Poor Aesthetic Outcomes Research Articles

Enzymatic Debridement (Nexobrid) on Burned Hands: Retrospective Review from a Burn Referral Center in Spain.

In deep burns, the gold standard of treatment is surgical debridement and coverage, but in hands, this may lead to poor aesthetic and functional results due to the complexity of this anatomical area. Enzymatic debridement (Nexobrid) allows for the preservation of the dermal remnant and reduces the number of skin grafts when compared with surgical excision. The study aimed to analyze the patients with intermediate second-degree or deeper burns in hands who required surgical treatment after Nexobrid and those who avoided it. A descriptive retrospective study of all patients who underwent Nexobrid following hand burns between May 2015 and April 2020 treated in Vall d'Hebrón University Hospital was conducted. After the enzymatic debridement, the burn unit team determined if the burn required conservative treatment or surgery, based on the characteristics of the wound bed. A total of 202 hands were collected. Most hands included in this study had deep second-degree burns (122; 60.4%). Almost half of the hands underwent surgery (99; 49%), and most had deep second-degree burns (61; 61.62%). During follow-up, 24 hands required surgery for sequelae (11.88%) and 62 did not undergo follow-up (30.69%). In the group that needed sequelae surgery, 21 needed surgery after Nexobrid and three of them were healed with conservative treatment after Nexobrid (P < 0.001). Nexobrid decreases the number of surgical procedures in deep burns of the hand because more conservative attitudes are adopted. Also, it seems to reduce the need of surgery due to burn sequelae.

The Breast-Pectoralis Flap: A New Advance in Autologous Breast Reconstruction-A Preliminary Report on 20 Cases.

In the past, several publications have described breast reconstruction techniques that utilize the contralateral breast; however, interest diminished because of technical difficulty, scarring, and poor aesthetic results. This study aimed to present a new breast reconstruction technique that uses a combination of the breast-pectoralis flap and the abdominal advancement flap. This retrospective study analyzed the results and complications of 20 consecutive breast reconstructions with the breast-pectoralis flap technique. The authors present a series of 20 breast reconstructions that utilized the breast-pectoralis flap. Delayed breast reconstruction was performed in 13 cases (65%), breast reconstruction in 5 patients (25%) with Poland syndrome, sequela correction after a chest wall sarcoma in 1 patient (5%), and sequela correction after breast cystic lymphangioma resection in 1 patient (5%). One complication required surgical reintervention without long-term consequences. The outcomes were considered very good in 50% of the cases, good in 45%, and fair in 5%. The combination of the breast-pectoralis flap and the abdominal advancement flap is an interesting advance in breast reconstruction. Evaluation of the presented cases suggests wider indications for this technique.

New neovagina-creating technique on the basis of a fasciocutaneous flap for Müllerian agenesis

To present a new surgical technique on the basis of an internal thigh fasciocutaneous flap for generating a compliant and sensitive neovagina with preservation of the external genitalia. Video demonstration of the surgical steps. An 18-year-old woman with Müllerian agenesis confirmed at ultrasound and magnetic resonance imaging. The residual vagina was 3 cm long and 1.5 cm wide. After counseling by a gynecologist and plastic surgeon, in which all available techniques with pros and cons were exposed, the patient opted for the new technique. The long time required by conservative approaches and the desire to preserve the external genitalia with the chance to have a sensitive vagina guided the choice. The cul-de-sac of the vaginal stump was incised transversally. A 4-cm-wide and 9-cm-long canal bounded anteriorly by the bladder, posteriorly by the rectum, and superiorly by the peritoneum of Douglas was developed by blunt dissection. Fasciocutaneous flaps of 12 per 5 cm on the anteromedial aspect of the thighs were developed, identifying the vascular-from the pudendal artery-and nervous pedicles. A tunnel between the flap pedicles and neovagina introitus was created between fascia and subcutaneous tissue, detaching the vulvar structures from the ischiopubic ramus. Flaps were tunneled up to the neovagina introitus and sutured together by interrupted suture to form a tube with outside skin. The flaps were transposed into the canal everting the tube to obtain the skin lining the internal neovagina. The inferior margins of the flaps were sutured to the vaginal stump mucosa. No internal stitches were placed. Antibiotic prophylaxis was used during surgery. The entire procedure lasted 6 hours. During the postoperative period, no special positioning or ambulation restrictions were used. Compliance and sensitivity of the neovagina, esthetic result, and perioperative and long-term complications. The postoperative course was uneventful, with early mobilization. The length of hospital stay was 16 days to allow proper vaginal dilator use; initial daily followed by intermittent use was planned. At a 2-year follow-up, the neovagina was sensitive and patent, allowing sexual intercourse. No complications were reported, and the patient was satisfied with the functional and esthetic result. The new surgical technique was feasible and effective, preserving the external genitalia and avoiding graft healing and bowel secretion drawbacks without an intra-abdominal surgical step and related risks. However, more cases-2 cases performed to date with similar results-and long-term follow-up are needed to confirm the efficacy. In this regard, the regular use of vaginal dilators and forecast adherence between flaps and the connective tissue of the bladder and rectum are expected to prevent neovagina prolapse without any anchoring to the pelvic structures.

