved advantageous by providing a clean surgical field, reducing infection risks, and offering a stable reference for tissue removal during contralateral procedures. This approach also facilitated preoperative discussions with patients regarding their desired breast size, allowing informed decision making aligned with their preferences. A carefully planned sequential strategy, augmented by advanced imaging technology, offers a logical, patient-centered method for correcting breast asymmetry, minimizing complications and optimizing outcomes. Future studies integrating advanced imaging and planning tools may further enhance surgical precision and patient satisfaction.

After studying this article, the participant should be able to (1) understand the nonsurgical and surgical techniques and advancements in the management of pediatric head and neck cancers, (2) describe the common management strategies used in pediatric head and neck cancers, and (3) Understand therapies to target head and neck cancers within pediatric patient populations. Pediatric head and neck cancer management is complex and often requires a multidisciplinary approach. Management goals aim to deliver a multimodal treatment approach that integrates surgery with concurrent medical management through adjuvant and/or neoadjuvant chemotherapy and/or radiation therapy. Patients in remission should be monitored closely for recurrence or long-term treatment complications. Harmonizing a multidisciplinary approach between pediatric oncologists, hematologists, radiologists, pathologists, and surgeons is a priority. This review discusses advances in management strategies used for common pediatric head and neck malignancies, with a focus on surgical and medical techniques as well as treatment complications that can arise.

Endoscopic suturectomy is increasingly favored over open cranial vault reconstruction for coronal synostosis patients due to decreased morbidity. However, ensuring an accurate craniectomy is challenging due to anatomical changes inherent to coronal synostosis. Given the improved intraoperative efficiency and postoperative outcomes previously seen with the use of virtual surgical planning (VSP) in traditional open craniosynostosis correction, we sought to utilize VSP to optimize the endoscopic correction of coronal craniosynostosis. Patients who underwent endoscopic-assisted suturectomy for unicoronal or bicoronal craniosynostosis from 2020 to 2024 were retrospectively reviewed. In one cohort, a surface marking guide was developed with VSP to facilitate percutaneous tattooing of the periosteum. These marks were then followed to confirm craniectomy completion after subgaleal exposure. The VSP- and non-VSP-guided cohorts were compared for patient demographics, estimated blood loss, operative time, and length of stay. Seventeen patients were included who underwent 12 unilateral and 5 bilateral suturectomies. Eight patients (4 unicoronal and 4 bicoronal) compared to 9 patients (8 unicoronal and 1 bicoronal) were in the VSP and non-VSP cohorts, respectively. Overall EBL for unilateral cases was 12.1 ± 7.5 mL. Patients who underwent VSP had equivalent EBL to the non-VSP cohort (10.0 ± 1.0 mL vs 13.1 ± 19.2 mL, P = 0.53). For bilateral cases, EBL for the VSP cohort was 28.8 ± 30.9 mL compared to 50 mL for the one bilateral non-VSP guided case. Patients who had VSP guidance had significantly reduced operative time for unilateral cases (63±17 vs 81± 20 minutes, P < 0.01). For bilateral cases, VSP guidance was 78 ± 26 minutes compared to 118 minutes for the one bilateral case with non-VSP guidance. Using VSP to assist endoscopic coronal suturectomy reduces operative time, which may reflect a decreased reliance on intraoperative assessment and increased fidelity of neosuture placement.

A chest wall defect after resection of a recurrent desmoid tumor of the right breast was reconstructed with a TRAM flap over a Gore-Tex graft. The tumor had involved 2 ribs, and the wide resection included 5 ribs with a portion of the lateral sternum. After the wide resection to effectively manage this aggressive, invasive lesion from the anterior chest of a 42-year-old woman, a 2-mm Gore-Tex graft was directly sewn in place to bridge the defect. A TRAM flap based on the left rectus abdominis muscle was delivered to the right chest to close the defect. The TRAM flap was initially well perfused and adequately reconstructed the chest wall defect. A clinical exam 6 hours after surgery found the flap pink, warm, and healthy. Within 18 hours of surgery, venous congestion of the distal TRAM flap was observed. Because of scarring from previous chest surgery and tightness of the flap, flap adjustment or advancement was not possible. Leech therapy was employed over 4 days. Twenty-six leeches alleviated the venous congestion and produced a persistent oozing that facilitated blood flow and oxygen delivery through hemodilution. The hospital had no established protocol for leech therapy, so there was resistance from the medical and nursing staff. The leeches were kept in the author's home refrigerator and personally driven to the hospital for each application over the 4 days. The leech therapy salvaged the congested flap, and the reconstruction successfully protected the heart and lungs. Radical resection of a desmoid tumor was the preferred management in 1993. The application of leeches to a myo-cutaneous flap was a novel approach. The leech therapy proved effective in reducing congestion and salvaging the TRAM flap reconstruction. Hemodilution was induced, which helped with tissue perfusion. Chest reconstruction continued in stages and included a solid silicone pectoralis implant inserted to add a rigid, more protective cover of the heart and lungs. Breast reconstruction with bilateral silicone gel implants produced a result acceptable to the patient. The desmoid tumor has not recurred.