Favorable Cosmetic Outcome Research Articles

Scoring System for Evaluating Cosmetic Appearance in Operated Hypospadias Patients

Background: Hypospadias is a common congenital anomaly affecting male infants, characterized by abnormal positioning of the urethral meatus. Surgical correction aims to achieve both functional and cosmetic outcomes.Objective: To evaluate the cosmetic outcomes of hypospadias surgery using a standardized scoring system.Methods: A prospective observational study was conducted at Shaheed Mohtarma Benazir Bhutto Institute of Trauma from January to July 2023, including 154 male infants and young children who underwent primary hypospadias repair.The surgeries performed were Tubularized Incised Plate (TIP) urethroplasty, Onlay Island Flap, and Mathieu repair. Cosmetic outcomes were assessed using the Hypospadias Objective Scoring Evaluation (HOSE) system. Data were analyzed using SPSS version 25.Results: The mean age at surgery was 2.8 years. Distal hypospadias was most common (62%), followed by midshaft (28%) and proximal (10%). TIP urethroplasty had the highest mean HOSE score (15.4 ± 1.0), with 86% achieving satisfactory outcomes. Onlay Island Flap scored 14.9 ± 1.2, and Mathieu repair scored 14.2 ± 1.5. Residual penile curvature was noted in 15% and scarring in 12% of cases.Conclusion: TIP urethroplasty yielded the most favorable cosmetic outcomes in distal hypospadias. Standardized scoring systems are crucial for evaluating surgical success.

Transoral robotic thyroidectomy: Lessons learned from consecutive series of 1,000 patients

BackgroundTransoral robotic thyroidectomy has gained popularity as a promising approach for thyroid surgery owing to its improved cosmetic outcomes. The objective of this retrospective study was to describe the surgical and safety outcomes of 1,000 consecutive transoral robotic thyroidectomy cases. Methods1,000 consecutive patients who underwent transoral robotic thyroidectomy for thyroid disease were reviewed at a large metropolitan tertiary hospital (Seoul, Korea) between September 2012 and March 2022. ResultsThe study comprised 1,000 patients (815 women), with 891 cancer cases. Lobectomy was the most common procedure (89.4%), followed by total thyroidectomy (9.8%) and isthmusectomy (0.8%), and their respective mean total operative times were 173.8 ± 36.2, 236.8 ± 50.5, and 107.5 ± 19.8 minutes. An obvious learning curve was noted. The respective postoperative pain scores on postoperative days 0, 1, and 2 were 4.6 ± 1.3, 3.1 ± 0.8, and 2.5 ± 0.8. The mean postoperative hospital stay duration was 2.6 ± 0.9 days. Complications occurred in 3.6% of cases, including oral wound infection, skin flap burn, bleeding, chyle leakage, transient and permanent mental nerve injury, and transient and permanent recurrent laryngeal nerve injury. Transient hypoparathyroidism occurred in 4.1% of total thyroidectomy cases. Thirty-seven patients (4.2%) underwent additional radioactive iodine therapy. The median follow-up period was 39 months, and there were no cases of recurrence. ConclusionsUnder the expertise of an experienced surgeon, transoral robotic thyroidectomy results in favorable cosmetic outcomes, tolerable postoperative pain, and acceptable complication rates in carefully selected patients.

Gasless trans-axillary endoscopic versus conventional open hemithyroidectomy for thyroid cancer patients: A propensity score-matched analysis of quality of life and oncological outcomes: A cross-sectional questionnaire study