Usage of Dermal Regeneration Templates (Pelnac) for Coverage of Exposed Hand Tendons in Acute Setting.

The loss of soft tissue coverage of tendons is a challenging reconstructive problem after acute hand trauma. Subsequent tendon adhesions and the loss of range of movement in addition to the poor aesthetic outcome and donor site scarring should be avoided when deciding the plan of management. Pelnac is one of the commonly used skin substitutes in reconstructive surgery that can be used for coverage of exposed tendons, but the postoperative functional outcome needs to be addressed in detail. Twenty-six patients with acute isolated tendon injuries distal to the wrist joint were included. Two-stage reconstructive procedures were performed; the first one was the application of Pelnac. The second stage was carried out after the complete integration of Pelnac via the application of a split-thickness graft. The function outcome assesses the return of the normal range of motion to the affected hand and the QuickDASH score questionnaire. The aesthetic outcome was assessed using the Vancouver scar scale. The Pelnac was integrated in 100% of cases, with complete grafts taken in 22 of 26 patients. The mean QuickDASH score was 20.5 ± 15.7, and mean Vancouver scar scale was 3.53 ± 3.2. The full range of motion returned in 22 of 26 patients. Using Pelnac to cover the exposed hand tendons in an acute setting is a convenient and efficient procedure with minimal morbidity. It can offer a good option for their coverage with preservation of hand function and acceptable aesthetic outcome.

Complications with Follicular Unit Excision.

Hair restoration surgery (HRS) is typically a safe outpatient or office-based procedure when physicians follow high ethical standards and uphold community practice standards. Patients' clinical outcomes are mostly operator dependent, and temporary and permanent complications rarely occur. Follicular unit excision (FUE) donor harvesting, in particular, is a challenging harvesting technique requiring a long learning curve, physical stamina, higher than average hand-eye coordination and manual dexterity. The types of complications associated with FUE are comparable to linear strip excision (LSE). Similar to LSE donor harvesting, FUE complications may occur irrespective if standard precautions are followed by the physician. As in any skin and scalp procedure, injuries and poor cosmetic outcomes occur despite appropriate preoperative precautions and intraoperative technique. In increasing and greater instances, however, FUE complications are observed when the physician fails to follow hair restoration practice standards and routine surgical precautions. Physician induced, or iatrogenic complications occur more often when untrained licensed surgeons perform HRS, and who fail to meet practice standards and best practices. In the last decade, physician-influenced FUE complications, or iatrogenic cause of FUE injuries are increasingly observed which results in poor aesthetic outcomes. Higher than average FUE complication rates occur in cases involving inadequately trained physicians, as well as in cases where improper delegation of the FUE hair transplant procedure is performed by unlicensed and untrained individuals. In this chapter, we described commonly encountered HRS complications, as well as physician influenced, or iatrogenic causes of FUE complications.

