Nonsurgical Options Research Articles

Obstructive Sleep Apnea in Adults and Ear, Nose, and Throat (ENT) Health: A Narrative Review.

Obstructive sleep apnea (OSA), a form of sleep-disordered breathing, is a significant health concern that leads to substantial morbidity. The collapse or occlusion of the upper airway, which results in reduced or cessation of airflow, is the pathophysiology of sleep apnea. The condition has been attributed to numerous cardiovascular, metabolic, and neuropsychological issues and carries serious health concerns. The ensuing intermittent hypoxia and sleep disruption set off a chain of physiological reactions that aid in developing endothelial dysfunction, systemic inflammation, and oxidative stress. The following line of treatment depends on the appropriate diagnosis of sleep apnea and the underlying cause. The gold standard for diagnosis is polysomnography (PSG), which assesses different physiological parameters during sleep. However, because polysomnography is expensive, patients may use more friendly screening and diagnostic testing kits, like home sleep apnea testing. The clinical symptoms and head and neck history may reveal essential risk factors. The primary objectives of management treatments for sleep apnea are to lessen symptoms, enhance sleep quality, and reduce any health concerns that may be present. It is advised to start with lifestyle changes such as quitting alcohol and sedative use, losing weight, and exercising frequently. The primary treatment for moderate to severe sleep apnea is continuous positive airway pressure (CPAP) therapy, which includes administering pressurized air to keep the airway open while you sleep. Oral appliances, positional therapy, surgery, and complementary therapies are other treatment choices that can be adapted to each patient's needs and preferences. The goal of the review is to evaluate the morphological and functional aspects of the upper airway, including the nose and throat, that influence the onset and severity of OSA. With a focus on the interaction between otorhinolaryngologists, sleep medicine specialists, and other healthcare professionals, we aim to consider how OSA affects otorhinolaryngology-related medical issues, look at any potential reciprocal relationships, and provide a summary of the interdisciplinary management strategy for OSA. We tried to analyse the various surgical and non-surgical therapy options for OSA management available in the otorhinolaryngology field for improving OSA symptoms and results.

Patient Interest in Exploring Nonsurgical Treatment Approaches for Early-Stage Breast Cancer: A Qualitative Study

IntroductionAdvances in radiotherapy have enabled the ability to deliver ablative treatments, but there has been limited application of these treatments to early stage breast cancers with a goal of omitting surgery. The purpose of this study was to explore patient interest in pursuing non-surgical treatment approaches for their early stage breast cancer. Material and MethodsWe conducted a qualitative study involving interviews with 21 patients with early stage breast cancer who were eligible for participation in a phase II clinical trial offering omission of definitive surgery. Interviews were transcribed and an inductive, thematic analysis was performed by three independent reviewers to generate themes and subthemes. ResultsData analysis revealed the following factors that impacted patient willingness and desire to explore non-surgical treatment options: 1) Perceptions and feelings about their cancer; 2) Current quality of life and the level of support available in their daily life; 3) External conversations focusing on family members’ and friends’ experiences with cancer and/or cancer treatments; 4) Personal healthcare experiences, including their current breast cancer diagnosis; 5) Perceptions and feelings about their physicians; 6) Conversations with their physicians about their treatment options; and 7) Self-identified desire to direct care decisions. Specifically, patients verbalized fearing surgery and surgical recovery, wanting to preserve their breast(s), the prior negative surgical experiences of friends, family and themselves, a desire to receive treatment per the latest research, wanting to match the level of treatment with the severity of their cancer, and other comorbidities as reasons for wanting to explore omitting surgery. DiscussionOur findings demonstrate an unmet need directed by patient interest to explore non-surgical options for early stage, biologically favorable breast cancer. These results may shape conversations around shared decision making, clinical trial design, and result in more personalized treatment options for women with early stage breast cancer.