BackgroundThyroid cancer predominantly affects young females who seek surgical intervention not only for excellent oncological outcomes but also for a high quality of life (QOL) and favorable cosmetic and functional outcomes. The gasless trans-axillary endoscopic (GTAE) approach is a commonly used remote access technique for thyroid surgeries. It holds the potential for comparable oncological outcomes and superior QOL, cosmetic, and functional outcomes. However, robust evidence supporting this hypothesis is scarce. Materials and MethodsWe collected data from patients diagnosed with papillary thyroid carcinoma who underwent hemithyroidectomy with central compartment dissection at Peking Union Medical College Hospital (PUMCH) between December 2019 and January 2023. After applying propensity-score matching analysis (PSMA), a total of 424 cases were included. For oncological outcomes, patients in both groups were prospectively followed through regular outpatient visits. The QOL, functional, and cosmetic outcomes were assessed using a cross-sectional online questionnaire, including EORTC-THY34 for QOL, PSAQ for cosmetic outcomes, SIS-6 for swallowing functions, and VHI-10 for voicing functions. We further compared oncological outcomes, QOL, functional, and cosmetic outcomes between these two groups. ResultsA total of 274 cases provided validated responses: 141 underwent the GTAE approach, and 134 underwent the conventional open (CO) approach. The operation time was approximately 60 minutes longer in the GTAE group. Notably, there was no difference in complications between the two approaches. Rates of suspicious recurrence in both groups remained low and showed no significant differences (2.55% vs. 1.57%, p>0.05). No pathological confirmed recurrence was reported in either group. Patients with the GTAE approach showed better body image and less joint pain (EORTC-THY34), better swallowing (SIS-6), and better cosmetic outcomes (PSAQ). Voice outcomes showed no difference between these two approaches (VHI-10). ConclusionCompared to the CO approach, hemithyroidectomy with central compartment dissection via the GTAE approach in low-risk patients maintains comparable oncological outcomes while offering better QOL, cosmetic benefits, and functional outcomes.

A coddling of the sagittal suture: inequality in spring-assisted expansion.

We examined differences in long-term morphometric outcomes of spring-mediated cranioplasty (SMC) for various forms of isolated nonsyndromic sagittal craniosynostosis. A retrospective review was performed of children who underwent SMC from 2011 to 2020 at the Children's Hospital of Philadelphia. Cephalic indices (CI), Whitaker grades, parietal bone thickness, and degree of suture fusion were assessed. Frontal bossing and vertex-nasion-opisthocranion (VNO) angles were compared to a normal control group. Fifty-four subjects underwent surgery at age 3.6 ± 1.0 months with follow-up of 6.3 ± 1.8 years. Mean CI was 75.2 ± 4.1 at 5.9 ± 2.0 years postoperatively. Mean CI were 75.8 ± 4.1 (n = 32), 76.4 ± 4.0 (n = 22), and 77.1 ± 4.8 (n = 11) at 5, 7, and 9+ years postoperatively, respectively. Three (5.6%) required reoperation for persistent scaphocephalic cranial deformity. Fifty-one (94.4%) were Whitaker Grade I. On physical examination, 12 (22.2%) demonstrated craniofacial abnormalities. At long-term follow-up, there were no differences in frontal bossing angle (102.7 ± 5.2 degrees versus 100.7 ± 5.6 degrees, p = .052) and VNO angle (44.9 ± 3.3 degrees versus 43.9 ± 2.2 degrees, p = .063) between study and control groups. Younger age at surgery predicted a lower Whitaker grade, more normalized VNO angle, and greater change in CI during active expansion. Increased percentage fused of the posterior sagittal suture predicted a higher Whitaker grade, while decreased anterior fusion was associated with frontal bossing and temporal hollowing. Overall, children undergoing spring-mediated cranioplasty for sagittal craniosynostosis demonstrated maintenance of CI, favorable cosmetic outcomes, and a low reoperation rate at mid-term follow-up. Early intervention is associated with improved aesthetic outcomes, and regional fusion patterns may influence long-term craniofacial dysmorphology.

Lateral canthal reconstruction for the treatment of macroblepharon/diamond eye conformation in dogs.

