Recurrent Ptosis Research Articles

Artificial Intelligence, Genuine Outcome: Analysis of 72 Consecutive Cases of Subfascial Augmentation Mastopexy With Smooth Round Implants Supported by P4HB Scaffold.

Ptosis recurrence often leads to unsatisfactory results after mastopexy, even more so when additional stress is provided by implants on compromised native tissue. The poly-4-hydroxybutyrate(P4HB) scaffold (GalaFLEX) with its favorable safety profile and proven long-term mechanical strength represents a preferred option for soft tissue support. The primary endpoint was assessment of lower pole stretch from the early postoperative period up to 3 years. Out of 151 patients who underwent surgery by G.B. from March 2020 to December 2023, a total of 72 with a 12-month-mininum follow-up who had primary (46) or secondary (26) augmentation mastopexy with subfascial round smooth implants and P4HB scaffold support were included in the study. Three-dimensional artificial intelligence software was utilized for all measurements. Further analysis included evaluation of ptosis recurrence and all complications. No recurrent ptosis, bottoming out, implant displacement, or capsular contracture was reported during follow-up (mean, 24.8 months). The lower pole arch's elongation was 8.04% and 9.44% at 1 and 3 years respectively, comparing favorably with previous reports. Statistically significant correlation (P < .05) between implant size and lower pole stretch was noted, this being greater for larger implants (> 400 cc; P = .0011) and primary cases (P = .1376). Progressive volume redistribution from upper to lower pole was observed in the first year, with substantial stability thereafter. This is the largest published series reporting long-term results (up to 45 months) in mastopexy augmentation with GalaFLEX, suggesting its supportive role in lower pole stability even in the setting of concurrent breast augmentation with smooth implants in a subfascial plane.

Augmentation mastopexy using the “double inner bra technique” (DIB) in post-bariatric surgery

BackgroundAugmentation mastopexy has a 20-fold higher complication rate than primary augmentation. Performing augmentation mastopexy in post-bariatric patients poses an additional challenge owing to the reduced quality of the soft skin tissue. Therefore, it is technically complex and also fraught with complications. Implant dislocation, recurrent ptosis, wound healing problems with exposed implants, and the threat of implant loss are complications that must be prevented. MethodsWe present a case series study on our technique for stabilizing breast implants using the double inner bra technique (DIB) in which a laterobasal myofascial flap and an inferiorly based dermoglandular flap form a double inner bra for implant stabilization and protection. ResultsThirty-seven cases were operated on using this technique from December 2020 to June 2023. No hematomas (0%), seromas (0%), infections (0%), and implant losses (0%) were recorded. Moreover, none of the patients had implant malposition (0%). With regard to recurrent ptosis mammae or waterfall deformity, 7 cases (2.6%) showed early ptosis within the first 3 months, and the number of ptosis decreased over time. Furthermore, 5 (1.81%) patients showed ptosis mammae after 6–12 months. Implant defect or rupture has not yet occurred (0%). ConclusionThe DIB is an easy-to-learn and versatile technique. It has low complication rates and can be used to achieve esthetically satisfactory mid- to long-term results.

Reviewing Outcomes and Complications with the Use of Mesh in Breast Reduction Surgery.

Reduction mammoplasty is a common reconstructive and esthetic procedure with variable long-term outcomes regarding breast shape, projection, and nipple-areolar complex. One common complaint is recurrent breast ptosis, which may be mitigated by sufficient support of the inferior pole. This review will look at the effects of mesh in mitigating postoperative ptosis following reduction mammoplasty. A comprehensive review of the literature was performed using the PubMed database. Manuscripts that provided data with respect to the effects of mesh on cosmetic outcomes, patient-reported outcomes, complications, and surveillance were utilized. Six studies with a total of 634 patients were included in this review. There is limited evidence to support a cosmetic benefit with the use of mesh in reduction mammoplasty patients. While subjective satisfaction was demonstrated in one paper, few others had objective measurements of the impact of mesh. Complications included infection, skin necrosis, and loss of nipple sensation. Mammography was found to not be affected by mesh placement. The use of mesh during reduction mammoplasty is a relatively modern innovation that does not appear to have a significantly different risk profile than that of traditional reduction procedures. There is limited cosmetic value based on currently available data. More objective future analysis is necessary in order to justify the use of mesh in reduction mammoplasty for its claimed cosmetic benefits. This 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 Table of Contents or online Instructions to Authors www.springer.com/00266.

