Irregularly Irregular Stellate Incisions for Selective Reduction of Benign Facial Lesions.

Background: Cosmetic outcomes are among patients' top concerns when discussing treatment options for facial nevi. Benign lesions of the face often enlarge with time, and many patients seek care to minimize the perceived deformity. Complete excision remains the frontline treatment for facial lesions, but a choice must be made between the deformity from the lesion itself and scar deformity incurred from its removal. Traditional elliptical excision results in a linear scar that is often conspicuous, while alternatives to surgical excision seek to minimize scarring but possess their own disadvantages. We report a new application for nevus reduction (subtotal or near-total excision) to diminish deformity from the lesion itself while minimizing scar visibility with a novel "irregularly irregular stellate incision" approach. Methods: Incisions are made in a stellate pattern with irregularly irregular borders circumscribed within the lesion. Therefore, the scar is restricted to the lesion surface, while a reduction in area and projection off the skin surface can be tailored to fit the patient's wishes for any benign skin feature. Results: This technique has been employed with hundreds of facial lesions, with two representative cases shown. No significant complications have been observed and the method has been used on a wide variety of sizes and types of lesions. Conclusions: The technique presented meets the need for minimal scarring when reducing benign lesions of the face. The method is applicable to a wide range of presentations and can also function as a method to biopsy lesions, should there be concerns about pathology.

Cartography and Topographic Mapping: The Historical Basis for the Standardization of Anatomical Analysis and Surgical Mark-Making to Improve Outcomes in Body Contouring.

SUMMARY: Maps have been used for thousands of years to guide and advance mankind's interests. Recently, cartography has grown exponentially into standardized, densely layered systems, facilitating countless functions that use complex algorithms and multifactorial data. Surgeons have successfully addressed bodily concerns for centuries, aided by consistency of human anatomy, physiologic responses to disease, and patterns of disease. However, body contouring techniques alter the much more inconsistent surface anatomy of stretched or aged skin and highly variable subcutaneous fullness. To date, no consistent strategy has been proposed to analyze, map, and alter human shape in a standardized fashion; however, well-established cartographic methods for topographic mapping can be logically adapted to meet surgical needs. Quantification of results, valid and meaningful comparison of techniques, and anatomical discovery could all be achieved by adopting cartographic methods. As anatomists and scientists, surgeons constantly seek logical and reproducible methods to improve patient outcomes. In this article, the authors present a technique derived from topographic mapping, applied directly to the surface of the human body, reflecting the actual underlying anatomy, to guide both elective and reconstructive procedures. The method provides logical and quantifiable methods for (1) the analysis of anatomy, (2) data-driven planning of surgical care, and (3) a consistent operative implementation-so that each patient can receive individualized, anatomically based procedures. Use of well-established mapping strategies would also promote interdisciplinary collaboration, permit adaptation of software to analyze volume and shape, and improve patient outcomes through quantification of change and meaningful comparisons of procedural options.

There is No "Axillary Tail": Rethinking the Assumption of James Spence.

Widely quoted, "the axillary tail of Spence" refers to a contiguous extension of adipose angling superolaterally from the primary breast into the axilla. Described anecdotally in 1871, the "tail of Spence" has been considered important to the fields of general surgery, oncology, plastic surgery, and anatomy ever since. Despite the ubiquitous presence of the concept in literature, clinical discussions, and educational settings, we argue against the very existence of Spence's "tail." While pinch-testing and topographically mapping 316 consecutive patients in preparation for breast and gynecomastia surgery, we found a consistent pattern of focal fat mounds without continuity between breast and axilla. The absence of an uninterrupted superolateral tail was reaffirmed while analyzing 20 research participants who were pinch-tested with calipers and topographically mapped, specifically to define fat pad anatomy. We documented that the axillary breast mound was always distinct from the primary breast and that all women and many men had an additional "lateral chest wall tail" that never angled toward the axilla. In most, rolling the shoulder girdle anteriorly created a visible groove between the axillary mound and the primary breast, with little or no pinchable fat beneath that crease. With all deference to Spence, we have established that the outer half of the chest is consistently defined by three focal adipose structures-an axillary mound, the primary breast mound, and a previously unnamed "lateral chest wall tail"-with no anatomic evidence of an "axillary tail" of fat extending superolaterally from breast to axilla.