Autologous Fat Grafting With CO2 Tissue Preparation (Carbo-pneumodissection): A Safe Method for Expanding and Enhancing Recipient Site Capacity and Aesthetic Outcomes.

BACKGROUND: Autologous fat grafting (AFG) is commonly used as part of aesthetic and reconstruction procedures, but expanding and enhancing the recipient site capacity remains a major challenge. OBJECTIVES: The aim of this study was to describe and assess an innovative intraoperative carbon dioxide (CO2) pneumodissection (CPD) recipient site preconditioning procedure intended to improve recipient site capacity and AFG outcomes. METHODS: From June 2019 to August 2021, 53 patients after mastectomy or lumpectomy (76 breasts) underwent 96 AFG procedures as a separate stage immediately following tissue preconditioning with CPD. RESULTS: There were no systemic or major local complications. The mean number of AFG procedures required to complete the reconstruction was 1.3 per breast. The vast majority of patients achieved a final satisfactory aesthetic outcome with either 1 or 2 procedures (77.6% and 18.4%, respectively). The volume of fat graft delivered into the recipient site per session following CPD was higher than previous literature reports for all study groups. Furthermore, the CPD procedure was associated with a reduced need for subsequent AFG to complete the reconstruction. The positive effect of CPD, in terms of AFG volume delivered, was even more prominent among scarred irradiated breasts. Despite the large fat graft volumes delivered in our study, only 5.3% of breasts experienced fat necrosis following the procedure. CONCLUSIONS: CPD constitutes a safe, innovative, intraoperative method to expand and enhance recipient site capacity and fat grafting outcome. CPD allows cavernous expansion alongside preservation of the microcirculation. CPD works for both healthy and compromised tissues, in either reconstructive or aesthetic procedures.

What 736 Plastic Surgeons Think about Explantation and Capsulectomy: A Global Opinion Poll.

BACKGROUND: Breast implant illness, although not classified as a disease entity, has recently gained significant attention globally. The purpose of this study was to assess the status of explantation practices, discuss plastic surgeon's attitude toward requests for explantation and capsulectomy, and evaluate surgical management when accepting these challenges. METHODS: Twenty closed-ended multiple choice questions were formulated to an opinion poll. The anonymous opinion poll was distributed to members of American Society for Aesthetic Plastic Surgery and presidents of plastic surgery societies on all continents. RESULTS: A total of 736 plastic surgeons responded to the opinion poll. Although geographic variation was noted, a majority of 69.8 percent stated that explantation surgery had increased in their practice compared to the previous year. Requests for explantation without capsulectomy met with high acceptance rates among surgeons, regardless of whether patients were asymptomatic or not. Patients who also requested capsulectomy received less enthusiastic replies depending on the type of practice, years in practice, implant position, and type of capsulectomy (en bloc, total, or partial). When fat grafting was indicated, 68.7 percent stated that simultaneous lipofilling is limited when capsulectomy is performed, yet 44.5 percent stated that they would remove thin normal capsules in a symptomatic patient even when simultaneous fat grafting is requested by the patient. CONCLUSION: The opinion poll supports the hypothesis that demand for explantation and capsulectomy increased globally among symptomatic and asymptomatic patients; that attitudes toward simultaneous capsulectomy are divided; and that management may differ according to geographic location, experience, and type of practice.

Hybrid Prepectoral Direct-to-Implant and Autologous Fat Graft Simultaneously in Immediate Breast Reconstruction: A Single Surgeon's Experience with 25 Breasts in 15 Consecutive Cases.

BACKGROUND: The direct-to-implant method depends on the quality of the mastectomy flaps and can be used only when the flaps are adequately perfused. Even though the method was designed to be a definitive reconstruction procedure, it has been associated with an increased likelihood that additional operative revision will be required in order to achieve the expected final cosmetic outcome. The authors describe a hybrid prepectoral direct-to-implant method that combines autologous fat grafting in the superior medial pole with immediate reconstruction. METHODS: In this prospective study, 15 patients (25 reconstructed breasts) underwent simultaneous hybrid prepectoral direct-to-implant reconstruction together with autologous fat grafting performed by a single senior plastic surgeon (Y.G). RESULTS: The mean quantity of autologous fat grafted in the superior medial aspect of the breast was 59.4 ± 12.8 cc. The mean total volume of the hybrid reconstructed breast, including implant and autologous fat graft, was 497.2 ± 89.1 cc. Satisfying final outcomes were achieved in all cases. There were no major complications, although minor complications were observed. CONCLUSIONS: The authors' hybrid approach allows the surgeon to achieve a more satisfying outcome with regard to the cleavage area. It results in a better natural appearance, an improved contour, and reduced upper pole rippling and deflation, with a lower likelihood that an additional operative revision will be required to achieve the desired final aesthetic outcome. The authors believe that their hybrid approach should be implemented as an integral part of the direct-to-implant prepectoral reconstruction procedure. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Anatomical distribution of basal cell carcinoma in Israel using relative tumor density scores.