RECURRENT CONGENITAL PTOSIS MANAGEMENT BY SUPRAMAXIMAL LEVATOR RESECTION TECHNIQUE

Introduction : Congenital ptosis is an abnormal low position of the eyelid since birth. Levator resection technique is one of the surgery technique for ptosis corection. Recurrence could be occured even after ptosis correction&#x0D; Case Illustration : A 22 year old male presented with a chief complaint of droopy left eyelid since birth. Visual aquity were 0,08 pinhole 0,2 and 0,25 pinhole 0,63 respectively. Opthalmology examination revealed interpalpebral fissure (IPF) 4 mm, margin reflex distance (MRD)1 0 mm, MRD2 4 mm and levator function test (LFT) 6 mm on the left eye (Figure 1). Levator resection technique was conducted on his left eye with a good result, MRD1 2 mm, MRD2 5 mm, IPF 7 mm. But the lid dropped again after3 months (Figure 2). Opthalmology examination of the left eye showed IPF 5 mm, MRD1 0 mm, MRD2 5 mm, LFT 2 mm and lagophtalmos 1 mm. Second surgery was done with supramaximal levator resection technique. Good result was achieved after second surgery, MRD1 3 mm, MRD2 5 mm, IPF 8 mm (Figure 3).&#x0D; Discussion : Recurrent ptosis could occured after ptosis surgery and had challenges due to scar from previous surgery. Frontal suspension technique was recommended for congenital ptosis levator function less than 4 mm. Supramaximal levator resection was done for this patient, with resection of 30 mm levator muscle, which had result as good as of frontal suspension technique.&#x0D; Conclusion : Levator resection technique could be repeated to repair recurrent congenital ptosis. Supramaximal levator resection technique is one of the option.

A Safe and Simple Method of Augmentation Mastopexy

Introduction: Combining breast augmentation with mastopexy has historically been considered challenging, with concerns about complications and suboptimal aesthetic outcomes. However, recent data suggest that the combined procedure can be performed safely and effectively. Materials and Method: This article presents a technique for augmentation mastopexy that aims to minimize complications and is safe to perform. The technique focuses on preserving a robust blood supply, minimizing lower breast contour bottoming out, maintaining upper pole fullness, reducing the risk of recurrent ptosis, minimizing scar burden, and avoiding periareolar scar widening. Precise preoperative and intraoperative markings are crucial for achieving long-lasting results. The use of tailor tacking and marking the vertical excess with the patient in an upright position provides a reliable method for determining the amount of soft tissue resection required. Results: The results are shown in the postoperative photographs at 10 days, 1 month, and 3 months, respectively. These are compared with the preoperative photographs of the patient’s features. Discussion: The technique incorporates the use of an implant placed in the dual-plane subpectoral pocket to address upper pole flatness and provide structural support in the lower pole. The article emphasizes the importance of preserving Cooper’s ligaments during skin resection to maintain the supportive role of the skin. Vertical wedge resection of the lower pole is employed to reconstruct the breast cone and create a strong vertical fibrous band, which contributes to the long-term shape and support of the breast. The article also discusses techniques to mitigate nipple-areolar complex widening and emphasizes the importance of patient selection based on specific criteria. Conclusion: Overall, the authors present a safe and simple technique for augmentation mastopexy that aims to achieve long-lasting results with minimal complications. The authors advocate for careful patient selection and adherence to their methodology, which incorporates principles of preserving blood supply, maintaining breast contours, and minimizing scar burden.

