Scientific Abstract Presentations: Global Partners Session 2 (Not for CME) Saturday, September 28 Sat, Sep 28 2:00-3:30 p.m. PDT

Background: No consensus exists on the selection of procedures for the treatment of submucous cleft palate, with scarce reports on long-term outcomes from single-surgeon experience. SubMucous Cleft Palate(SMCP) may be difficult to diagnose at birth, especially in cases of Occult SubMucous Cleft Palate. The SubMucous cleft portion may be limited to soft palate, or extend anteriorly into the posterior half of the hard palate or even up to the anterior half of the hard palate up to the incisive foramen. Vast majority of individuals with unrepaired submucous cleft palate (SMCP) experience speech difficulties secondary to velopharyngeal insufficiency. There is no classification system to properly describe different types of SubMucous Cleft Palate and as such there is no algorithm available to handle these types of SubMucous Cleft Palate.

Method: We reviewed 127 cases of SMCP operated in the last 8 years at CLAPP Hospital, Lahore Pakistan. Different similar types of SMCP were placed in different groups. Different surgical plans used to operate different SMCP cases were also noted.

Results: We divided the SCMP into 3 main types and then devised an algorithm to manage all these cases accordingly. When the SMCP was limited to Uvula and Soft Palate only, we label it as SMCP1; If the soft palate is of normal or acceptable length, it will be labelled as SMCP1a, however in case the soft palate length is short, then we label it as SMCP1b. Similarly, when SMCP involved Uvula, Soft Palate and posterior half of the hard palate, we label it as SMCP 2; If the soft palate is of normal or acceptable length, it will be labelled as SMCP 2a, however in case the soft palate length is short, then we label it as SMCP 2b. When SMCP involved Uvula, Soft Palate, posterior half of the hard palate and extending into the anterior half of the hard palate, we label it as SMCP 3; If the soft palate is of normal or acceptable length, it will be labelled as SMCP 3a, however in case the soft palate length is short, then we label it as SMCP 3b. We devised an Algorithm to manage all these types of SMCP cases.

Conclusion: Individuals with Non syndromic SMCP present with speech difficulties similar to those experienced by individuals with overt cleft palate. Health care professionals should be aware of diagnosing different types of SMCP and possible presenting symptoms and plan the surgical solutions according to anatomical defects in each type of SMCP.

Although frontal prominence is an infrequent benign defect that causes no sequelae, it gives the patient distress due to its unaesthetic visual aspect. Proper surgical recontouring of the forehead can radically change one's appearance. In consequence, different techniques have been proposed for its management and correction. The aim of this study is to describe a surgical algorithm to treat male patients with forehead reduction to soften the "forceful" look. An observational cross-sectional study was conducted at the head and neck surgery ward of a general hospital between 2019 and 2022. We performed 35 forehead reduction operations on male patients. The median age was 29 years (range, 26–32 years). The forehead reduction procedures performed was categorized as follows: 27 anterior table osteotomy and 8 anterior table osteotomy contouring. Median forehead reduction was 2.7 mm (range, 2–3.2 mm). The average medical follow-up for patients was 6 months, with an interval ranging from 4 to 8 months. Surgery of the forehead in properly selected male patients is sufficiently safe that it can be done for entirely aesthetic reasons. The choice of surgical technique depends on the presence or absence of the pneumatized frontal sinus. If the frontal sinus is not pneumatized, an anterior table contouring is performed and if the frontal sinus is pneumatized, an anterior table osteotomy is preferred. 1 Eppley BL. Forehead/brow reduction or augmentation with cus- tom implants for enhanced facial profileplasty. Facial Plast Surg 2019;35(05):430–445 2 Galiè M, Consorti G, Clauser LC, Kawamoto HK. Craniofacial surgical strategies for the correction of pneumosinus dilatans frontalis. J Craniomaxillofac Surg 2013;41(01):28–33 3 Altman K. Forehead reduction and orbital contouring in facial feminisation surgery for transgender females. Br J Oral Maxillofac Surg 2018;56(03):192–197 4 Wolfe SA, Berkowitz S. Plastic Surgery of the Facial Skeleton. Boston: Little Brown; 1989:728–731 5 Ousterhout DK. Feminization of the forehead: contour changing to improve female aesthetics. Plast Reconstr Surg 1987;79(05):701–713