To introduce a novel surgical technique for treatment of macroblepharon and diamond eye conformation in dogs. Lateral canthal reconstruction was used in dogs with prominent eyelid malformations resulting in ocular surface disease. Lateral canthus was resected and new lateral canthus was created using a two-layer closure. This technique was performed either alone or in combination with additional procedure(s). Additionally, this technique was used to resect lateral canthal dermoid. One hundred and fifty-three eyes of 85 dogs were included in the study. Procedure was done for macroblepharon and/or lateral canthal entropion (149 eyes of 81 dogs) or for lateral canthal dermoid (four eyes of four dogs). Procedure was done either alone (n = 68 eyes) or in combination with additional procedure (n = 85 eyes). Favorable cosmetic outcome and client satisfaction was achieved in all dogs. Good to excellent functional outcome was recorded in all but 6 eyes of 4 dogs, which required additional surgery. Most common complications included slight undercorrection or overcorrection. Lateral canthal reconstruction is a simple yet effective surgical procedure for macroblepharon and/or lateral canthal entropion. If done early, it prevents development of secondary eyelid malformation ("pagoda defect") in giant breed dogs. If done after severe eyelid malformation has developed, combining this technique with concurrent pagoda resection is recommended to achieve ideal eyelid conformation. None.

Minimally invasive versus conventional methods for aortic root surgery: Choosing the right approach.

Partial upper sternotomy is preferred for isolated aortic valve replacement because of its optimal surgical visibility and favorable cosmetic outcomes; however, it is not commonly used for aortic root surgery, and the conventional median sternotomy is still the preferred method for most surgeons. We aimed to compare the safety and effectiveness of a minimally invasive approach (partial sternotomy [PS]) and conventional approach (median sternotomy [FS]) for aortic root surgery. Patients who underwent aortic root surgery at our hospital from 2016 to 2021 were retrospectively enrolled and divided into two groups. After propensity score matching, the conventional group included 156 patients and the minimally invasive group-57 patients. Bicuspid aortic valves were observed in 63 (40.4%) and 33 (57.9%) patients in the FS and PS groups, respectively. Valve-sparing surgery was performed on 69 (44.2%) and 30 (52.6%) patients in the FS and PS groups, respectively. The minimally invasive approach was beneficial in terms of blood loss during the first 24 h after surgery (p = 0.029) and postoperative blood transfusion (p = 0.023). The survival rates and freedom from reoperation or severe aortic regurgitation after the David procedure were comparable between the standard and minimally invasive groups (p = 0.25; p = 0.66) at mid-term follow-up. A minimally invasive approach for aortic root surgery can be safely performed as the standard approach. Partial upper sternotomy has the advantage of lower blood loss in the early postoperative period and does not negatively affect the results of valve-sparing root replacement.

Medial Plantar Artery Flap for Soft Tissue Coverage of Heel Defect: A Case Report

Background: Numerous flap options exist for providing soft tissue coverage for defects on the heel region. This study presents a case where a bone-exposed wound on the left heel region was successfully reconstructed using a medial plantar artery flap. Case Report: A 16-year-old girl presented with a necrotic wound on the left heel region with calcaneus, malleolus, and talus fractures following trans-ankle external fixation on her left leg. After debridement and necrotomy, the wound revealed exposed calcaneus and implant. A medial plantar artery flap was dissected, preserving its vascularization. The flap was then carefully transferred to the wounded area and sutured appropriately. A skin graft harvested from the ipsilateral femoral region was used to cover the donor site. Discussion: This case demonstrates the efficacy of the medial plantar artery flap as a local flap option for heel defect coverage. It is a relatively easy-to-perform procedure that provides a strong and thin skin flap. Moreover, it offers a favorable cosmetic outcome for the patient, as the surgical scar can be be relatively easy to hide with footwear. However, limitations of the medial plantar artery flap include its size and depth constraints, as well as loss of vascularization from a medial plantar artery on the plantar region. Conclusion: The medial plantar artery flap is a feasible option as a local flap for the heel region. It is relatively easy to perform, provides a strong thin skin flap, and can results in a preferable cosmetic outcome.