Метод подвешивания при птозе верхнего века тяжелой степени: преимущества техники скользящей восьмерки

Relevance. Frontalis suspension is used in patients with severe upper eyelid ptosis. Despite the long history of the operation and multiple modifications, none of them gives a lifelong result. The use of suspensions sling materials that grow into tissue increases the surgical trauma during their removal if correction is necessary or recurrence of ptosis. Thus, the task is to choose a method of frontalis suspension, that would be easy to perform have an excellent result. Purpose. To evaluate the effectiveness, execution simplicity and reliability of the frontalis suspension using the «sliding eight» technique with polypropylene suture in patients with severe upper eyelid ptosis. Material and methods. A retrospective study of 84 patients (110 eyelids) with severe ptosis of upper eyelid. A frontalis suspension surgery for removing upper eyelid with the use of 4/0 polypropylene suture was performed in he all patients. The threads were passed into the thickness of the eyelids and brows through previously made skins incisions. The patients were divided into 3 groups: in the first group (25 patients) we used polypropylene frontalis suspension with two needles of the pentagon suspension designs, in the second group (28 patients) we used two polypropylene sutures in the form of two rectangles, in the third group (31 patients) we used the «sliding eight» technique. Results. In the first group, in 5 cases there was a deformation of the upper eyelid contour, in 2 cases a recurrence of ptosis was diagnosed. In the second group, the deformation of the upper eyelid contour was in 4 cases, and a recurrence of ptosis also developed in 2 patients. In the third group, we did not notice any deformation of the upper eyelid contour and palpebral folds. In two cases, recurrent ptosis was diagnosed. The operation time in the first group of patients was 30.21±5.048 min, in the second group – 32.97±3.68 min, in the third – 26.5±3.03 min. The duration of the operation was statistically significantly different between groups 1 and 3 and groups 2 and 3. Conclusion. Surgical treatment of severe ptosis of upper eyelid using the «sliding eight» technique has shown its effectiveness, ease of execution and reliability. This elegant technique minimizes postoperative complications in the form of asymmetry in the position of the upper eyelid, is easy to perform, leaves virtually no scarring, and can be repeated without significant surgical trauma. Key words: severe ptosis of eyelids, brow suspension surgery, polypropylene

Use of Efgartigimod in Treatment of Myasthenia Gravis Relapse after Possible Recurrence of Invasive Thymoma: A Case Report. (P1-5.011)

<h3>Objective:</h3> NA <h3>Background:</h3> Myasthenia gravis is an autoimmune neuromuscular junction disorder with established association with thymoma. There is no consensus on optimal treatment of recurrent thymoma post-resection. Efgartigimod is a first-in-class FcRn antagonist approved by the FDA in December 2021 for treatment of AChR-antibody-positive adults with generalized MG. <h3>Design/Methods:</h3> NA <h3>Results:</h3> A 53-year-old right-handed man presented to us in September 2020 with a 10-month history of recurrent diplopia, ptosis, dysarthria, dysphagia, and bilateral hand weakness. Workup for MG revealed blocking, binding, and modulating AChR antibodies. CT scan of his chest demonstrated an invasive anterior mediastinal mass. He started pyridostigmine, mycophenolate and prednisone, and underwent a sternotomy with thymectomy with sparing of the directly adjacent right phrenic nerve in October 2020. Histopathology revealed a locally invasive Masaoka stage IIIA, pT1bN0M0, WHO type B2 thymoma. He received adjuvant radiotherapy until January 2021. He was weaned off prednisone and pyridostigmine by May 2021. He remained asymptomatic for about 18 months post-thymectomy except for transient dysarthria in September 2021 attributed to missed mycophenolate doses. Patient noticed recrudescence of bulbar and respiratory symptoms around April 2022. Tests showed elevated AChR antibodies but surveillance chest CT scans did not demonstrate tumor recurrence or metastases. His cardiothoracic surgeon remained suspicious of residual thymoma. He started efgartigimod in July 2022 which he tolerated well, resulting in symptom resolution and objective improvement on MG-specific outcome measures (MG-ADL, MG-QoL15r and MGC). His symptoms recurred during a COVID-19 infection a month later, but he rapidly became asymptomatic after completing the second efgartigimod cycle in September 2022. <h3>Conclusions:</h3> Our patient with AChR antibody-positive, thymoma-associated, generalized MG with recurrent symptoms despite mycophenolate treatment, thymectomy and radiotherapy showed a dramatic response to initial cycles of efgartigimod therapy without significant adverse effects. We propose that efgartigimod be considered early in the management of MG patients with recurrent symptoms after thymectomy. <b>Disclosure:</b> Dr. Akemokwe has stock in CVS HEALTH CORP. Dr. Akemokwe has stock in LABORATORY CORP AMERICAN HOLDINGS. Dr. Coskun has nothing to disclose. Dr. Meyerson has nothing to disclose. Dr. Ebong has nothing to disclose.