Participant Satisfaction and Investigator Assessment of Collagenase Clostridium Histolyticum Injection as a Nonsurgical Intralesional Treatment Option for Plantar Fibromatosis

Category: Midfoot/Forefoot; Basic Sciences/Biologics Introduction/Purpose: Currently, there is no safe and efficacious injectable therapy for symptomatic plantar fibromatosis (PFi) that addresses its pathophysiology. Patients with PFi nodules experience symptoms that reduce quality of life, causing functional disability leading to severe impairment in some patients. Collagenase clostridium histolyticum (CCH) is approved for Dupuytren’s and Peyronie’s disease treatment, which are both fibroproliferative disorders that may coexist in patients with PFi. This first study of CCH treatment for PFi evaluated participant satisfaction and investigator assessment of improvement. Methods: Participants were randomly allocated (1:1:1) in this Phase 1, multicenter study to receive 0.6, 1.2, or 2.25 mg/mL CCH. All participants underwent the initial treatment period (ITP) and received 1–2 intralesional injections per nodule on Day 1 with follow-up assessments at specified intervals. Participants with palpable treated nodules could enter the retreatment period (RP) and receive additional CCH doses (at 2.25 mg/mL), with follow-up at specified intervals. Assessments included the Subject Satisfaction with Treatment Rating Scale (+2: very satisfied; to -2: very dissatisfied), and the Investigator Assessment of Improvement Scale (+3: very much improvement; to -3: very much worse). Results: After ITP, ≥75% of participants reported “very” or “quite” satisfied across all treatment groups, with 2.25 mg/mL group reporting 100% satisfaction. For ≥72.7% of nodules, participants reported satisfaction with outcome. Investigators reported improvement (“minimal”, “much”, or “very much”) in ≥75% of participants and ≥80% of treated nodules. After RP, 63.6% of participants reported treatment satisfaction; participants were satisfied with 66.7% of treated nodules, indicating continued improvement from the ITP. Almost all participants (90.9%) were deemed by investigators to have shown improvement, with 86.7% of treated nodules being assessed as having improvement. Conclusion: CCH-treated PFi participants were satisfied with their improvement; physicians assessed improvement in >90% of participants. Results indicate CCH as a potential nonsurgical intralesional option for PFi treatment.

Tolerability and Safety of Collagenase Clostridium Histolyticum Injection in Participants with Plantar Fibromatosis

Category: Midfoot/Forefoot; Basic Sciences/Biologics Introduction/Purpose: Plantar fibromatosis (PFi) is a functionally disabling disorder characterized by fibrous collagen-containing nodules along the plantar fascia. Collagenase clostridium histolyticum (CCH) is a nonsurgical treatment approved for Dupuytren’s and Peyronie’s disease; both can coexist with PFi. Composed of two collagenases, CCH specifically hydrolyzes certain collagen types and may disrupt the nodule when injected directly. This proof-of-concept study evaluated pharmacokinetics, immunogenicity, and assessed tolerability and safety of CCH treatment of PFi. Methods: In this Phase 1, multicenter study, participants were randomly allocated (1:1:1) to receive 0.6, 1.2, or 2.25 mg/mL CCH. All participants underwent the initial treatment period (ITP) and received 1–2 intralesional injections per nodule on Day 1 with pharmacokinetic samples collected over 24hrs, followed by 5 follow-up visits. Post-ITP, participants with a remaining, palpable nodule could enter the retreatment period (RP) and receive additional CCH doses (at 2.25 mg/mL) with follow-up at specified intervals. Immunogenicity test sampling occurred at screening and at the end of ITP/RP. Adverse events (AEs) were monitored throughout. Results: Twenty-four participants enrolled into ITP, with 11 continuing into RP. Pharmacokinetic and immunogenicity findings were consistent with previous CCH studies in other therapeutic areas. CCH treatment was generally well tolerated, with no serious treatment emergent adverse events (TEAEs), drug discontinuations, or study withdrawals by study end. Over 70% of participants during ITP (19/24) and RP (8/11) reported at least 1 TEAE. Eighty-six TEAEs occurred during ITP and 35 in RP; most were mild in severity (73%, ITP; 83%, RP), and 67% of ITP and 49% of RP TEAEs were treatment related. TEAEs were reportedly injection site- related, with injection site bruising, pain, and swelling frequently recorded. Conclusion: CCH had an expected pharmacokinetics/immunogenicity profile and was safe and well tolerated in participants with PFi. CCH may be a potential nonsurgical intralesional option for PFi treatment.