Controversies in Thyroid Surgery: Debating Transoral Endoscopic Thyroidectomy versus Small Incision Thyroidectomy

In the ever-evolving landscape of thyroid surgery, one cannot ignore the ongoing debate surrounding the optimal approach for thyroidectomy. minimally invasive thyroidectomy techniques have been developed. However, there is currently no single accepted technique in minimally invasive thyroidectomy (MIT) [1]. Proponents of transoral endoscopic thyroidectomy via vestibular approach (TOETVA) advocate for its minimally invasive nature and favorable cosmetic outcomes [2]. Experienced thyroid surgeons performing thyroidectomy with an anterior incision, shortening the classic Kocher incision by 2-3 cm without the need for additional complex instruments with simple preparation and minimal costs, have obtained better cosmetic results compared to open surgery [1]. Supporters of open thyroidectomy with or without endoscopic assistance through a 3 to 4-cm incision (small incision thyroidectomy; SIT) argue that their approach achieves similar minimally invasive results while maintaining the safety and efficacy of traditional open surgery [3,4]. TOETVA has garnered attention for its innovative approach, utilizing a natural orifice—the mouth—as the entry point for thyroidectomy. Advocates of TOETVA highlight its cosmetic advantages, as the incisions are hidden within the oral cavity, resulting in virtually scarless necks. Furthermore, TOETVA offers reduced postoperative pain and faster recovery times than traditional open surgery, enhancing patient satisfaction and quality of life. Proponents argue that the evolution of TOETVA represents a paradigm shift in thyroid surgery, offering patients a less invasive alternative with comparable oncological outcomes [5]. Conversely, proponents of SIT through a 3 to 4-cm incision contend that their approach achieves similar minimally invasive results while preserving the safety and efficacy of traditional open surgery. They argue that the smaller incision size of open thyroidectomy minimizes tissue trauma and postoperative pain, leading to faster recovery times and superior cosmetic outcomes compared to larger incisions (Figure 1,2). Moreover, advocates of SIT emphasize the importance of tactile feedback and direct visualization in ensuring optimal surgical outcomes, which may be compromised in endoscopic approaches such as TOETVA [2,3,5]. Among these contrasting viewpoints, it is essential to recognize that TOETVA and SIT have their respective strengths and limitations. While TOETVA offers the attraction of scarless necks and enhanced cosmetic outcomes, concerns remain regarding its learning curve and technical challenges, particularly in cases of large or multifocal thyroid tumors. Conversely, SIT boasts a long-standing safety and efficacy track record, with established surgical technique and perioperative care principles. However, its neck incision may be perceived as a drawback by patients seeking minimally invasive alternatives. Addressing these controversies requires understanding patient preferences, tumor characteristics, and surgeon expertise. Individualized decision-making is paramount, carefully considering the risks and benefits of each approach. Moreover, ongoing research and innovation are essential to refining surgical techniques and optimizing outcomes in thyroid surgery.

Analgesic effects of pectoserratus plane block and intermediate cervical plexus block for transaxillary endoscopic thyroidectomy: a prospective randomized controlled trial.

Transaxillary endoscopic thyroidectomy (TAET) is favored for its favorable cosmetic outcomes and the preservation of anterior cervical function. Despite these benefits, postoperative analgesia has traditionally relied on pharmacological interventions, and regional anesthetic procedures may be an alternative method. This study aimed to evaluate the efficacy of an ultrasound-guided pectoserratus plane block (PSPB) combined with an intermediate cervical plexus block (ICPB) for TAET. Forty patients undergoing TAET were randomized into two groups: the nerve block group (N.=20) received ultrasound guided PSPB with 20 ml of 0.375% ropivacaine and ICPB with 8 mL of 0.3% ropivacaine, while the control group (N.=20) received no block. The primary outcome was the Visual Analog Scale (VAS) scores for postoperative neck and axillary pain at different time points (1, 6, 12, 24 h) during rest and movement post-TAET. The secondary outcomes included intraoperative remifentanil consumption, incidence of postoperative nausea and vomiting (PONV), number of remedial analgesic requirements, and patient satisfaction postoperatively. Compared to the control group, patients in the nerve block had significantly lower VAS scores of the neck and axilla whether at rest or movement, and 1, 6, 12, and 24 h postoperatively (P<0.0125). The nerve block group showed higher patient satisfaction (P<0.001). No difference was observed in intraoperative remifentanil consumption, need for rescue analgesics, or other adverse effects 48 h postoperatively. Ultrasound-guided PSPB with ICPB significantly alleviated postoperative pain and improved patient satisfaction with TAET.