Background: The dynamic landscape of aesthetic surgery demands innovative strategies for achieving facial rejuvenation in a harmonious manner. This study delves into the concurrent application of open structured precision rhinoplasty and Bullhorn lip lift, investigating criteria, indications, techniques, challenges, complications, and clinical implications. Meticulous patient selection is paramount, with inclusion criteria emphasizing shared concerns for both procedures and exclusion criteria designed to mitigate risks.

Methods: Ethical clearance was secured for a prospective cohort analysis involving 10 women undergoing simultaneous precision rhinoplasty and Bullhorn lip lift. Rigorous criteria ensured a homogeneous patient selection. Surgical challenges and complications were minimized through detailed planning, with a single practitioner performing both procedures for consistency. Clinical effects were evaluated using the NOSE scale for nasal breathing and the ROE questionnaire for aesthetic satisfaction.

Results: The simultaneous approach yielded promising outcomes, addressing both nasal refinement and lip aesthetics. Challenges included intricacies in surgical planning, managed through thorough preoperative assessments. Complications were minimal, primarily consisting of early postoperative symptoms. Significant improvements were observed in nasal breathing (mean NOSE score decrease from 72.4 to 4) and aesthetic satisfaction (ROE score increase from 15.4 to 92.4).

Discussion: The integration of simultaneous precision rhinoplasty and Bullhorn lip lift presents intriguing possibilities for enhancing facial harmony. Strict inclusion criteria facilitated a focused evaluation, revealing a successful balance between nasal and lip enhancements. Challenges were navigated through meticulous planning, underscoring the importance of patient selection and surgical expertise. Clinical implications suggest a comprehensive approach with unified recovery and heightened patient satisfaction.

Conclusions: Simultaneous precision rhinoplasty with Bullhorn lip lift offers a holistic and efficient approach to facial rejuvenation, aligning with patient preferences. Despite procedural complexities, the benefits of a unified recovery period and enhanced overall facial harmony are noteworthy. Ongoing research with larger cohorts and extended follow-up will refine the understanding of this approach. As the field advances, the integration of simultaneous precision rhinoplasty and Bullhorn lip lift emerges as an exciting avenue for achieving enhanced youthful facial harmony.

Introduction:The reconstruction of tissue defects by using flaps is recognized nowadays as the best solution. Large and/or complex posttraumatic or post oncologic resections can often include ischemia of a segment because of vascular defects. Such cases need a simultaneous coverage and revascularization of the segment. One of the methods able to solve both these problems is the flow-through-flap procedure. The procedure consists in using a free flap in which both ends of the vascular pedicle can be anastomosed, offering so the possibility to both cover a defect and revascularize a devascularized segment. This paper will try to clarify some aspects of this concept and to better classify the flow-through flaps. Materials and Methods:This study enrolled more than 50 patients with complex injuries of both upper or lower limb with tissue defects and devascularization of distal segments or with need to reconstruct some missing segments. We used in these cases either a flow-through flap to cover a defect and revascularize a segment and/or a second flap. Results:All the flaps, used either as true flow-through flap or flow-through conduit survived, without any kind of complications. Based on our observations, we elaborate a new possible classification of this kind of flaps, in true flow-through flap sand flow-through conduit flaps.

Conclusions:Both the true flow-through flaps and flow-through conduit flaps represent a very important tool in solving the complex cases associating tissue defects and vascular defects in the upper extremity. Most indicated is the use of traditional axial and perforator flaps because an arterial conduit offers more long-term patency. Even if the venous flaps have more possible complications, because some technical modifications they proved to be useful in covering small to medium large defects.