Efficacy of Collagenase Clostridium Histolyticum Injection, a Potential Nonsurgical Intralesional Treatment Option for Plantar Fibromatosis: A Randomized, Open-Label, Dose-Ranging Study

Category: Midfoot/Forefoot; Basic Sciences/Biologics Introduction/Purpose: Plantar fibromatosis (PFi) is characterized by collagen-containing nodules on the foot along the plantar fascia that can cause pain and functional disability. Current treatments focus on symptom relief, which may become ineffective, or surgery, which can have lengthy recovery times. Collagenase clostridium histolyticum (CCH) is approved for Dupuytren’s and Peyronie’s disease treatment, which are both fibroproliferative disorders that may coexist in patients with PFi. This dose-ranging study assessed the efficacy and safety of CCH treatment of PFi. Methods: In this Phase 1, multicenter study, participants were randomly allocated (1:1:1) to receive 0.6, 1.2, or 2.25 mg/mL CCH. All participants underwent the initial treatment period (ITP) and received 1–2 intralesional injections per nodule on Day 1 with 5 follow-up assessments. Participants with palpable treated nodules could receive additional CCH doses (at 2.25 mg/mL; retreatment period, RP), with follow-up at specified intervals. Assessments included a 5-scale measure of nodule hardness (0 [nonpalpable] to 4 [hard]), and the Foot Function Index-Short Form23 (FFI-SF23) reported as a composite score (0 – 100) of 3 subscale scores (disability, difficulty, and pain subscales). Results: After ITP (n=24), 100% (8/8) of participants receiving 2.25 mg/mL CCH showed improvement in nodule hardness, compared with 87.5% (7/8) and 75% (6/8) of participants receiving 1.2 and 0.6 mg/mL, respectively. FFI-SF23 also showed a negative change from baseline across treatment groups, indicating improvement. Participants that received 2.25 mg/mL reported the largest percent improvement (-83.7%). After RP (n=11), 81.8% (9/11) of participants showed improvement in nodular hardness and an FFI-SF23 score change of -9.3%, indicating further improvement from baseline after ITP. CCH had a consistent safety profile in ITP/RP. Conclusion: CCH caused dose-dependent improvement of nodule hardness after treatment, with 2.25 mg/mL utilized for nodule retreatment; FFI-SF23 scores correlated with this finding, indicating CCH may be a potential nonsurgical intralesional option for PFi treatment.

Esthetic rehabilitation of mutilated maxillary anterior alveolar segment by combining orthodontic osseous distraction and implant-supported crowns: A clinical report

Bony defects in the esthetic zone, especially in the maxillary anterior region, increase the complexity of surgical and prosthetic procedures. Moving teeth with preprosthetic osseous distraction techniques can be an alternative nonsurgical option to traditional regenerative or reparative surgical therapies to increase bone volume. Healthy peri-implant bone, periodontium, and adjacent teeth provide a favorable environment for implant restorations. The esthetic rehabilitation of the maxillary region after the removal of 2 ankylosed central incisors is presented. The lateral incisors were moved mesially to the central incisor positions, and implants placed in the lateral incisor positions after new healthy bone had been induced.

Surgical or Nonsurgical Facial Rejuvenation: The Patients' Choice.

Patients seeking a pan-facial rejuvenation may not receive appropriate medical advice on surgical versus nonsurgical treatments, resulting in those who are best-suited for surgery receiving nonsurgical options, and vice versa. Patients who requested total-face, nonsurgical revitalization were surveyed to understand the factors influencing this decision-making. Patients consulting for total facial rejuvenation were surveyed on their reasons for seeking nonsurgical versus surgical interventions by an investigator with 30 years of plastic surgery experience, practicing in a nonsurgical clinic alongside a dermatologist and aesthetic physician. Of the 92 patients surveyed, 78% completed the survey, 47% of whom had considered facelift surgery, and 14% of whom proceeded to inquiries or consultations with a plastic surgeon about facelift surgery. All respondents were women, and age was not an exclusion factor. Forty-four percent would still consider facelifts in later life. Among the most common reasons for choosing nonsurgical approaches were a desire for natural and subtle results, cost, having flexibility in treatment choice, concerns about surgical and anesthesia risks, downtime, the ability to distribute treatments over time, and scarring. Many patients book nonsurgical treatments without prior professional advice, and consider these as a temporary solution, but may desire surgery later in life. Before conducting nonsurgical treatments, doctors should identify this group and avoid interventions that may interfere with optimal surgical outcomes later. Also, some patients desire surgical outcomes when surgery is not a feasible option, and thus seek nonsurgical alternatives. For this group, realistic goals must be set before treatment to avoid disappointment.