The treatment of axillary hidradenitis suppurativa with a thoracodorsal artery perforator V-Y advancement flap: a case report

Hidradenitis suppurativa, a recurrent and chronic inflammatory skin disease, presents with extensive scars and multiple abscesses. Moreover, axillary hidradenitis suppurativa could be impacted by scar contracture, which can limit arm mobility. The most reliable treatment for advanced hidradenitis suppurativa is meticulous and radical excision. Several methods exist for the reconstruction of axillary wounds after reconstruction. Skin grafts are an option, but their drawbacks include secondary contracture and poor aesthetic results. Local flaps could be useful, but also have a limited arc of rotation for larger defects. Thoracodorsal artery perforator (TDAP) flaps have been proven to be very effective as part of the armamentarium for axillary wounds. Herein, we describe the use of a TDAP flap in a V-Y advancement fashion with minimal pedicle dissection. We only dissected the perforator pedicle about 1 to 2 cm from its muscle entry point. With this maneuver, the flap could be easily moved to cover the defect without vascular compromise. We found that the TDAP flap performed in a V-Y fashion, with a propeller design, was very useful for an axillary defect over an island. This procedure was simple, easy, and time-saving.

Penile and testicular prosthesis following gender-affirming phalloplasty and scrotoplasty: a narrative review and technical insights.

Transgender and gender diverse (TGD) individuals may seek gender-affirming phalloplasty with specific functional goals, including erectile function sufficient for penetrative sexual intercourse. Individuals seeking penile prosthesis placement must accept the potential risks to their phallic anatomy. We review current practices at our center and narrative review of literature discussing techniques for penile prosthesis and testicular prosthesis placement after phalloplasty and scrotoplasty, as well as surgical outcomes, and quality of life outcomes where available. Early discussion of a staged approach to phallic construction with a last step of implant placement is important during initial phalloplasty counseling. Pre-operative counseling at our multi-disciplinary center includes: discussion of surgical history, complications, goals and priorities; physical exam to evaluate phallic size and position, scrotal size, and other anatomic findings that may influence prosthesis selection; urinary evaluation, including uroflowmetry with post-void residual, and a cystoscopy with retrograde urethrogram if indicated based on symptoms or urinary studies, and discussion of surgical risks, benefits and alternatives. Although none of the commercially available penile prosthesis devices in the United States are designed for phalloplasty, modern inflatable and malleable prostheses are adapted for use in the post-phalloplasty setting. Due to the lack of native corpora cavernosa, highly variable phallic anatomy, and the need to adapt implants designed for natal penile anatomy, complication rates of prosthesis placement after phalloplasty remain high, with reported ranges of complications from 20% to 80%. Major complications requiring surgical revision are common relative to implant placement in natal penile anatomy, and include: infection requiring explantation, device extrusion, erosion, migration or malposition, inadequate rigidity, poor aesthetic result, pain, decrease or loss of erogenous and/or tactile sensation, device failure, injury to the urethra, and injury to the neurovascular supply of the penis with resultant partial or complete flap loss. This broad range of complication rates represents the variability with which results are reported and reflect a lack of clear reporting guidelines, significant variability in techniques, and need for more standardization. To optimize outcomes, it is important that surgeons have an in-depth understanding of phalloplasty anatomy and are equipped to manage potential complications in the short- and long-term.

ALT Flap Single-Stage Donor Site Closure with Loco-Regional Flaps: A Systematic Review

The anterolateral thigh (ALT) flap is currently the main choice as a free flap for head and neck reconstruction, including intraoral and facial defects and it is gaining popularity in abdominal, orthopedic and pelvis reconstruction [1]. It can also be used as a pedicled flap in abdominal or perineum reconstruction. One of the most important property of the ALT flap is the low donor site morbidity, both functionally and aesthetically, compared to other workhorse flaps, thanks to the possibility to reach a direct suture in 80% of the cases. Many possibilities are currently available to cover the defect when direct suture is not achievable. A split thickness skin graft has traditionally been used to address the remaining skin defect. Due to the alteration of the thigh skin sensitivity and poor aesthetic outcomes, loco-regional flaps are gaining tremendous momentum in the field. In fact, they allow surgeons to get the donor site closure in one stage surgery, with a good tissue quality, with a like-with-like tissue. A systematic review according to the PRISMA guidelines was performed concerning the issue of donor site closure after ALT harvesting.

An Algorithm for Correction of Mild Tuberous Breast Deformity in Augmentation Mammaplasty: Camouflage or Correct?