Introduction. Today, liposuction is positioned as the most frequent surgery in the world. Body contouring procedures are evolving every day and a new generation of specialists is actively using new methods that have been established in the world practice of plastic surgery, moving beyond traditional methods of removing excess skin and fat deposits. Nowadays there is a tendency to solve complex problems of body aesthetics, restoring the figure in one visit to a plastic surgeon, undergoing more complex procedures and therefore with higher risks. Hypothermia occurs in 50-90% of cases during such operations. Referred as the "hidden enemy", hypothermia is a modifiable risk factor, usually unnoticed, that increases the risk of other complications such as bleeding, infections, need for transfusion and longer recovery periods, even cardiac complications. Therefore, predicting the risk of hypothermia when performing body contouring surgery is an urgent task. Aims: The aim of this is study is to improve the safety and outcomes of complex body contouring surgeries, including liposuction and lipofilling, by developing a system for predicting the risk of hypothermia for each patient before surgery. Methods. A retrospective and prospective analysis of the data from 100 patients undergoing liposuction, lipofilling and/or abdominoplasty from 2020 to 2023 was carried out. The objective research methods implemented included: thermometry and capillaroscopy. The patients were classified in four groups depending on the complexity of the surgery. The temperature was measured during every step of the surgery and/or every 30 minutes. The data was compared with the data obtained from patients undergoing facial and breast surgery, to assess the difference between groups. Results. Based on the results of the analysis, a unified system for predicting hypothermia in patients undergoing programmed complex body contouring surgery was developed and applied in clinical practice for the first time in Russia. Preliminary warming of the patient, air temperature in the operating room, isolation and limitation of the exposed body surface area, temperature of solutions for subcutaneous infiltration, temperature of solutions for intravenous administration and heating of the operating table were some of the factors included. Conclusion. Using a comprehensive patient body hypothermia risk prediction scale, the hypothermia risk can be effectively predicted and prevented by adopting specific measures during the perioperative period. The implementation of this decision support tool into the everyday practice of medical institutions of the Russian Federation has helped to improve the safety and quality of complex body contouring surgeries.

OBJECTIVE: The purpose of this study is to demonstrate the practicality of doing a breast reduction procedure on patients who have had a breast reconstruction using a deep inferior epigastric flap (DIEP) flap.

INTRODUCTION: Debulking breast flap surgery post breast reconstruction is occasionally required (1). Here, we provide a novel approach-one that has never been described before-that uses a superomedial pedicle inverted "T" technique for breast reduction in patients who have had prior free DIEP flap breast reconstruction. We propose that after a free DIEP flap breast reconstruction, a breast reduction technique is a safe and reasonable alternative procedure.

METHODS: The study focuses on breast reduction in women who have had free DIEP flap breast reconstruction using the superomedial pedicle inverted "T" technique. Results: Given the satisfactory survival of the debulked DIEP flaps, our observations suggest that employing the superomedial pedicle inverted "T" breast reduction technique in reconstructed breasts with DIEP free flaps shows great potential.(2,3,4)

CONCLUSIONS: We propose an alternative approach for secondary breast reshaping after DIEP flap reconstruction, by utilizing superomedial pedicle inverted "T" breast reduction technique. Potential benefits of this approach include maintaining blood circulation and protecting the pedicle (5). However, due diligence is required due to the scant evidence that is currently available and the superior surgical skill and expertise that is required. Still, this method shows promise for performing breast reductions after free DIEP flap breast reconstruction.