S3409 Exploring Non-Surgical Options for Stump Appendicitis: Colonoscopy-Guided Fecalith Removal as an Effective Solution

S3409 Exploring Non-Surgical Options for Stump Appendicitis: Colonoscopy-Guided Fecalith Removal as an Effective Solution

Sex-related differences in functional capacity and its implications in risk stratification before major non-cardiac surgery: a post hoc analysis of the international METS study

Poor functional capacity has been identified as an important modifiable risk factor for postoperative complications. Cardiopulmonary exercise testing (CPET) provides objective parameters of functional capacity (e.g., oxygen consumption at peak exercise, peak VO2), with significant prognostication for postoperative complications. However, sex-specific thresholds for functional capacity to predict surgical risk are yet to be established. Therefore, we performed a post hoc analysis of the international, multicentre, prospective observational METS (Measurement of Exercise Tolerance before Surgery) study to evaluate if sex-specific thresholds of peak VO2 improve risk prediction of postoperative complications. We undertook a post hoc analysis (HREC/71824/PMCC) of the METS study, which was performed between March 2013 and March 2016. We investigated whether sex-specific differences exist for CPET-derived parameters and associated thresholds for predicting postoperative complications in this large cohort of patients that had major non-cardiac surgery (n=1266). Logistic regression models were analyzed for the association of low peak VO2 with moderate-to-severe in-hospital postoperative complications. Optimal sex-specific peak VO2 thresholds were obtained by maximizing the Youden index of receiver operating characteristic (ROC) curves. Finally, multivariable logistic regression models tested the resulting sex-specific thresholds against the established non-sex-specific peak VO2 threshold (14mLkg-1 min-1) adjusted for clinically relevant features such as comorbidities and surgical complexity. Models were evaluated by bootstrapping optimism-corrected area under the ROC curve and the net reclassification improvement index (NRI). Female patients (n=480) had a lower mean (SD) peak VO2 than males (16.7 (4.9) mL kg-1 min-1 versus 21.2 (6.5) mL kg-1 min-1, p<0.001) and a lower postoperative complication rate (10.4% versus 15.3%; p=0.018) than males (n=786). The optimal peak VO2 threshold for predicting postoperative complications was 12.4mLkg-1 min-1 for females and 22.3mLkg-1 min-1 for males, respectively. In the multivariable regression model, low non-sex-specific peak VO2 did not independently predict postoperative complications. In contrast, low sex-specific peak VO2 was an independent predictor of postoperative complications (OR 2.29; 95% CI: 1.60, 3.30; p<0.001). The optimism-corrected AUC-ROC of the sex-specific model was higher compared with the non-sex-specific model (0.73 versus 0.7; DeLong's test: p=0.021). The sex-specific model classified 39% of the patients more correctly than the baseline model (NRI=0.39; 95% CI: 0.24, 0.55). In contrast, the non-sex-specific model only classified 9% of the patients more correctly when compared against the baseline model (NRI=0.09; 95% CI:-0.04, 0.22). Our data report sex-specific differences in preoperative CPET-derived functional capacity parameters. Sex-specific peak VO2 thresholds identify patients at increased risk for postoperative complications with a higher discriminatory ability than a sex-unspecific threshold. As such, sex-specific threshold values should be considered in preoperative CPET to potentially improve risk stratification and to guide surgical decision-making, including eligibility for surgery, preoperative optimization strategies (prehabilitation) or seeking non-surgical options. There was no funding for the present study. The original METS study was funded by Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Ontario Ministry of Health and Long-Term Care, Ontario Ministry of Research, Innovation and Science, UK National Institute of Academic Anaesthesia, UK Clinical Research Collaboration, Australian and New Zealand College of Anaesthetists, and Monash University.