The Recurrence of Ptosis after Correction Surgery Is Associated with Refractive Error

Background and objectives: Previous studies on ptosis recurrence after correction surgery have tended to focus on postoperative complications, surgical methods and suspension materials, few have mentioned refractive error. This research is to investigate the potential relation between refractive error and recurrence after correction surgery in pediatric patients with simple congenital ptosis. Materials and Methods: We conducted a retrospective analysis of data from patients with simple congenital ptosis who were treated at Zhongshan Ophthalmic Center (ZOC) between 2017 and 2020. In total, 111 eyelids of 85 patients without surgery-related complications who underwent frontalis muscle flap suspension (FMFS) for simple congenital ptosis were included. Postoperative changes in eyelid height were assessed. Cycloplegic refraction was assessed before surgery and during the follow-up period (every 3 months after surgery). Recurrence in the postoperative period was defined as a marginal reflex distance 1 (MRD1) of <1 mm. Results: There were 16 recurrence and 69 non-recurrence cases, with no statistically significant differences, in terms of patient age at the time of surgery, patient sex, or preoperative MRD1, between the recurrence and non-recurrence groups. The postoperative cylindrical diopter (adjusted odds ratio [OR] = 0.432, p = 0.005), laterality (adjusted OR = 0.202, p = 0.006), and preoperative MRD1 (adjusted OR = 0.617, p = 0.019) were associated with ptosis recurrence after surgery. Differences between the recurrence and non-recurrence groups in spherical diopter and spherical equivalent (SE) before and after surgery were not statistically significant. In addition, preoperative refractive error and postoperative spherical diopter were not significantly associated with ptosis recurrence after correction surgery. Conclusions: Ptosis recurrence after FMFS in pediatric cases of congenital ptosis is associated with refractive error. Timely refractive correction and amblyopia treatment may help to reduce ptosis recurrence.

Orbital Schwannoma With Frontal Bone Lysis.

Orbital schwannoma is an exceptionally rare cause of ptosis. Diagnosis may be elusive given its slow rate of growth and its various presentations depending on localization. Herein, we report the case of a 50-year-old male who presented to our clinic with a complaint of unilateral, recurrent ptosis of the left eye. He underwent levator palpebrae resection, which was unsuccessful at improving his ptosis. He later represented with acute-onset diplopia for which magnetic resonance imaging was obtained. Magnetic resonance imaging showed a lesion in the superior orbit with secondary bony dehiscence of the orbital roof. Through a vertical lid-split incision, the lesion was removed, and the frontal lobe was observed protruding through the defect in the orbital roof. This case highlights the importance of diagnostic skepticism in the face of recurrent ptosis and emphasizes the utility of the vertical lid-split approach for anterior lesions of the superior orbit.

Anatomic and Magnetic Resonance Imaging-Based Correction of Upper-Eyelid Depression and Blepharoptosis in Senile Patients.

In senile patients with sunken superior sulcus, involutional ptosis, and higher eyelid crease, a single operation to correct depression or ptosis cannot achieve good results. We demonstrated the anatomy of periorbital septum fibers, which may contribute to the levator muscle's volume depletion and dynamic power transmission disorder, and described a procedure for correcting upper-eyelid depression and blepharoptosis in senile patients. The fibrous webs in these patients connected the posterior aspect of the orbicularis and the orbital septum and extended to the orbital fat and levator aponeurosis. These fibers were dissected to release the periorbital septal fibers, and the orbital septal fat flap was transferred to the depressed region. Advancement or plication of the levator aponeurosis was performed in patients with uncorrected blepharoptosis after the procedures described above. The technique was applied to 13 Chinese patients (25 eyes) between May 2021 and April 2022. Postoperative magnetic resonance imaging revealed that the preaponeurotic fat was displaced forward and down to the upper margin of the tarsus, and the curvature of the upper-eyelid depression was significantly improved. Moreover, the superior sulcus deformity improved, the ptosis was corrected, and the uppermost crease decreased in all patients. No recurrence of ptosis or abnormal adhesion was observed. We believe this is the first study using magnetic resonance imaging to evaluate eyelid anatomy and the effects of surgery in this patient group. Releasing periorbital septum fibers is crucial for correcting a portion of the sunken eyelid and ptosis in Asians.