Treatment of Nevus Sebaceous with Short-term Photodynamic therapy combined with simple Surgery

SignificanceNevus sebaceous is a benign cutaneous hamartoma involving the epidermis, pilosebaceous units, and other adnexal structures. To avoid or minimize the scar, photodynamic therapy (PDT) is recommended as a non-surgical treatment. ApproachIn this report, we present a successful case of recurrent nevus sebaceous treated with a combination therapy of PDT and surgical excision. The patient was followed-up for a period of 6 months to evaluate the effectiveness of the treatment. ResultsThe patient underwent three sessions of PDT at three-week intervals, followed by surgical resection. Following the procedure, there was no recurrence of the lesion after 6 months, and the achieved a favorable cosmetic outcome. ConclusionsIn cases where the nevus sebaceous affects larger areas, employing a short-term PDT regimen in conjunction with surgical intervention proves to be an effective strategy, reducing the extent of surgical excision and yielding superior cosmetic results for our patients.

Modified Valente Technique for Cauliflower Ear: Outcomes in Children at Two-Year Follow-Up

BackgroundCauliflower ear deformity, a common sequela of auricular trauma, presents an esthetic and reconstructive challenge. Existing surgical techniques have limitations, including complexity, donor site morbidity, and variable long-term outcomes.Materials and MethodsIn this case series, we present a novel and minimally invasive surgical approach for the correction of cauliflower ear deformity that adapts the Valente otoplasty technique; it combines cartilage debulking with helical rim release and Mustardé mattress stitches to restore ear contour and reduce the risk of recurrence. The procedural steps include bielliptic post-auricular skin and soft tissue incision, release of the cartilaginous spring, removal of excess fibrocartilaginous tissue, cartilage reshaping with suture to restore contour, and tissue redistribution to promote adherence of skin to the cartilage framework.ResultsOutcomes were evaluated in 7 patients (9 ears) with cauliflower ear deformity, assessing surgical duration, complications, patient satisfaction, and esthetic outcomes at two years after surgery. The mean surgical duration per patient was 52 ± 17 minutes, including 2 bilateral procedures. Follow-up at 24 months showed favorable esthetic outcome in all patients with sustained improvements in auricular contour and symmetry with neither loss of the shape nor recurrence of deformity. Patients reported high satisfaction and improved quality of life, with mean Glasgow Children Benefit Questionnaire scores of 99.3 ± 6.3.ConclusionsThis technique thus demonstrated lasting correction of cauliflower ear with favorable cosmetic outcomes, low risk of complications, and high patient satisfaction. Further investigations and longer-term follow-up are warranted to validate the technique's durability and expand its application to older and more diverse patient populations.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of contents or the online Instructions to Authors www.springer.com/00266.

“Sorting hat” flap as a modification of the classic A-T flap

This article presents a case study featuring a novel modification of the A-T flap, termed the "Sorting Hat" flap, employed in dermatologic surgery for facial reconstruction. In the treatment of an 89-year-old male's squamous cell carcinoma lesion on the forehead, the "Sorting Hat" flap, introduced as an innovative alternative, eliminates the need for Burrow triangles and relies on flap shape for inconspicuous scarring and favorable cosmetic outcomes.