Clinical and Radiographic Outcomes for Patients with Cervical Adjacent Segment Disease Treated with Anterior Cervical Discectomy and Fusion with Integrated Interbody Spacers

Anterior cervical discectomy and fusion (ACDF) is among the most common spine procedures. Adjacent segment disease (ASD), characterized by degenerative disease at an adjacent spinal level to a prior fusion, is a well-recognized and significant sequela following ACDF. Adjacent segment ACDF may be considered after the failure of non-surgical options for patients with symptomatic ASD. This study aimed to assess the incidence of dysphagia and other complications as well as radiographic outcomes in adult patients who have undergone ACDF with an integrated interbody spacer device for symptomatic ASD. This was a retrospective review of patients who underwent ACDF for symptomatic ASD with commercially available integrated interbody spacers by three spine surgeons at an academic institution from March 2018 to April 2022. Demographic, radiographic, and postoperative data were collected, including dysphagia, device-related complications, and the need for revision surgery. There were 48 patients (26 male, 22 female) who met inclusion criteria (mean age 59.7 years, mean body mass index 19.5 kg/m2) who underwent ACDF for symptomatic ASD (1one-level, n= 44; 2-level, n= 4). Overall, 12 patients (25%) experienced dysphagia postoperatively before the first follow-up appointment. Nine of 44 (20.4%) of 1-level ACDF patients experienced dysphagia, and 3 of 4 (75%) of 2-level ACDF patients experienced dysphagia. Three patients had severe dysphagia which prompted an otolaryngology referral. Two of those patients remained symptomatic at 6 weeks postoperatively. Of 43 patients with prior plate cage systems, none required hardware removal at the time of surgery. Preoperative global and segmental lordosis were 9.07° ± 8.36° (P= 0.22) and 3.58° ± 4.57° (P= 0.14), respectively. At 6 weeks postoperatively, global and segmental lordosis were 11.44° ± 9.06° (P= 0.54) and 5.11° ± 4.44° (P= 0.44), respectively. This constitutes a change of+2.37° and+1.53° in global and segmental lordosis, respectively. The mean anterior disc height change between preoperative and immediate postoperative time points was 6.3 ± 3.1 mm. Between the immediate postoperative and 6-week postoperative time points, the mean anterior disc height change was -1.5 ± 2.7 mm. Between the immediate postoperative and 3-month postoperative time points, the mean anterior disc height change was -3.7 ± 5.0 mm. The posterior disc height changes at the same time points were 2.5 ± 1.7 mm, -0.4 ± 1.8. and -0.5 ± 1.4 mm, respectively. This fusion rate was 50% and 70% at 6 months and 1 year post-surgery, respectively. ACDF with integrated spacer is a viable alternative to traditional plate-cage systems for symptomatic ASD. An advantage over traditional plate-cage systems is that the removal of prior instrumentation is not needed in order to place implants. Based on a review of the literature, these standalone systems allowed for a shorter operative time and had less incidence of dysphagia than plate-cage systems for ASD after ACDF. The different standalone and plate-cage systems used in treating ASD after ACDF surgeries should be compared in prospective studies.

Diabetes remission and relapse following an intensive metabolic intervention combining insulin glargine/lixisenatide, metformin and lifestyle approaches: Results of a randomised controlled trial.

Non-surgical options for inducing type 2 diabetes remission are limited. We examined whether remission can be achieved by combining lifestyle approaches and short-term intensive glucose-lowering therapy. In this trial, 160 patients with type 2 diabetes on none to two diabetes medications other than insulin were randomised to (a) an intervention comprising lifestyle approaches, insulin glargine/lixisenatide and metformin, or (b) standard care. Participants with glycated haemoglobin (HbA1c) <7.3% (56 mmol/mol) at 12 weeks were asked to stop diabetes medications and were followed for an additional 52 weeks. The primary outcome was diabetes relapse defined as HbA1c ≥6.5% (48 mmol/mol) at 24 weeks or thereafter, capillary glucose ≥10 mmol/L on ≥50% of readings, or use of diabetes medications, analysed as time-to-event. Main secondary outcomes included complete or partial diabetes remission at 24, 36, 48 and 64 weeks defined as HbA1c <6.5% (48 mmol/mol) off diabetes medications since 12 weeks after randomisation. A hierarchical testing strategy was applied. The intervention significantly reduced the hazard of diabetes relapse by 43% (adjusted hazard ratio 0.57, 95% confidence interval 0.40-0.81; p = .002). Complete or partial diabetes remission was achieved in 30 (38.0%) intervention group participants versus 16 (19.8%) controls at 24 weeks and 25 (31.6%) versus 14 (17.3%) at 36 weeks [relative risk 1.92 (95% confidence interval 1.14-3.24) and 1.83 (1.03-3.26), respectively]. The relative risk of diabetes remission in the intervention versus control group was 1.88 (1.00-3.53) at 48 weeks and 2.05 (0.98-4.29) at 64 weeks. A 12-week intensive intervention comprising insulin glargine/lixisenatide, metformin and lifestyle approaches can induce remission of diabetes.