Does Acellular Dermal Matrix Really Reduce the Risk of Recurrent Ptosis after Mastopexy?

Does Acellular Dermal Matrix Really Reduce the Risk of Recurrent Ptosis after Mastopexy?

Clinical Characteristics of Post-surgical Ptosis Patients at Dr. Mohammad Hoesin General Hospital Palembang

Introduction: Blepharoptosis is drooping of the upper eyelid in a primary position, causing the narrowing of the palpebral fissure. This condition can partially or completely cover the visual axis. Establishing the diagnosis of ptosis requires a comprehensive eye examination, including history taking, physical examination, and examination of the eyelids in ptosis patients. The majority of patients with ptosis require surgery, and clinical characteristics play an important role in classifying the type of ptosis and then formulating a detailed treatment plan strategy so that a better outcome is obtained.&#x0D; Methods: A descriptive retrospective study was conducted from medical records of post-surgical ptosis patients at Dr. Mohammad Hoesin Hospital Palembang from January 2016 to December 2021. The data taken included age, gender, the onset of occurrence, laterality, type of ptosis based on the onset, vertical palpebral fissure (FPV), horizontal palpebral fissure (FPH), margin-reflex distance (MRD), margin limbal distance (MLD), lid lag, bell's phenomenon levator muscle function, type of ptosis surgery and postoperative condition. This study aims to determine the clinical characteristics of patients with ptosis at Dr. Mohammad Hoesin Hospital Palembang.&#x0D; Results: Of the 57 ptosis patients in this study, the majority of patients were male, as many as 32 patients (56.1%) with the age category &gt;40 years, as many as 24 patients (42.1%) with unilateral lateral ptosis as many as 50 patients (87.7%) with the more frequent comparison was the left eye in 29 patients (58%). Acquired ptosis was the most common cause in this study in as many as 46 patients (80.7%), and the most common mechanism of acquired ptosis was neurogenic (33.3%). The majority of patients had no previous surgical history of 41 patients (71.9%), moderate levator function of as many as 42 (73.7%), and frontal suspension surgery technique with synthetic materials as many as 17 (34%) patients. the mean FPV was 5.08±2.627 with a median of 5.00 (0-11), FPH 25.94±1.726 with a median of 26.00 (20-29), MRD 0.246±1.78 with a median of 0.00 (-4 -5), MLD 4.789±2.801 with a median of 5.00 (-4-11) and LA 7.16±4.083 with a median of 7.00 (0-14). Ptosis patients had negative lid lag in 47 patients (82.5%) and positive bell's phenomenon in 49 patients (86%). The postoperative condition of ptosis patients was satisfactory where there was no recurrence and reoperation of ptosis, postoperative complications as many as 1 (1.8%) patients experienced overcorrection, 6 (10.5%) patients experienced lagophthalmos, and 2 (3.5%) patients had an outcome. asymmetric.&#x0D; Conclusion: Clinical characteristics of ptosis patients can determine the diagnosis and treatment that will be given to the patient.

Myasthenia gravis coexisting with HINT1-related motor axonal neuropathy without neuromyotonia: a case report