REFERENCES: 1. Farace F, Rubino C, Posadinu A, Pittalis E, Campus GV. Secondary shaping of the free TRAM: an inferior pedicle reduction mammaplasty. J Plast Reconstr Aesthet Surg [Internet]. 2008;61(2):204–6. Available from: http://dx.doi.org/10.1016/ j.bjps.2007.02.031 2. Kroll SS. Fat Necrosis in Free Transverse Rectus Abdominis Myocutaneous and Deep Inferior Epigastric Perforator Flaps. Plast Reconstr Surg [Internet]. 2000;106(3):576–83. Available from: http://dx.doi.org/ 10.1097/00006534-200009030-00008 3. Moolenburgh SE, van Huizum MA, Hofer SOP. DIEP-flap failure after pedicle division three years following transfer. Br J Plast Surg [Internet]. 2005;58(7):1000–3. Available from: http://dx.doi.org/10.1016/j.bjps.2005.04.040 4. Kim SW, Kwon YH, Kim YH. Incidental total necrosis of a successful flap due to a secondary operation after one year. Arch Plast Surg [Internet]. 2014;41(3):294–6. Available from: http://dx.doi.org/10.5999/aps.2014.41.3.294 5. Tsur H, Daniller A, Strauch B. Neovascularization of skin flaps: Route and timing. PlastReconstr Surg [Internet]. 1980;66(1):85–93. Available from: http:// dx.doi.org/10.1097/00006534-198007000-00017

Younger patients in their thirties and early forties are presenting to the plastic surgeon because they want to reduce the early tear-trough deformity and lighten early naso-labial grooves that make them looked tired. This results from the medio-inferior descent of malar fat and Sub Orbicularis Occuli Fat. There is a loss of the "ogee" curve of the face and in order to restore a youthful appearance to the face the surgeon has to reposition these two essential "padding" structures. However, this is not achieved even with a traditional full surgical face lift which tends to address the lower face and hardly deals with the mid-face. Improvement of the sagging mid-face can only be achieved by re-positioning of the malar and SOOF pads. This paper describes a simple scar-less technique to do that By using 4-6 stab-incisions in a special pattern behind the temporal and side-burn hairline a number of 4/0 non-absorbable (polypropylene) suspensory suture-loops, are positioned in the malar fat pads with a spinal needle and anchored, under traction, on the superficial temporalis fascia. One can easily lift the malar and sub-orbicularis oculi fat to create a youthful lower eyelid and ogee curve to rejuvenate the face. Traction on the malar fat pads will also lighten the jowls and improve the corner of the mouth. The operation is performed with simple instruments. It is easy, safe and suitable for younger patients (as well as part of the full face-lift) and there is a rapid recovery. It is also a valuable tool to "restore" a classical face-lift after a few years. The disadvantages are that accurate positioning of the loops is essential. This can be a rather uncomfortable operation for about 50% cases in the initial 24 hours.

This report will cover over 500 cases done over the past 20 years.

Implant-supporting materials utilized in breast reconstruction often pose challenges when used in humans. To address these issues, a novel mesh, the polycaprolactone (PCL)-collagen hybrid mesh, was developed by combining a collagen sponge with a 3D-printed PCL mesh. This mesh, exhibiting promising results in pig experiments, has the potential to replace the commonly used acellular dermal matrix (ADM) for breast reconstruction. In a study involving four 12-month-old minipigs, silicone implants were wrapped with either ADM or PCL-collagen hybrid mesh. The breast tissue was excised and implanted along with the wrapped implant. After three months, the minipigs were sacrificed for further analysis. Histological analyses and immunostaining revealed that, although there was no significant difference in capsule thickness between the ADM and PCL-collagen hybrid mesh groups, the latter demonstrated better tissue regeneration with increased collagen involvement. Additionally, the PCL-collagen hybrid mesh induced lower levels of inflammatory markers TNF-α and IL-6 compared to ADM. While ADM-induced capsules displayed higher collagen fiber alignment and alpha-smooth muscle actin (α-SMA) positive immunoreactivity, suggesting a potential for capsular contractures, the PCL-collagen hybrid mesh showed promise in minimizing these issues in the porcine model. The study suggests that the PCL-collagen hybrid mesh offers advantages over ADM, including easier tissue invasion and reduced capsular contracture in a porcine model. These results position the PCL-collagen hybrid mesh as a promising alternative for implant-based breast reconstruction (IBBR), potentially replacing ADM in clinical applications.