Tuberous breast deformity (TBD) is a common abnormality, particularly in patients presenting for breast augmentation. Failure to correct each regional abnormality, including the inframammary fold, lower pole deficiency, nipple-areola complex widening or herniation, or any degree of ptosis, will result in exaggeration of the deformity and a poor aesthetic outcome. To describe an algorithm, including novel techniques, to address each region of mild TBD in patients undergoing breast augmentation. This is a retrospective review and description of the senior author's (K.T.) techniques for correction of early-stage TBD from 2016 to 2021. One hundred forty-two patients underwent a stepwise approach to correct milder TBD features when undergoing breast augmentation. The authors propose a regional algorithm for management of TBD, to allow mostly single-stage correction, except in cases with marked ptosis, severe asymmetry, or marked macroareola.

Radiation and free flaps: what is the optimal timing?

The debate over when to perform flaps in patients undergoing radiation remains an ongoing dilemma without definitive resolution. Classically, reconstructive surgeons recommended avoiding exposure of autologous flaps to radiotherapy due to concerns over surgical complications and poor aesthetic outcomes. However, delayed reconstruction carries its own risk profile and aesthetic limitations, given the irreversible changes to the breast envelope. Immediate reconstruction not only confers psychosocial benefits but allows for preservation of the native breast skin and footprint. In recent years, a growing body of evidence suggests that with modern radiation techniques, long-term outcomes of immediate vs. delayed autologous reconstruction may be more similar than previously thought. This review examines the advantages and disadvantages of each treatment algorithm and critically evaluates the existing literature on autologous breast reconstruction in the setting of post-mastectomy radiotherapy. Importantly, radiation regimens have varied widely over time and between institutions, introducing significant heterogeneity in published outcomes of flap contracture or fat necrosis after immediate reconstruction. While delayed autologous reconstruction remains a reasonable pathway, the benefits of immediate reconstruction should not be dismissed. Our findings ultimately corroborate the view that immediate flap reconstruction is a sound treatment option that can be safely offered to patients. The decision regarding which pathway to pursue should ultimately be patient-centric and driven by multidisciplinary consensus, rather than by prior dogma.

First dorsal metacarpal artery flap in soft tissue reconstruction of recurrent thumb squamous cell carcinoma

Background. Subungual squamous cell carcinoma (SCC) of thumb is a rare disease. However, it is the most common malignancy affecting the nail bed. Early recognition is crucial and important for prompt diagnosis and effective treatment. Often this tumour needs to be treated surgically with wide local resection, which results in a defect in the thumb. If not handled appropriately, such defects render restriction in functionality of the involved thumb as well as a poor aesthetic outcome. In the worst-case scenario, it may result in a poor function of involved hand. Thus, reconstruction of the involved thumb is necessary. The main aim of reconstruction is to regain the hands' function and preserved the thumbs' sensation. Secondarily, to have an aesthetically pleasing hand. Our hands carry out delegate job and important duty for daily function. Especially, the thumb working together with the other fingers to carry out the hand function as one unit. Loss of thumb function affects the whole performance of the hand. Case descriptions. We report a case of recurrent subungual squamous cell carcinoma of thumb, which had wide local resection and subsequently underwent soft tissue coverage with an islanded first dorsal metacarpal artery (FDMA) perforator flap. One month after surgery, the patient was able to regain a good functional outcome of the hand. In this report, we discussed the procedures that had been done. Conclusion. The patient regained full functional hand after reconstruction with preserved sensation over distal thumb. The aesthetic outcome is satisfactory. The FDMA perforator flap is a very pliable and robust flap for reconstruction of distal thumb defect.

Ceramic anterior veneer restorations in periodontally compromised patients: A retrospective study.