BackgroundHINT1 mutations cause an autosomal recessive axonal neuropathy with neuromyotonia. This is a first case report of coexistence of myasthenia gravis (MG) and HINT1-related motor axonal neuropathy without neuromyotonia.Case presentationA 32-year-old woman presented with recurrent ptosis for 8 years, diplopia for 2 years and limb weakness for 1 year and a half. Neostigmine test, elevated AChR antibody level and positive repetitive nerve stimulation supported the diagnosis of MG. Electroneurography (ENG) and electromyography (EMG) examinations revealed a motor axonal neuropathy without neuromyotonic or myokymic discharges. Next-generation sequencing and Sanger sequencing were performed to identify the gene responsible for suspected hereditary neuropathy. Genetic testing for a HINT1 mutation was performed and revealed a homozygous mutation at c.278G>T (p. G93V). The patient was treated with pyridostigmine, oral prednisolone and azathioprine. Her ptosis and diplopia have significantly improved at 6-month follow-up.ConclusionsConcurrence of MG and hereditary motor axonal neuropathy without neuromyotonia is quite rare. Detection of ptosis with or without ophthalmoplegia, distribution of limb weakness, and reflex can help in recognizing the combination of MG and peripheral neuropathy. Early diagnosis is important for initial treatment and prognosis. The novel homozygous variant c.278G>T(p.G93V) contributes to the pathogenic variants spectrum of the HINT1 gene.

Combined levator and frontalis muscle advancement flaps for recurrent severe congenital ptosis

BackgroundTo evaluate the outcomes of combined levator resection and frontalis muscle advancement for surgical management of recurrent severe congenital ptosis.DesignRetrospective, nonrandomized interventional case series.MethodsA retrospective review was performed of patients who underwent combined levator resection and frontalis muscle advancement for recurrent congenital ptosis between 2017 and 2020. Inclusion criteria were levator function of 4 mm or less and margin reflex distance 1 (MRD1) of 0 mm or less. Main outcome measures were postoperative MRD 1, lagophthalmos, lash angle, and grades of eyelid contour and crease. The outcomes were assessed by reviewing medical charts and photographs.ResultsThirty-one patients (35 eyelids) met the inclusion criteria. The mean preoperative MRD1 was −1.14 ± 1.56 mm, which improved to 3.93 ± 0.52 mm with an average lagophthalmos of 0.91 ± 0.74 mm at the last follow-up. A total of 91.4% of eyelids had excellent eyelid contour, crease, and eyelash angle at the final follow-up. One eyelid required revision surgery. There were no other significant complications.ConclusionsFor poor function recurrent congenital ptosis, combining levator resection and frontalis muscle advancement is an effective method that results in long-term correction with cosmetically pleasing outcomes and minimal complications.

Recurrence of breast ptosis after mastopexy – a prospective pilot study

Breast ptosis is characterized by severe volumetric deficiency of the upper pole, excess of skin in the lower pole and descent of the nipple-areola complex (NAC). Mastopexy, also known as breast lifting, is the surgical operation aimed to reshape the ptotic breast. Recurrence of breast ptosis after mastopexy is common but to the best of our knowledge no study before has measured it. The aim of this study was to measure the recurrence of breast ptosis after mastopexy in aprospective study. Female patients affected by unilateral or bilateral moderate or severe breast ptosis were enrolled in the study. All the patients underwent mastopexy performed only with the removal of skin excess following aWise pattern. The jugular notch-nipple distance was measured before surgery, immediately after surgery and after 1, 3, 6 and 12 months. Ten patients were included in the study, four underwent unilateral mastopexy and six underwent bilateral mastopexy. The lifting of the NAC, measured in the immediate post-operative period, ranged from 3 to 8.5 cm, with an average value of 6.3 cm. This lifting, one year after surgery, ranged from 2 to 7 cm, with an average value of 4.6 cm. The percentage loss of the NAC lifting one year after surgery compared to the immediate post-operative time ranged from 12.5 to 41.7%, with an average value of 27.5%. In our case series, the lifting of the NAC obtained immediately after surgery showed an average loss of 27.5% one year after surgery. Even if limited by the low number of patients included, this pilot study is eye-opening on avery common phenomenon that occurs after mastopexy. The patients should be informed about the possible recurrence of the breast ptosis.

Structured Mammoplasty (Breast Reduction and Mastopexy with Silicone Implants): Standardization of Technique for Predictable Results.