BACKGROUND: Ultraviolet radiation (UVR) is considered a major risk factor for the development of basal cell carcinoma (BCC). Calculating the relative tumor density (RTD) by adjusting the proportion of BCC lesions relative to the skin surface area at a specific site enables comparison of the proportion of tumors at different anatomical sites and better understanding of the association with sun exposure. OBJECTIVES: To characterize anatomical distribution of BCC in the Israeli population using RTD score. METHODS: A retrospective, cross-sectional study that includes all histologically confirmed BCC samples obtained from a major national pathological institute, which receives specimens from numerous surgeons throughout Israel, during the first trimester of 2012. RESULTS: A total of 1,712 skin lesions were diagnosed as BCC during the study period. RTD in the head and neck area was the highest over the body (RTD = 6.6). We found that RTD over the upper arms in males was higher than the proportion of skin surface area (RTD = 1.1). A comparison of RTD values in subsites of the head and neck region indicates that men have higher RTD values for the ears, neck, and scalp than women. However, the nose and eyes areas have female predominance. CONCLUSIONS: Using RTD scores, our study demonstrates the unique UVR exposure pattern in the Mediterranean climate of Israel and supports the notion that UVR is an important risk factor for the development of BCC lesions.

[MOHS MICROGRAPHIC SURGERY FOR CUTANEOUS MALIGNANT LESIONS EXCISION: EXPERIENCE OF A SINGLE TERTIARY MEDICAL CENTER IN ISRAEL].

AIMS: To review the literature, to present the experience with MMS of a single medical center in Israel and to compare findings to worldwide MMS trends. BACKGROUND: Mohs Micrographic Surgery (MMS) is a surgical technique that examines all of the cutaneous malignancy margins during surgery through precise mapping. This technique achieves the highest cure rates for cutaneous malignancies, while sparing normal tissue. The incidence of cutaneous malignancy is rising worldwide. The volume of Mohs surgeries increases as well. Therefore, physicians should gain knowledge about MMS utility in the treatment of cutaneous malignancy. This study is the first to be conducted is Israel and it aimed to present trends in the utilization of MMS. METHODS: A retrospective review of all MMS performed from 2012 to 2018 at the Sheba Medical Center. RESULTS: Overall, MMS technique was used in 3,795 cases. There was an upward trend in the utility volume of MMS during study period, from 372 cases in the year 2012 to 702 cases in 2017. We found an upward trend in the volume of MMS procedures within patients groups in the ages 65 to 74 and 75 years old and older. Male patients presented a double fold upward trend, in comparison to the female group. CONCLUSIONS: The upward trends found in this study correlate with the worldwide MMS trends and the rising incidence of cutaneous malignancy in Israel. More specialists are needed due to the increase in demand of MMS procedures.

Clinical outcomes of endoscopic balloon dilatation of intestinal strictures in patients with Crohn's disease.

Intestinal strictures are common complications of Crohn's disease (CD). Endoscopic balloon dilatation (EBD) constitutes an alternative therapy to surgery, but associated factors of procedure success are inconclusive. Therefore, we aimed to evaluate the EBD success rate and its associated factors in CD patients.This is a retrospective cohort study of consecutive EBDs that were conducted between 2006 and 2014 among patients with CD with lower gastrointestinal tract strictures. Patients' and stricture characteristics, short term procedure success and related complications at 1 week follow-up, and long-term clinical endpoints were documented.A total of 138 dilatations were performed on 64 CD patients. The overall dilatation success rate was 84.8%, with no difference between primary or anastomotic strictures, or between first or recurrent dilatation procedures. Long strictures (≥4 cm) were negatively associated with successful EBDs, but not with perforations. A multivariate analysis adjusting for age, sex, smoking, and disease duration revealed that a maximal dilatation diameter of ≥15 mm was positively associated with a successful EBD, while an inflamed stricture was negatively associated with procedure success. Strictures which were both long and inflamed were associated with the lowest EBD success rates compared with other strictures. Only 32.8% of patients required surgery during the follow-up period. Long-term prevention of surgery was negatively associated with stricture length and with a successful EBD.EBD is highly successful in treating intestinal strictures and in prevention of surgery in CD patients. Although EBD of long strictures is safe, it will not prevent surgery in the majority of cases.

[Benign multiple sclerosis].

Multiple sclerosis is a demyelinating disease of the central nervous system affecting young adults and leading to significant disability over time. The disease subtype, which results in minimal disability over time, has been defined as benign multiple sclerosis. This review will discuss the various features of benign multiple sclerosis, including cognitive and motor criteria for defining the disability, the disease duration, magnetic resonance imaging characteristics, disease progression and criteria for treatment.