Jawline Refinement in Face Lifting: The Five Zones and the Five-Step Technique✰

Facial aging changes due to increased skin laxity as well as soft tissue atrophy and decent lead to blunting and distortion of previously well-defined zones of the face and neck. A critical component of re-establishing a youthful appearance during facelift and neck lift surgery is restoring a well-defined mandibular contour. Key principles of jawline refinement include the addition of volume to deficient areas and removal of volume in areas of unwanted fullness to re-establish facial harmony in the lower face and neck. In this article, we describe a novel classification of jawline zones and discuss our stepwise surgical approach to aid in the systematic evaluation and surgical treatment of the jawline.     

An Alternative Technique for Fixation of Tongue-Type Calcaneal Fractures: The “Hurricane Strap”

Traditionally, tongue-type calcaneal fractures have been treated using screw fixation or tension band wiring. In this work, we aim to present a technique guide for an alternative approach to fixation of these fractures given the high potential for failure with traditional methods. Additionally, we present the results of 4 patients treated with this technique. A modified lateral extensile incision is made for application of a midfoot fusion plate that is pre-bent and fit to the calcaneus with 2 holes covering the superior surface of the calcaneus for bicortical interfragmentary purchase. Four screws are then placed orthogonally into the calcaneus through the plate. Typically, this allows for 2 screws to be placed in the superior fragment and 2 screws to be placed in the inferior fragment. All 4 patients went on to timely osseous union and were weightbearing in regular shoe gear at their last follow-up appointment. Average follow-up time was 16.5 (range 15 to 21) months. We believe that the “hurricane strap” provides a more mechanically sound construct than other methods. This construct may be especially useful in patients with osteoporotic bone where screws alone may not maintain adequate reduction or in neuropathic patients where noncompliance with weightbearing status may jeopardize maintenance of reduction.     

Multiple Z-Plasty in Pilonidal Sinus—A New Technique under Local Anesthesia

Background Pilonidal sinus is a common surgical condition. Though benign, it causes a lot of distress with its associated morbidity and financial loss to the patient. Many procedures have been tried, ranging from nonsurgical to surgical methods (both conservative and radical ones). It is well known that recurrences are low when the scar is away from the midline. Materials and Methods The author has described a new technique of multiple Z-plasty for the treatment of pilonidal sinus that has been effective in the cure of this problem. This article reports a prospective, nonrandomized noncomparative preliminary clinical study of 115 cases of pilonidal sinus operated on by the author over 14 years. Results The results were compared with the results of other methods mentioned in the literature. There were only two recurrences. Conclusions The author proposes that multiple Z-plasty can be considered as an option in the surgical treatment of pilonidal sinus.     

New Technique for Rectal Division in Laparoscopic Anterior Resection—with Video

BACKGROUND: A new technique for performing laparoscopic anterior resection is described. Main differences from the standard technique are (1) pneumoperitoneum to improve exposure of the rectum, even in a narrow pelvis; (2) rectal division performed using a conventional linear stapler inserted via a 4.5 cm suprapubic incision; and (3) eversion of the rectum for tumors close to the anal verge, with transection performed under direct vision. METHODS: Results in 78 patients who underwent transabdominal transection and in 7 patients requiring rectal eversion were compared retrospectively with those in 61 consecutive patients who had undergone standard laparoscopic resection. RESULTS: The duration of the operation and estimated blood loss were greater with rectal eversion, and more staple cartridges were used for the conventional technique; however, the incidence of complications was similar for all three groups. Five patients in the conventional group required conversion to an open procedure. CONCLUSION: The new technique should improve the safety of resection.     

eRFA: Excision Followed by RFA—a New Technique to Improve Local Control in Breast Cancer