Background:Several methods have been developed for the treatment of ptosis and breast hypertrophy, with good early results but with dissatisfaction in the long term, due to loss of volume and projection of the upper pole and recurrence of ptosis. In the face of this adversity, the purposes of the present study were to describe a surgical technique of breast reduction and mastopexy with silicone implants, named structured mammoplasty, and to present the outcomes of patients who underwent this technique.Methods:The structured mammoplasty technique with round silicone prostheses (surgical marking and stages), performed on 100 patients who were operated on between 2017 and 2020 and were followed up for a minimum of 12 months, was described. Postoperative and patient satisfaction assessments were made.Results:No major complications were observed in an average of 18 months of follow-up (ranging from 12 to 30 months). The maintenance of the outcome with a projected upper pole and rounded breasts resulted in a high level of satisfaction.Conclusions:Structured mammoplasty with silicone implants is a safe and predictable option, ensuring a long-lasting shape. It can be applied to any breast that has surplus skin, making it a more reliable option in the arsenal of the plastic surgeon.

Head and Neck Langerhans Cell Histiocytosis in Children

Controversy exists among head and neck surgical specialties regarding management of Langerhan's Cell Histiocytosis (LCH). The purpose of this study was to evaluate diagnosis, management, and treatment outcomes in children with LCH of the head and neck. This is a retrospective cohort study of children with LCH of the head and neck who presented to Children's Healthcare of Atlanta hospital from 2009 to 2021. The independent variables were demographic information, lesion locations, clinical presentation, radiographic findings, diagnostic workup, treatment, and length of follow-up. The patients were grouped based on these variables. The outcome variable was disease reactivation. Descriptive statistics were calculated. There were 3 presentations of LCH of the head and neck. Group 1 presented as a lesion in 1 system without CNS risk (SS-). There were 24 patients with an average age of 10 years. Lesions were located in calvaria and/or mandible. Majority of the patients were treated with only debridement. Two of the patients experienced reactivation. Group 2 presented as a lesion in 1 system with CNS risk (SS+). There were 30 patients with an average age of 6 years. Common locations were temporal bone and/or orbit. These patients present with recurrent ear infections and ptosis. Majority of the patients were treated with chemotherapy (n=28). One patient had disease reactivation. Group 3 presented with multisystem involvement. There were 13 patients with an average age of 2 years. LCH was found in skin and the lymphatic system. Imaging demonstrated extracranial organ involvement. All of them were treated with chemotherapy. There was 40% reactivation of LCH. Treatment of LCH depends on presentation. SS- subgroup can be adequately treated via surgical debridement. SS+ and multisystem groups benefit from an early disease diagnosis and require chemotherapy.