The treatment of prominent ears remains one of the most frequent procedures performed in pediatric plastic surgery. Despite the multiple techniques that have been described, there still isn't a consensus about the optimal procedure. In recent years some studies point at the cartilage "sparing" techniques as quick and easy procedures to achieve good outcomes with low complication rates. We believe the aesthetic outcomes of cartilage scoring techniques can be superior and more stable, with less risk of recurrence and still maintain a low amount of complications. In this work we present a retrospective review of our experience over the last 15 years with more than 624 cartilage scoring otoplasties, assessing the results and complications and providing some useful tips to ensure good outcomes with this technique.

Introduction Periprosthetic joint infection (PJI) is a severe complication after total knee arthroplasty (TKA). The increasing number of elderly and comorbid patients undergoing primary arthroplasty imply a greater number of revision surgeries and higher rates of PJI. Here, we present a single-center series of patients with confirmed PJI of the knee and accompanying combined soft-tissue / extensor apparatus defects, which were treated with a pedicled, myocutaneous medial or lateral sural artery perforator (MSAP/LSAP) gastrocnemius flap. No microvascular anastomosis was necessary, which in the subgroup of elderly and more comorbid patients is advantageous. Furthermore, this reconstructive method can be applied in centers where microsurgery is not available. Methods At the Center for Musculoskeletal Infections (CMSI) at the University Hospital of Basel, a retrospective study included all patients with PJI of the knee undergoing a pedicled myocutaneous MSAP/LSAP gastrocnemius flap reconstruction for a composite soft tissue defect involving both the skin and the underlying extensor apparatus. Thereby, the tendinous back of the gastrocnemius muscle flap and if needed Achilles tendon was used to reconstruct the extensor apparatus. The skin island was utilised to reconstruct the cutaneous defect. Perioperative complications were assessed (short-term follow-up) and the postoperative orthoplastic outcome minimally one year after surgery (long-term follow-up) is reported. This includes perioperative complications, pre- and postoperative functional and clinical assessment with the American Knee Society Score (AKSS) and the rate of new or recurrent PJI of the reconstructed knee. Results In total eight patients with a myocutaneous MSAP/LSAP gastrocnemius flap in PJI after TKA were included (5 female patients, mean age 73 years). Staphylococcus aureus was the most commonly found bacteria and cultured in two patients. In two cases a chronic fistula was present, but no bacteria was found. Six reconstructions were performed with a myocutaneous MSAP and 2 with a myocutaneous LSAP gastrocnemius flap. In two patiens the flap was extended with the proximal portion of the Achilles tendon. The flap design of the skin island was chosen in such way that the donor site could always be closed primarily. The median time for the wound to heal (dry wounds) was 9 days (IQR 11, 5 – 35). Short-term follow-up (<3 weeks) showed successful reconstruction in 7 patients. One patient developed minor wound dehiscence which was treated conservatively. During long-term follow-up 1 patient developed a perigenicular haemato-seroma which required flap elevation and evacuation. In 2 patients a new hematogenous infection occurred with a new pathogen. Patients with a myocutaneous MSAP/LSAP gastrocnemius reconstruction showed a significant improvement in the AKSS functional and clinical score after reconstructive surgery (median functional AKSS was 33 before and 85, the clinical AKSS was 64 before and 91 after surgery, p=0.001). Conclusion The pedicled myocutaneous MSAP/LSAP gastrocnemius flap is a safe, reliable and versatile option to reconstruct combined soft-tissue and extensor apparatus defects, in particular in patients with PJI after TKA. It allows complex orthoplastic composite reconstruction without the need for microsurgical free tissue transfer, which in the elderly and comorbid patient subgroup is relevant. The functional outcome is excellent with little peri- and postoperative complications.

Purpose The recently licensed immunotherapy drug cemiplimab is used to treat metastatic or locally advanced cutaneous squamous cell carcinoma (cSCC) that cannot be treated with surgery or radiotherapy. We report the experience with cemiplimab in a single tertiary centre.