Introduction Excision followed by RFA (eRFA) may allow improved cosmesis while ensuring negative margins in patients with breast cancer. This technique utilizes heat to create an additional tumor-free zone around the lumpectomy cavity. We hypothesized that eRFA will decrease the need for re-excision of inadequate margins.Methods Between July 2002 and January 2005, we conducted a multiphase trial of RFA of prophylactic mastectomy specimens and of women desiring lumpectomy. In both models, a lumpectomy was performed, the RFA probe was deployed 1 cm circumferentially into the walls of the lumpectomy cavity and maintained at 100°C for 15 min. Whole mount slides were used to measure the zone of ablation for ex vivo specimens. Hematoxylin and eosin staining of in vivo lumpectomy margins <3 mm was considered inadequate.Results Nineteen prophylactic mastectomy ablations revealed a consistent perimeter of ablation. Forty-one patients (mean age 63 ± 14 years) had an average tumor size of 1.6 ± 1.5 cm underwent in vivo eRFA, and 25% had inadequate margins: one focally positive, one <2 mm, eight <1 mm and one grossly positive. Only the grossly positive margin was re-excised. Overall complication rate of in vivo ablations was 7.5%. Twenty-four of 41 patients did not have post-eRFA XRT. No in-site local recurrences have occurred during a median follow-up of 24 months (12–45 months). Two patients have occurred elsewhere.Conclusions The ex vivo ablation model reliably created a 5–10 mm perimeter of ablation. In vivo, this zone reduced the need for re-excision for inadequate margins by 91% (10/11). Short-term follow-up suggests that eRFA could reduce re-excision surgery and local recurrence.     

“Super-rapid” Technique in Donation After Circulatory Death Liver Donors: Advantages and Disadvantages

In recent years, donation after circulatory death (DCD) has increased as an option to overcome the organ donor shortage crisis and to decrease the large number of patients on liver transplant waiting lists. The “super-rapid” technique is now the “gold standard” procurement method because of its availability, reproducibility, low cost, and extensive experience. Recently, extracorporeal support has been implemented, with encouraging results. Strict donor acceptance criteria have proven to be essential to optimize the DCD liver graft outcomes and minimize biliary complication rates. In this study we assessed the state of the art of DCD liver transplantation with regard to its development and the actual strategies to prevent graft complications, with aim of expanding the pool of marginal liver donors.     

The King's Sliding Hindfoot Osteotomy for the Treatment of Talus Body Defects—Results of a New Technique in Tibiotalocalcaneal Arthrodesis

Bone loss after avascular necrosis of the talus secondary to acute traumatic or chronic pathologies often requires surgical reconstruction. This study reports the early results of a sliding oblique hindfoot osteotomy for salvage procedures combined with tibiotalar arthrodesis to achieve a well-aligned, painless, plantigrade foot. All patients presenting to our institution with severe talus body defects requiring corrective surgery between January 2016 and August 2020 were included. An oblique osteotomy of the diseased talus was performed to correct anterior talus subluxation and prevent excessive loss of height at the tibiotalar apposition and to correct varus-valgus deformity. A retrograde hindfoot nail was used for intramedullary tibiotalocalcaneal arthrodesis. Patients were prospectively followed. Primary outcomes included assessment of mobility and union at 6 months. Secondary outcomes included 30-day postoperative complications, patient satisfaction and change in American Orthopaedic Foot & Ankle Society (AOFAS) score at 1-year postoperation. Nine patients underwent this procedure with a mean follow-up of 18 months (4-36 months). Average age was 66 (58-81) years. Mean body mass index was 33.7 (22-38) kg/m². All patients went on to fusion and were ambulating at 6 months (n = 8). At 1 year, the mean improvement in AOFAS was 28.9 points (p < .05) (n = 7) and all patients were satisfied with the outcome of their treatment. This technique represents an alternative to conventional hindfoot salvage techniques showing predictable outcomes in complex hindfoot deformity with talar body collapse and anterior subluxation. Further quantitative studies are needed to define if this technique minimizes limb shortening/limb-length discrepancies when compared to traditional horizontal cuts.