Breast Conserving Therapy for Patients With Prior Cosmetic Implant-Based Breast Augmentation: Outcomes and Comparison Against a Matched Cohort

IntroductionControversy exists regarding potential increased toxic effects in patients with cosmetic implant-based augmentation (CIBA) who receive radiation therapy. We evaluated acute and chronic toxic effects associated with radiation therapy in women with prior CIBA treated with whole-breast irradiation (WBI) as part of breast conserving therapy (BCT) and compared these results against a cohort of patients without prior breast augmentation who received similar therapy. MethodsA retrospective review was performed to identify patients with a prior history of CIBA who subsequently underwent BCT with WBI. The control group consisted of consecutively treated patients without prior CIBA who also underwent BCT with WBI. Analyses included a comparison of baseline and treatment-associated factors between the augmentation and control groups, evaluation of toxic effects between both groups, and multivariable analysis of factors associated with the receipt of additional surgery following radiation. ResultsThirty-six patients with prior CIBA and 135 consecutively treated patients without CIBA were identified. Patients with prior CIBA were treated from 2006 through 2019, and patients without CIBA were treated from 2016 through 2019, though treatment characteristics and median follow-up time were similar between the two groups. Patients with prior CIBA were significantly less likely to experience acute moist desquamation (0% vs. 18%; P = .005). There were otherwise no statistically significant differences in acute (≤ 6 months) or chronic (> 6 months) toxic effects between the two groups. Rates of excellent/good chronic cosmetic outcome were 89% for the CIBA group and 97% in the control group (P = .094). On multivariable analysis, patients without prior CIBA (OR = 0.04; CI = 0.01-0.13; P < .001) and patients treated with moderately hypofractionated irradiation (OR = 0.08; CI = 0.02-0.23; P < .001) were significantly less likely to undergo additional surgery following receipt of WBI. Two patients experienced implant loss following radiation therapy. ConclusionsWBI as part of BCT in patients with prior implant-based breast augmentation appears safe and is associated with favorable cosmetic outcomes. There was an increased need for additional surgery in patients with prior CIBA, but rates of acute and chronic toxic effects appeared similar to those in nonaugmented patients.

Photodynamic Therapy in Treating a Subset of Basal Cell Carcinoma: Strengths, Shortcomings, Comparisons with Surgical Modalities, and Potential Role as Adjunctive Therapy.

Basal cell carcinoma (BCC) is the most common skin cancer, for which there are multiple treatment options, including the gold standard Mohs micrographic surgery (MMS), surgical excision, electrodesiccation and curettage, radiation therapy, cryosurgery, and photodynamic therapy (PDT). While PDT is currently approved for treating actinic keratosis, it has been used off-label to treat BCC patients who may not tolerate surgery or other treatment modalities. We present a review of the efficacy of these modalities and describe important considerations that affect the usage of PDT and MMS. ALA-PDT and MAL-PDT are both efficacious treatment options for lower-risk BCC that can serve as non-invasive alternatives to surgical excision with favorable cosmetic outcomes in patients unsuitable to undergo surgery. In particular, PDT may be considered an adjuvant for the prevention and treatment of BCC lesions in patients with some genetic syndromes such as Gorlin syndrome, and in combination with surgical excision in lesions presenting in certain locations. Limitations to PDT include lack of margin control to prevent recurrence, pain, and cost of certain photosensitizers. Future studies should investigate the role of PDT as adjunctive therapy, standardization of protocols, and causes and ways to address recurrence following PDT treatment.