Methods & Materials Patient demographics, histology and clinical data were retrospectively collected for patients receiving cemiplimab for metastatic or locally advanced cSCC between November 2018 and March 2023. Primary objective was overall response rate (ORR). Secondary objectives included progression-free survival (PFS), overall survival (OS), and adverse events (AEs). AEs were reported according to the Common Terminology Criteria for Adverse Events, Version 4.0, as outlined by the National Cancer Institute (1).

Results Our cohort was composed of 31 individuals: 27 male and 4 female. The median age was 78 (inter-quartile range: 10.5, range: 87). 26 patients had surgery as the primary treatment before developing metastatic/locally advanced cSCC and going on to receive cemiplimab. 20 of these 26 also received adjuvant radiotherapy at time of surgery. 3 patients had radiotherapy as the primary treatment and 2 patients had cemiplimab as the primary treatment. 20 (64.5%) patients achieved complete response, 6 (19.4%) patients achieved partial response, 2 (6.5%) patients experienced disease progression, 3 (9.7%) patients died before response assessment. ORR was 83.9% (95%CI 66.3-94.6%). Median PFS and OS were not reached after median follow-up of 13 months. 2-year PFS was 64.0% (95%CI 41.6-86.4%). 2-year OS was 73.5% (95%CI 54.2-92.8%). 24 (77.4%) patients reported AEs. Treatment was ceased in 10 (32.3%). AEs were grade 1 or 2, except myocarditis (grade 3). At data cut off, 4 (12.9%) patients had completed 2 years of treatment.

Conclusions Our 83.9% (95%CI 66.3-94.6%) ORR exceeds the 46.1% (95%CI 38.9-53.4%) ORR of EMPOWER-CSCC 1, and our 2-year OS (73.5%) is comparable (73.3%) (2). Our findings in our cohort of 31 patients, in the context of the trial with 59 participants which gained global approval for cemiplimab, adds substantial data to the growing body of evidence on cemiplimab's long-term efficacy and supports cemiplimab as an option for patients with advanced cSCC not amenable to surgery or radiotherapy. Additionally, many patients achieved complete response with partial courses. Future studies are necessary to optimise dose and duration of cemiplimab treatment.

References 1. US Department of Health and Human Services NCI. Common Toxicity Criteria for Adverse Events, Version 4.0. https://evs.nci.nih.gov/ftp1/CTCAE/CTCAE4.03/CTCAE4.032010-06-14QuickReference_8.5x11.pdf2010. 2. Migden, Michael R., Danny Rischin, Chrysalyne D. Schmults, Alexander Guminski, Axel Hauschild, Karl D. Lewis, Christine H. Chung, et al. "PD-1 Blockade with Cemiplimab in Advanced Cutaneous Squamous-Cell Carcinoma." New England Journal of Medicine (NEJM) 379, no. 4 (July 26, 2018): 341–51. https://doi.org/10.1056/NEJMoa1805131.

Background: Obesity is a worldwide problem that affects millions of people from a medical and psychological point of view. To solve the related complications, patients should lose weight with the consequent need to be subjected to body contouring due to the presence of a loose and redundant skin. We report our experience in the treatment of the post-bariatric breast. Material and methods: We considered all the post-bariatric patients subjected to a breast reshaping, and we viewed the features of the breast, the type of surgery performed, the outcomes, and the complications. All patients filled out BREAST-Q surveys both preoperatively and after 6 months to study the rate of satisfaction. Results: 300 post-bariatric patients underwent breast reshaping in the last 5 years. The average age was 42 years old. The follow-up period ranged from 6 months to 10 years. The most represented ptosis was second grade; the favorite technique has been mastopexy with parenchymal remodelling and augmentation with autologous tissue. The mean duration of the surgery has been 2 h. The most represented complications have been delayed healing, unfavorable scarring, hematoma, and seroma. Statistically significant improvements were observed in satisfaction with breast appearance, psychological, and physical well-being. Conclusions: Breast reshaping in post-bariatric patients is a big challenge and only a careful analysis of the degree of ptosis of the breast, its volume and shape, and a clear communication with the patients about the real outcomes and complications can make the winning surgeon.