EarWell Infant Ear Molding Device: Experience and Parent Survey.

EarWell infant ear molding device is a noninvasive, nonsurgical option to treat ear deformities in early infancy. There are no studies involving the parents' perspective to the use of the EarWell. To investigate our experience with EarWell infant ear molding device and to assess the parents' satisfaction. A retrospective case series study of infants with congenital ear deformities who were treated with EarWell device from October 2021 to November 2022. Demographic and clinical data were collected. Clinical photographs were obtained before, during, and after treatment. Parents' satisfaction level was assessed through telephone encounters and surveys, and issues associated with device application were identified. Clinical improvement of ear deformity was graded into poor, fair, good, and excellent. A total of 9 patients with congenital ear deformities were identified and included in this study (7 bilateral deformities and 2 unilateral deformities). The mean adjusted age of the initial treatment is 17 weeks (4-23 weeks), and the mean treatment duration is 5.7 weeks. The authors received full 8 responses from the parents' survey, and all parents were satisfied with post-treatment results (4 satisfied, 1 fully satisfied, and 2 very satisfied). Issues associated with device application were 3 superficial skin ulcers and 4 skin irritation. Clinical Improvement grades were: 5 excellent improvement, 2 good improvement, and 2 fair improvement. On the basis of our experience, the EarWell device has shown a high success rate and a low complication rate. It is well accepted by parents, but it needs close follow-up to detect minor device-related issues. The device is safe for multiple skin types.

Recommendations for Cost-Conscious Treatment of Basal Cell Carcinoma.

Basal cell carcinoma (BCC) affects 3.3 million Americans annually. Treatment modalities for BCC include many surgical and nonsurgical options. The cost of BCC treatment can pose a substantial burden to patients and the healthcare system. Cost can be an important consideration in BCC treatment planning. We present an approach to the management of BCC when cost reduction is a priority. A PubMed literature search identified studies on effectiveness of current BCC therapies. Treatment prices were obtained from the Medicare National Fee Schedule, GoodRx, and pharmaceutical companies. The American Academy of Dermatology's (AAD) guidelines for treating BCC were used to develop recommendations for cost-reductive treatment. The cost of treating a primary superficial BCC < 0.5cm arising on Area M (cheeks, forehead, scalp, neck, jawline, pretibial surface) was $143 with curettage and electrodesiccation (C&E), $143 with cryosurgery, $210 with standard excision and simple reconstruction (SE), $1221 with Mohs Micrographic Surgery (MMS) and simple reconstruction, $472 with imiquimod, $186 with 5-fluorouracil (5-FU), and $354-$371 for photodynamic therapy (PDT). The cost of treating a primary nodular BCC 1.1-2cm arising on Area L (trunk and extremities, excluding pretibial surface, hands, feet, nail units and ankles) was $183 with C&E, $183 with cryosurgery, $251 with SE and simple reconstruction, $1163-1351 with MMS and simple reconstruction, $472 with imiquimod, $186 with 5-FU, and $354-$371 for photodynamic therapy (PDT). The cost of treating a giant BCC (BCC > 10cm with aggressive behavior) was $465-3311 with radiation, $139,560 with vismodegib, $144,452 with sonidegib, ~ $44.5 with cisplatin (medication cost only), and at least $184,836 with cemiplimab-rwlc. For a primary superficial BCC < 0.5cm arising on Area M, the cost-conscious algorithm prioritizes C&E or cryosurgery. For a primary nodular BCC 1.1-2cm arising on Area L, the cost-conscious algorithm prioritizes C&E, cryosurgery, or 5-FU. For a giant BCC, the cost-conscious algorithm identifies superficial radiation therapy as first line.

Treatment Options for the Clinical Management of Axillary Breast Tissue.