Successful periodontal therapy can lead to poor esthetic results, especially in the anterior region, for which there are treatment options such as direct composite or indirect veneer restorations. Until now, there are no data describing the long-term results of veneer restorations in periodontally treated patients. The aim of this retrospective study was to evaluate the outcome of anterior porcelain veneer restorations in periodontally compromised and noncompromised patients. Periodontally healthy and periodontally compromised patients, who had received anterior veneer restorations at least 5years ago, were invited to a follow-up examination. Groups were divided according to their periodontal diagnosis (periodontally healthy, stage I/II, stage III/IV). Tooth loss, veneer loss, biologic parameters, and complication rates were examined. Also, veneers were evaluated according to modified United States Public Health Service criteria. A total of 68 patients with 312 veneers were examined with a mean follow-up time of 8years. Veneered teeth in patients with periodontitis stage III/IV showed no difference regarding tooth-specific, overall, and functional veneer survival when compared to periodontally healthy patients (Kaplan-Meier analyses). In Cox regression analysis, follow-up time had an impact on complications and veneer loss, whereas periodontal diagnosis showed no significant influence on the survival of restorations. Comparative tests showed that patients with severe periodontitis at baseline have slightly lower veneer survival rates after 8years and slightly higher complication rates after 13years. Long-term results and complication rates of veneer restorations in periodontally compromised patients are comparable to periodontally healthy patients over a mean follow-up of 8years.

Transoral versus transfacial surgical approach to maxillary tumors: evaluation of outcomes and perspectives

Neoplasms of the maxilla have multiple different origins and histology, and often extend towards the infratemporal fossa, orbit, or skull base. Extensive resection may be required, often leading to poor esthetic and functional results. Usually, these lesions are removed via a transfacial approach. The aim of this study was to compare the outcomes of the transoral versus transfacial approach for maxillary tumors. A single-institution retrospective study was conducted on patients with maxillary-midface tumors, treated between January 2009 and December 2019. The patients were divided into two groups according to the surgical approach, transfacial or transoral, and the following outcomes were assessed: extent of the resection based on Brown’s classification; postoperative pathology margin assessment; reconstruction technique; esthetic/functional results. A total of 178 patients were included. A satisfactory resection was obtained in both groups, with the transoral cohort achieving a higher rate of clear oncological margins (positive margins: transoral group 3.7% versus transfacial group 6.8%, P = 0.389) and a significantly higher University of Washington Quality of Life score (mean 72.2 versus 67.8, P < 0.001). Even large and invasive tumors can be treated successfully with the transoral approach, avoiding unesthetic facial scars while still providing complete resection of the tumor.

SP37. Fortification or Fibrosis? An Evaluation of Immune System Disorders and the Development of Capsular Contracture

PURPOSE: Two-stage implant-based procedures remain the most common approach for women pursuing post-mastectomy reconstruction. Up to 20% of patients develop capsular contracture after surgery, which can lead to poor functional and aesthetic outcomes, cause significant discomfort, and require additional corrective procedures. While the etiology of capsular contracture has not been fully elucidated, most literature attribute the process to a pro-inflammatory response involving the innate immune system. Additionally, some have postulated that peri-operative bacterial colonization of the implant site may lead to fibrosis and contracture formation. Autoimmune disorders, which are linked to abnormal systemic inflammatory responses, and immunosuppression, which can increase susceptibility to a range of infections, are not uncommon in patients diagnosed with breast cancer. Thus, an understanding of the intersectionality between these conditions and post-operative complications could prove useful for surgical planning. The aim of this study is to evaluate the effects of autoimmune disorders and immunodeficiency on rates of capsular contracture among two-stage breast reconstruction patients. METHODS: A dataset consisting of 296 patients (520 samples) who had undergone two-stage breast reconstruction between 2009 - 2021 at a tertiary-care facility was used in the study. An array of patient data, such as demographics, past medical history, and social history were collected. The primary endpoint was contracture development, which was ascertained by reviewing the electronic health record. The secondary outcome of interest was time to contracture formation. The date of contracture development (t_c) is defined as the first mention of capsular contracture based on clinical assessment. The time to event is defined as t_c - t_implant if the subject developed contracture, t_c - t_present if the subject was contracture-free. Univariate logistic regression was used for statistical analysis. RESULTS: Among the cohort, 5% (26/520) and 10.6% (55/520) had concurrent immunosuppression and autoimmune disorders, respectively. The autoimmune disorders examined were rheumatologic and endocrine in origin. The immunosuppressed states included both viral (HIV, Hepatitis A/B/C) and oncological (multiple myeloma, monoclonal gammopathy of undetermined significance, chronic myelogenous leukemia) conditions. On univariate analysis, compared to patients without either conditions, autoimmune disorders (OR 1.15, p-value 0.64) and immunosuppression (OR 1.06, p-value 0.88) were not linked to significantly higher odds or earlier development of capsular contracture (p-value > 0.05). Further stratified analysis examining only patients with immune-based conditions did not reveal statistically significant differences in the timeline (OR 0.14, p-value 0.43) or odds (OR 1.07, p-value 0.878) of contracture formation between the subgroup with immune-overactivation and the subgroup with immunosuppression. CONCLUSION: Comorbid autoimmune disorders and immunosuppression do not appear to significantly affect the odds or timeline of capsular contracture development. When counseling post-mastectomy patients with similar past medical history, surgeons may safely offer the choice of implant-based procedures when presenting the various reconstruction modalities.