Assessment of therapeutic efficacy in seven cases of basal cell carcinoma in the ear and nose region treated with new surgical excision and immediate photodynamic therapy

BackgroundBasal cell carcinoma (BCC) is the most prevalent non-melanoma skin tumor. It commonly affects exposed areas. Currently, surgical resection is considered the primary approach for BCC treatment. However, BCC frequently affects exposed facial areas, leading to visible scars after surgery. PDT has garnered increasing recent attention, demonstrating superior efficacy and favorable cosmetic outcomes for superficial BCCs. However, it shows limited treatment effectiveness for deep-seated tumors. Most of the current literature focuses on the combination of surgery and postoperative PDT, while no studies have reported on the use of standard surgical excision with intraoperative margin pathological monitoring and immediate PDT. Therefore, we implemented a treatment protocol combining surgery and immediate PDT. Accordingly, this paper aimed to explore the effectiveness, cosmetic outcomes, and other relevant advantages of this therapeutic approach. MethodsWe aimed to evaluate this approach in seven patients with BCC on the nose and ears. Standard surgical excision of skin lesions was performed, with intraoperative frozen section examination of the margins, followed by immediate postoperative PDT for the wounds, and continued periodic PDT during the second phase of wound healing. ResultsAll seven cases demonstrated significant improvement. The cosmetic rating was 100 % and no cases of recurrence existed among the seven patients. ConclusionsThis approach effectively minimized the surgical wound, improved tumor clearance, achieved precise therapeutic effects, and reduced the recurrence rate. Moreover, it produced favorable cosmetic outcomes.

How I do it: micro-neurosurgical resection of spheno-orbital meningioma with customized orbit reconstruction technique.

Spheno-orbital meningioma (SOM) is a rare intracranial pathology with intraosseous hypertrophy and intraorbital extension. We described a middle-aged female with SOM who was managed in a micro-neurosurgical manner. The titanium implant was customized and applied to rebuild the orbital wall to prevent postoperative enophthalmus. Despite technical demands, favorable cosmetic, and clinical outcomes without complications can be achieved by meticulous surgical technique following radical resection. NA.

Late Frontal Bone Reconstruction Using Three-Dimensional Printed Models for Titanium Mesh Customization: A Case Series

The convex frontal bone is covered by thin skin rendering its reconstruction cosmetically challenging. Customized alloplastic implants provide better contouring than autologous bone, yet their high cost and availability limit their application. We assess customized titanium mesh implants pre-contoured using patient specific 3-D printed models for late frontal cranioplasty. We retrospectively analyzed the prospectively collected cases of unilateral frontal titanium mesh cranioplasty with 3-D printing assisted preplanning from 2017 to 2019. We used two 3-D printed patient specific skull models for preoperative planning: the mirrored normal model for implant contouring, and the defect model for edge trimming and fixation planning. The endoscope was used in four cases for percutaneous mesh fixation. We documented postoperative complications. We assessed the reconstruction symmetry clinically, and radiologically on postoperative computed tomography. 15 patients were included. The duration after previous surgery ranged from 8-24 months. Four patients developed complications that were managed conservatively. Favorable cosmetic outcomes were achieved in all patients. Pre-contouring of titanium mesh implants using in-house 3-D printed models could optimize cosmetic and surgical outcomes in late frontal cranioplasty. Preoperative planning could permit minimal access surgery that could be aided by the endoscope in select cases.

Above-The-Hairline Suboccipital Transverse Approach for the Treatment of Chiari I Malformation.

Chiari I malformation is a common pediatric neurosurgical disorder with an established treatment paradigm. Posterior fossa decompression and duraplasty (PFDD) is associated with symptom improvement but it carries postoperative risk, particularly cerebrospinal fluid (CSF) leak and wound complications. In addition, the cosmetic outcomes of PFDD have been overlooked in the literature. To describe a novel approach for PFDD in which the transverse surgical incision is completely hidden above the hairline and to report early outcomes in a prospective patient cohort. Clinical and cosmetic outcomes were recorded for 15 consecutive pediatric patients who underwent PFDD for Chiari I malformation via the above-the-hairline transverse suboccipital approach. The median clinical follow-up time was 6 months (range 1-12 months), and the majority of patients experienced significant improvement of their preoperative symptoms. Three patients (20%) experienced complications associated with surgery, which included injury to the greater occipital nerve, CSF hypotension and subfascial pseudomeningocele, and superficial wound dehiscence that resolved spontaneously with oral antibiotics. Zero patients (0%) returned to the operating room for persistent CSF leak, deep wound infection, or revision decompression. An excellent cosmetic outcome was achieved in 12 patients (80%). No patient had a poor cosmetic outcome. The above-the-hairline transverse suboccipital approach for PFDD in patients with Chiari I malformation offers favorable cosmetic outcomes and fascial closure while permitting adequate decompression.