Axillary breast tissue includes any combination of fat, nipple, areolae, and glandular tissue alongside breasts and affects 2%-6% of women and 1%-3% of men. Patients may experience functional and/or cosmetic concerns due to axillary breast tissue. There are nonsurgical options for its removal, such as CoolSculpting and Kybella, and surgical options such as liposuction, BodyTite liposuction, and excision. Determining which technique to use in each case is critical in achieving an excellent outcome. Currently, there are no established treatment algorithms for the removal of axillary breast tissue. A retrospective review between January 1, 2013, and June 20, 2022, was performed. Data that were extracted included age, BMI, date of procedure, procedure, fat suctioned, tissue excised, and follow-up period. The authors analyzed outcomes and formulated a treatment algorithm based on tissue type (fat versus glandular), amount of tissue excess, skin laxity, and accessory nipple presence. A total of 43 patients (83 axillae) met our inclusion criteria and were included in our analysis. All patients were female with a mean age of 35.5 ± 10.9 years, a mean BMI of 23.0 ± 3.1, and a mean follow-up period of 8.8 ± 11.1 months. For inclusion, patients had to have undergone CoolSculpting, liposuction, BodyTite liposuction, liposuction with excision, or excision alone. All patients tolerated the procedures well and reported no serious complications. Nonsurgical and surgical removal of axillary breast tissue is safe and effective. The algorithm presented can be utilized by plastic and reconstructive surgeons to ensure optimal results for axillary breast tissue removal.

Microneedling for Medical and Aesthetic Purposes: Current Indications and New Advances

Microneedling has become a valuable tool in dermatology, offering a non-surgical option to treat various skin conditions. The procedure creates microchannels in the skin, triggering the release of growth factors and promoting non-fibrotic skin remodeling. The current utilities for microneedling include treating wrinkles, scars, stretch marks, pigmentation disorders, warts, skin texture issues, rosacea, and hair regrowth. Multiple studies have shown its efficacy in improving these conditions, with significant improvements in patient assessments. However, further research is needed to optimize protocols and determine the ideal needle size, frequency, and interval between treatments for the best clinical outcomes for subjects. Through their novel research, clinicians have made significant advancements in microneedling, expanding its uses, and revolutionizing its application. Despite previous beliefs, microneedling can effectively treat active acne lesions without exacerbating the condition. It has also shown promise in treating facial spider veins, providing comparable efficacy to other methods with a better safety profile. Initiating microneedling treatment at an earlier stage for surgical scars improves outcomes compared to waiting for scar maturation. Microneedling combined with topical agents has shown positive results in treating gingival hyperpigmentation. Its expanding applications and recent advancements highlight the potential benefits of integrating microneedling into clinical practice.

Tamoxifen and the risk of breast cancer in women with a BRCA1 or BRCA2 mutation.

Chemoprevention with a selective estrogen receptor modulator (tamoxifen or raloxifene) is a non-surgical option offered to high-risk women to reduce the risk of breast cancer. The evidence for tamoxifen benefit is based on trials conducted among predominantly postmenopausal women from the general population and on studies of contralateral breast cancer in women with a pathogenic variant (mutation hereafter) in BRCA1 or BRCA2. Tamoxifen has not been assessed as a primary prevention agent in women with an inherited BRCA mutation. We conducted a prospective analysis of tamoxifen chemoprevention and the risk of breast cancer in women with a BRCA1 or BRCA2 mutation. Data on tamoxifen (and raloxifene) use was collected by questionnaire and updated biennially. Information on incident cancers was collected by self-report and was confirmed by medical record review. In a matched analysis, we estimated the hazard ratio (HR) and 95% confidence intervals (CI) for developing a first primary breast cancer associated with tamoxifen or raloxifene use, using Cox proportional hazards analysis. There were 4578 unaffected women in the cohort, of whom 137 reported tamoxifen use (3%), 83 reported raloxifene use (2%) and 12 used both drugs (0.3%). Women who used tamoxifen or raloxifene were matched 1:3 with women who used neither drug on year of birth, country of residence, year of study entry and gene (BRCA1 or BRCA2). We generated 202 matched pairs. After a mean follow-up of 6.8years, there were 22 incident breast cancers diagnosed among tamoxifen/raloxifene users (10.9% of users) and 71 cases diagnosed among non-users (14.3% of non-users; HR = 0.64; 95% CI 0.40-1.03; P = 0.07). Chemoprevention may be an effective risk-reduction option for BRCA mutation carriers, but further studies with longer follow-up are necessary.