Is Using Closed Incision Negative Pressure Therapy in Reconstructive and Oncoplastic Breast Surgery Helpful in Reducing Skin Necrosis?

Introduction Skin necrosis is a major concern of morbidity in patients undergoing reconstructive and oncoplastic breast surgery (ROBS) as it may lead to a poor aesthetic outcome, necessitate further surgery, and delay adjuvant chemotherapy and radiotherapy if required postoperatively. Some studies have reported that closed incision negative pressure therapy (ciNPT) immediately after surgery can reduce the incidence of wound complications. Our study aimed to investigate the effect of ciNPT on skin necrosis rate after ROBS. Methods Our study included 82 patients in a single center who underwent 121 ROBS procedures. We used conventional dressing in 42 patients (62 procedures, group A), while we used ciNPT in 40 patients (59 procedures, group B). When ciNPT dressing was introduced in our breast unit, 40 patients with 59 ROBS procedures who had ciNPT dressing were studied prospectively. The risk factors recorded were age, body mass index (BMI), history of previous radiotherapy, history of smoking, type of incision, type of operation, breast tissue specimen weight, use of neoadjuvant chemotherapy, and implant size. Skin necrosis was classified as "minor" if it was managed conservatively with regular dressings and "major" if surgical debridement in theater and/or exchange or implant removal was necessary. Results The incidence of overall skin necrosis in the conventional dressing group was 17.7% (11/62), while in the ciNPT group, it was higher at 25.4% (15/59), although this was not statistically significant (p = 0.51). ciNPT also did not show a statistically significant difference from the conventional dressing in the rate of minor necrosis (18.6% versus 11.2%, respectively; p = 0.44) and major necrosis (6.7% versus 6.4%, respectively; p = 1.00) Conclusion Our data has shown no superiority of ciNPT in reducing skin necrosis rate in a patient undergoing reconstructive and oncoplastic breast surgery, contrary to many other published reports. However, it may have reduced rates of other wound complications such as wound dehiscence, wound infection, and hypertrophic scar formation, which were not studied in our cohort. Further studies are needed to confirm its benefits, especially in high-risk patients.

How to perform breast augmentation using a composite myofascial flap

Breast augmentation is one of the most frequently performed by specialist plastic surgeons in Australia.^1^ Refinements in operative breast augmentation techniques have continued to evolve over time. Implant migration remains a concern, especially when using smooth implants. The breast implant can either displace laterally towards the mid-axillary line or inferiorly through the inframammary fold, resulting in a loss of cleavage, upper pole fullness, ‘bottoming out’ and in some cases a mega pocket. Specifically, this technique aims to prevent telemastia, defined as an abnormally wide separation between the breasts.^2^ We propose an intraoperative technique unique to primary breast augmentation that ensures the breast implant is secured by means of a composite autologous myofascial (CMF) sling involving the pectoralis major muscle. This aims to prevent inferno-lateral displacement of the breast implant which renders a poor aesthetic result secondary to loss of ‘cleavage’ and the resultant formation of a ‘mega pocket’. The authors have integrated this technique into their practice since August 2020, with case numbers now in excess of 500. The authors use the technique to mitigate implant displacement in both breast augmentation and augmentation mastopexy cases.

The British Association of Aesthetic Plastic Surgeons (BAAPS) Gluteal Fat Grafting Safety Review and Recommendations.