POST TRAUMATIC CAROTID CAVERNOUS FISTULA PRESENTING AS PARATHYROID CRISIS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: This is a case of two rare entities causing non-specific symptoms. Carotid-cavernous sinus fistula (CCF) arises from miscommunication of carotid arterial flow and the cavernous sinus. Post traumatic CCF presents bilaterally are uncommon, only 1-2% of patients. While already a rare diagnosis, our patient presented in an acute parathyroid crisis defined by symptomatology caused by markedly elevated calcium and parathyroid hormone, which may have masked our diagnosis of CCF. CASE PRESENTATION: A 57-year-old Colombian female presented with dizziness, anorexia, nausea, and vomiting. She also endorsed intermittent diplopia in the left eye. Physical exam revealed left sided ptosis. She reports a remote history of head trauma a month prior. Serum calcium on presentation was 13.6 mg/dL, ionized calcium of 6.8 mg/dL, and parathyroid hormone (PTH) was 219.8 pg/mL. Subsequently, a Technetium 99m sestamibi scan showed increased radioisotope along the right lower pole of the thyroid gland confirming primary hyperparathyroidism. She was resuscitated with normal saline fluid and started on Cinacalcet for hypercalcemia. Attempts to lower serum calcium can be achieved using bisphosphonates and may be effective within the first 24 hours. In our patient, Cinacalcet did not achieve sufficient calcium lowering thus, Zoledronic acid was used due to its potency with small doses. Nausea, vomiting, and positional dizziness resolved. Despite resolution of symptoms, she continued with ptosis; thus prompting further work up. Magnetic resonance angiography and venography revealed extensive time of flight enhancement throughout the bilateral cavernous sinuses. A cervical and cerebral angiography revealed bilateral carotid cavernous fistulas with ophthalmic vein arterialization. The next day, she underwent left cavernous sinus embolization with coiling. Parathyroidectomy was delayed due to recurrence of ptosis and need for a second embolization for persistent diplopia that resulted in resolution of symptoms. DISCUSSION: Each of these diagnoses are rare and both require timely evaluation and treatment. The patient's symptoms are classically seen in a parathyroid crisis, with nausea, vomiting, and anorexia being the most common symptoms in up to 48% of parathyroid crises. Like the aforementioned, CCF symptomatology also includes non-specific symptoms; however, may pose more of a challenge during diagnosis as symptoms wax and wane depending on the hemodynamic flow within the fistula. CONCLUSIONS: This case highlights the necessity of a thorough physical exam and further as a reminder that a clinician must be vigilant in ruling out alternative pathologies supported by the objective findings no matter how rare or unlikely. REFERENCE #1: Churojana A, Chawalaparit O, Chiewwit P, Suthipongchai S. Spontaneous occlusion of a bilateral post traumatic carotid cavernous fistula. Interv Neuroradiol. 2001;7(3):245-252. doi:10.1177/159101990100700311 REFERENCE #2: Singh DN, Gupta SK, Kumari N, et al. Primary hyperparathyroidism presenting as hypercalcemic crisis: Twenty-year experience. Indian J Endocrinol Metab. 2015;19(1):100-105. doi:10.4103/2230-8210.131763 REFERENCE #3: Lowell AJ, Bushman NM, Wang X, et al. Assessing the risk of hypercalcemic crisis in patients with primary hyperparathyroidism. J Surg Res. 2017;217:252-257. doi:10.1016/j.jss.2017.06.041 DISCLOSURES: No relevant relationships by Roman Bernstein, source=Web Response No relevant relationships by Ariol Labrada, source=Web Response No relevant relationships by Tram Nguyen, source=Web Response No relevant relationships by Elena Tellez, source=Web Response No relevant relationships by Yaswanraj Yuvaraj, source=Web Response

The "Shirt Pocket" Technique-An Alternative for Augmentation-Mastopexy.

Augmentation-mastopexy is a frequent procedure with high rates of early recurrence of breast ptosis, mainly after subglandular approach. The dual-plane techniques, based on the cranial dissection of the pectoralis, is the most used, but this plane does not cover the inferior pole of the breast. Then, the possibility of a downward dissection of the muscle seems to be more reasonable to retain the implant and improve postoperative results. This study aimed to review the anatomy of the pectoralis in cadavers and the use of its downward dissection to create a pocket for breast implant as a “shirt pocket.” This maneuver was associated with a superior-based dermoglandular flap to overprotect the inferior pole. No complications were related in the postoperative period. The anatomic review showed that the “shirt pocket” is a safe option if done carefully. The technique demonstrated to be feasible and seemed to be effective, being another alternative to prevent early recurrence of breast ptosis in these procedures.

Ptosis and Bottoming out Following Mastopexy and Reduction Mammoplasty. Is Synthetic Mesh Internal Breast Support the Solution? A Systematic Review of the Literature.

Relying on soft tissues with low structural strength to provide long-term support of the breasts following aesthetic mammoplasty may be inadequate in many instances. To address the inherent weakness of tissues still present after surgery, use of synthetic non-autologous additional tissue reinforcement has been described. The current review is aimed at analyzing available evidence about safety and effectiveness of mesh support in various reduction mammoplasty, mastopexy, or augmentation-mastopexy. An advanced PubMed and Medline search was conducted to identify clinical studies about the use of synthetic mesh in aesthetic breast surgery. An additional search of breast symmetrization and synthetic mesh was also conducted. Ten studies were identified and judged to be relevant to this review. Retrieved studies were relatively few, characterized by marked heterogeneity, lack of well-defined outcome end points, poor outcome measures, and inherent bias in outcome documentation providing low level of evidence. Despite reported relative safety and some promising results, available data indicate that meshes do not effectively prevent recurrent ptosis and bottoming out; they may not be superior to described techniques with superior pedicle and hammocks or "balcony" flaps. Well-conducted studies are yet to be conducted comparing internal bra technique to procedures with innovative autologous tissue support. This 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 Table of Contents or online Instructions to Authors www.springer.com/00266 .