Effect of Microneedling and Injectable Platelet-Rich Fibrin on Gingival Phenotype – A Case Series

Introduction: Gingival phenotype is a crucial determinant of the periodontium. It not only maintains the health of the tissue but also plays a decisive role in the prediction of periodontal treatment outcomes. Thin gingival phenotype poses certain risks of poor periodontal treatment outcome in cases of implant, coronally advanced flap, and other root coverage procedures. Thus it becomes the duty of the clinician to deal with such cases by prior planning treatments which can improve the gingival phenotype and thereby enhancing the postperiodontal treatment outcomes to benefit patients. In this case series, a nonsurgical treatment modality microneedling (MN) and injectable platelet-rich fibrin (i-PRF) are employed in an attempt to increase the thickness of thin gingival phenotype. Methods: Five systemically healthy patients with thin gingival phenotypes were included in this study. The lower anterior teeth with split-mouth study pattern have been randomly allocated to nonsurgical treatment modality, i.e., MN alone and MN along with i-PRF. All the patients were followed up for 9 months. Outcomes Assessed: Gingival thickness (GT), Width of Keratinized Tissue (WKT), oral hygiene index, gingival index (GI), the patient reported outcome measures. Results: Both the groups showed an increase in the thickness of gingiva in 9-month follow-up. The mean increase of 0.62 mm in thickness was seen in Group 1 (42%), whereas Group 2 showed a 0.34 mm (27.3%) of increment. No difference is seen with respect to the change in the width of keratinized gingiva in both groups. Conclusion: MN along with i-PRF can provide an efficient nonsurgical option to clinicians to increase GT in cases of thin gingival phenotype.

ID: 196299 Axillary Peripheral Nerve Stimulation for Severe Glenohumeral Osteoarthritis Not Amenable to Surgery: A Case Report

Glenohumeral osteoarthritis (OA) is a common cause of chronic shoulder pain in the elderly (1). When conservative management fails to provide adequate pain relief, total shoulder arthropathy (TSA) may be considered (1). If surgical treatment is not feasible due to poor surgical candidacy, there are currently limited non-surgical options for end-stage shoulder OA (1,2,3). Peripheral nerve stimulation (PNS) has been utilized successfully for refractory shoulder pain, even when the pain is secondary to degenerative joint disease (2,3).

Current Evidence on the Use of Hyaluronic Acid as Nonsurgical Option for the Treatment of Peyronie’s Disease: A Contemporary Review

Peyronie’s disease is a condition characterized by the formation of fibrous plaques in the tunica albuginea, which can cause pain, curvature, and erectile dysfunction. Preclinical studies have demonstrated the potential benefits of hyaluronic acid in treating Peyronie’s disease, including antifibrotic, anti-inflammatory, and proangiogenic effects, although more research is needed to fully understand its mechanisms of action. Clinical studies have shown promising results, with hyaluronic acid injections leading to improvements in plaque size, penile curvature, and erectile function, and being well tolerated by patients. The findings suggest that HA injections could be a viable and safe treatment option for Peyronie’s disease, particularly in the early stages of the disease. However, more research is needed to determine the optimal dosage and treatment duration for HA injections, and to confirm its efficacy in the stable phase of Peyronie’s disease. Overall, hyaluronic acid is a potentially effective therapy for Peyronie’s disease, with the ability to inhibit fibrosis and promote angiogenesis, and low risk of adverse effects, making it an attractive option for patients who are unable or unwilling to undergo surgery.

ID: 217178 Percutaneous Stimulation of Suprascapular Nerve Improves Pain And Pain-Related Impairment Associated With Rotator Cuff Arthropathy

Treatment of rotator cuff arthropathy begins with conservative measures. Surgery is considered when pain progresses, and shoulder function deteriorates. Recently, percutaneous peripheral nerve stimulation (PNS) offers another non-surgical option for treating pain. Below is a case of chronic shoulder pain from rotator cuff damage that was successfully treated via percutaneous PNS stimulation with long term pain relief.