Superficial gluteal lipofilling is a fat grafting procedure performed to correct a trochanteric depression and buttock deflation. Brazilian butt lift (BBL) is a gluteal lipofilling procedure traditionally associated with exaggerated appearance and intramuscular fat transfer. The risk of mortality from fat embolism in BBL was previously reported as being 1:2500. The actual risk was later estimated to be nearer 1:15,000, which is similar to the mortality risk in abdominoplasty. There is increasing evidence regarding the safety of subcutaneous gluteal lipofilling. This has principally been related to new technologies, surgical techniques, and training being developed to avoid intramuscular injection of fat. The efficacy and benefits of intraoperative ultrasound for guiding the subcutaneous placement of fat and avoiding inadvertent deep lipofilling have been demonstrated. Other serious risks and complications must be considered in addition to mortality. These include hypothermia, sepsis, skin necrosis, and poor aesthetic results, as well as the much-publicized risk of fat embolism. Complications are better controlled and managed in strictly regulated healthcare settings. Patients seeking surgery at unregulated facilities or via medical tourism are deemed to be at higher risk of being exposed to these serious complications and/or inadequate subsequent management.

Survival and Fracture rates of One-Piece Zirconia Implants: A Systematic review

Introduction: The implementation of endosseous showed expected outcomes related to survival and successful oral management. Nowadays, interest in achieving an excellent esthetic outcome increased in implant dentistry. Dental implants’ aesthetic outcomes demand understanding of fundamental biological principles and proficiency in various surgical procedures. Titanium alloys and titanium are the gold standards as a material of choice. Evaluate the rate of survival and fracture by dental implants of one-piece zirconia with a year follow-up history. Methodology: This study was based on a systematic review, carried out through PubMed, Embase and Medline databases considering clinical studies only from 2016–2022 published data. Results: Eleven articles were selected out of 1024 initially. Evaluated a total number of 658 one-piece implants, with follow-ups from 1–7 years. The comprehensive survival and fracture rate of one-piece zirconia implants is 87.7 % and 4.9% after at least a year of function. Z-system Zirconia implants showed the highest fracture rate among other systems. Conclusion: Zirconia dental implants are a promising solution to replace missing tooth/teeth, especially in the case of Titanium allergy, or in patients with sub-optimal soft tissue conditions can lead to poor esthetic results. However, more clinical practice is required to determine the effective implants with fewer complications.

Successful reconstruction using a de-epithelialized rectangular flap on a nipple necrosis site after DIEP flap-based breast reconstruction: a case report

Postmastectomy nipple necrosis is a factor that leads to a poor aesthetic outcome in breast reconstruction because of the unique projective structure of the nipple. We present a case of successful nipple reconstruction using a de-epithelialized rectangular flap. A 45-year-old woman was diagnosed with left breast cancer. She had a vertical scar below the nipple-areolar complex due to previous reduction mammoplasty. She underwent nipple-sparing mastectomy, breast reconstruction with a deep inferior epigastric artery perforator (DIEP) flap, and contralateral reduction. After the operation, the nipple gradually necrotized, and full-thickness nipple necrosis was observed on postoperative day 12. For nipple reconstruction, we designed a 38×23 mm rectangular flap from the DIEP flap considering the contralateral nipple diameter (12 mm), protrusion (2 mm), and ipsilateral mastectomy skin flap thickness (15 mm). The area in contact with the mastectomy skin flap was placed in the defect area after de-epithelialization. The reconstruction was successful and the nipple survived with a slight loss of projection. When unexpected nipple necrosis occurs after DIEP-based breast reconstruction, designing a de-epithelialized rectangular flap using the DIEP flap tissue is a feasible reconstructive method to consider.

Complications related to axial orientation of implants and their research progress

The ideal axial orientation of implant is the key to the success of implant denture restoration. According to the restoration-oriented concept of implant, the implant axis direction should be consistent with the long axis direction of the suprastructure. In clinical practice, implant axial deviation leads to related complications, such as implant fracture, periimplant inflammation, and poor esthetic outcome of implant restoration, resulting in implant treatment failure. In this paper, complications related to improper implant axial orientation, their causes and treatment strategies are reviewed.