Flexible endoscope-assisted suture release and barrel stave osteotomy for the correction of sagittal synostosis.

Early suturectomy with a rigid endoscope followed by orthotic cranial helmet therapy is an accepted treatment option for single-suture craniosynostosis. To the authors' knowledge, flexible endoscope-assisted suture release (FEASR) has not been previously described. Presented herein is their experience with FEASR for the treatment of isolated sagittal craniosynostosis. A retrospective analysis of the health records of patients who had undergone FEASR between March 2018 and December 2020 was performed. Patients under the age of 6 months who had been diagnosed with isolated sagittal synostosis were considered eligible for FEASR. Exclusion criteria included syndromic synostosis or multiple-suture synostosis. The cephalic index, the primary measure of the cosmetic endpoint, was calculated at prespecified intervals: immediately preoperatively and 6 weeks and 12 months postoperatively. Parental satisfaction with the cosmetic outcome was determined throughout the clinical follow-up and documented according to a structured questionnaire for the first 12 months. A total of 18 consecutive patients met the criteria for study inclusion. The mean patient age at the time of surgery was 3.4 months (range 2-6 months). All patients underwent a wide craniectomy with no need to convert to an open procedure. The mean craniectomy width was 3.61 cm. Estimated blood loss ranged from 5 to 30 ml. The mean operative time was 75 minutes. No intraoperative complications were observed. The average length of stay was 2.6 days. The mean cephalic index was 67.7 preoperatively, 77.1 at 6 weeks postoperatively, and 76.3 at 1 year postoperatively. The mean percentage change in the cephalic index from preoperatively to the 12-month follow-up was 10.44 (p < 0.001). The mean follow-up was 17 months (range 12-28 months). All parents were satisfied with the cosmetic outcome of the procedure. No patients developed symptoms of raised intracranial pressure (ICP) or needed invasive ICP monitoring during the follow-up period. No patients required reoperation. In this modest single-hospital series, the authors demonstrated the feasibility of FEASR in treating sagittal synostosis with favorable cosmetic outcomes. The morbidity profile and resource utilization of the procedure appear similar to those of procedures conducted via traditional rigid endoscopy.

Circumumbilical incision for neonatal abdominal surgery: additional skin incision when there is difficulty in manipulating the intestine.

This study aimed to evaluate the safety and effectiveness of circumumbilical incision (CUI) for neonates requiring intestinal anastomosis. Seventy neonates requiring intestinal anastomosis at our institution between 2003 and 2020 were included in this retrospective case-control study. Patients were classified into the CUI (25 patients: 36%) and transverse incision (TI) groups (45 patients: 64%). Postoperative complications and surgical outcomes were compared between the two groups. Intestinal perforation at the non-anastomotic site occurred significantly more often in the CUI group than in the TI group (3 patients: 12%, and 0 patients: 0%, respectively (p = 0.042)). There were no between-group differences regarding anastomotic leakages, anastomotic strictures, time to enteral feeding, operative time, and blood loss. Neonatal intestinal surgery employing CUI might be associated with increased intestinal perforation at the non-anastomotic site. Hesitating to enlarge the skin incision to maintain favorable cosmetic outcomes might cause severe injury to the delicate neonatal intestine during the surgical procedure owing to the restricted surgical field. When performing CUI, we suggest that the skin incision should be extended without hesitation whenever there is difficulty in manipulating the intestine.