Carlo M. Oranges

Labia Minora Reduction Techniques: A Comprehensive Literature Review

BACKGROUND Many studies of techniques to reduce the labia minora have been published in recent decades, including case reports and retrospective case series. However, to date, there has been no study of the overall complications or satisfaction rates associated with the broad spectrum of techniques. OBJECTIVES The authors performed a comprehensive literature review to determine outcomes and complications of labiaplasty techniques, including patient satisfaction. METHODS A search on PubMed/Medline was performed with the keywords labiaplasty, labioplasty, labial hypertrophy, and techniques plus labia minora reduction. The inclusion criterion was clinical studies in which techniques of labia minora reduction were described. Excluded from the study were publications not dealing with surgical procedures and review articles. RESULTS Thirty-eight studies, published from 1971 through 2014, were included; this represented 1981 treated patients. Eight labiaplasty techniques were identified from these studies: edge resection, wedge resection, deepithelialization, W-plasty, laser labiaplasty, custom flask, fenestration, and composite reduction. Satisfactory results, judged from clinical examination, were observed with all 8 techniques. Few postoperative complications occurred. In a small number of cases, complications required surgical revision or secondary resection. CONCLUSIONS All 8 labiaplasty techniques resulted in good outcomes, including high patient satisfaction and low morbidity.

Universal and Ethnic-specific Considerations on Facial Rejuvenation: Where Do You Inject Your Fillers?

1 Sir: I May 2016, Plastic and Reconstructive Surgery published updated guidelines for aesthetic use of hyaluronic acid fillers and botulinum toxin type A, developed by a Global Aesthetics Consensus Group including a multinational panel of key opinion leaders in plastic surgery and dermatology from Asia, Australia, Europe, and North and South America.1 Notably, in recognition of increasing patient diversity in clinical practice, the panel recommended a broad perspective, encompassing patient age, ethnicity, and sex, to achieve the more accurate objective of facial harmonization rather than mere rejuvenation. We aim to further explore this topic with a special regard to universal and ethnic-specific facial features in females. Universal ideals are traditionally based on neoclassical canons developed by artists and anatomists in the 17th and 18th centuries and derived from the Ancient Greece culture, yet representing mostly white.2 Review of the modern literature identifies 7 key facial features that subconsciously impact perception of beauty.3 Four of those (facial shape, eyebrow shape, nose, and lips) are amenable to injection contouring with fillers, whereas 3 (forehead height, eye size and intereye distance, and skin tone and texture) are beyond the domain of injection therapy.3 However, the growing heterogeneity of our society in terms of multiple ethnic groups makes these ideals not applicable to a large extent of the US population. Analysis of studies recently published in Plastic and Reconstructive Surgery reveals midface and lips to be the regions of the face with the higher degree of interethnic variability, which can be effectively reshaped with injectables.4–6 This and our daily practice allow to formulate practical and simplified guidelines on appropriate facial injection areas in Asian, black, and Hispanic patients compared with their white counterparts (Fig. 1). Because of underlying skeletal and morphological features, Asians tend to present a shorter face, with wider bitemporal, bizygomatic, and bigonial width and structural low projection of the central third of the face.4 Therefore, in distinct contrast with patients of European descent, who commonly seek augmentation of lateral maxilla and zygoma, adequate treatment of Asian patients should be limited to medial maxilla volumization to enhance central projection and avoid the creation of facial disharmony by further widening the midface. Lip augmentation is normally not indicated in Asians, especially those of South-Eastern origin, who present greater lip fullness and may more likely desire lip reduction to balance the lower third of the face. Women of African descent may experience fewer issues requiring facial soft-tissue augmentation, as a consequence of specific characters of their skin, such as less thinning of collagen bundles and elastic tissue.5 However, aging black patients may seek to restore the youthful fullness of their lips. To this end, injectable products are placed only in the upper lip, as the lower lip usually maintains its volume. Finally, Hispanics, who have mainly originated by the intermingling of European immigrants and native populations of the Americas, may present with predominately white or Native American facial features.2,6 Practically, the white aesthetic standards apply well to Hispanic patients of European descent, whereas patients with predominant Native American characters, including a strong mongoloid component on their facial features, can be treated by referring to the abovementioned recommendations formulated for Asians. Carlo M. Oranges, MD Department of Plastic, Reconstructive, Aesthetic, and Hand Surgery Basel University Hospital Spitalstrasse 21 4031 Basel, Switzerland E-mail: carlo.oranges@usb.ch

Effectiveness and safety of topical tacrolimus monotherapy for repigmentation in vitiligo: a comprehensive literature review

Thus far, several small studies and case reports on the use of topical immunomodulators in vitiligo have been published. We undertook a comprehensive literature review, searching for studies evaluating clinical response to tacrolimus topical therapy for vitiligo. A search was performed on PubMed/Medline using the term “vitiligo”, combined with “topical” and “ointment”. Our inclusion criteria were: use of tacrolimus ointment as monotherapy to treat vitiligo. We found 29 studies from 2002 to 2014. Overall, 709 patients were treated in 29 studies. Pooling the lesions, 50% repigmentation of vitiligo patches was never achieved before 2 months of treatment, with a peak after 6 months of therapy. The best results were obtained on lesions of the cephalic region, especially the face, with tacrolimus 0.1% ointment two times daily. The percentage of non-responsive patients ranged from 0% to 14%. Treatment was generally well-tolerated; only localized adverse effects were reported. Our objective was to verify the effectiveness and safety of tacrolimus ointment monotherapy. It has good efficacy and tolerability. At present, only small trials and case series are available in the literature. Further, standardized investigations on a larger number of patients are needed.

Body Contouring: The Success of the Androgynous Model.

1 Carlo M. Oranges, MD Andreas Gohritz, MD Mathias Tremp, MD Dirk J. Schaefer, MD Department of Plastic, Reconstructive, Aesthetic and Hand Surgery Basel University Hospital Basel, Switzerland Sir: T pharaonic belief in androgynous nature of gods was the motivation for practicing female circumcision in ancient Egypt.1 This historical observation leads us, as plastic surgeons, to consider how much the aesthetical ideals are influenced by philosophical and ethical views. We are called to translate into adequate treatments for our patients the concept of beauty, which evolves along the history and is strictly related to the spirit of every period. Interestingly, several studies during the last decades reported a reemerging trend toward the androgynous model. An androgyny index, based on waist, bust, and pelvic width, was introduced in 2002 to investigate female body attractiveness.2 Analyzing temporal changes, a trend toward the success of a more androgynous appearance was observed in photograph models’ body shapes over the period of 50 years until 2001. The androgyny index was further validated by studies published in Plastic and Reconstructive Surgery.3 Moreover, this evolution of aesthetical ideals was reflected by the increased preoccupation for specific parts of the body, leading to an increase in requests for related body contouring operations.4 After the Egyptians, the idea of the androgynous nature of the primordial human being was philosophically developed by Plato in Symposium 189a– 193e through the speech of Aristophanes. By using a mythical narration, Plato said that in the beginning, the androgynous human being was participating in both male and female natures. Afterwards, Zeus, the king of gods in Greek Olympus, divided the androgyne in man and woman to reduce the extraordinary power related to the androgynous nature. However, as a consequence, one of the strongest desires was generated in the human being: the research of the lost unity through Love. These philosophical beliefs oriented the aesthetical ideals of the Hellenistic period and were expressed in art by many sculptures representing Aphroditus. During the Italian Renaissance period, these ideas were rediscovered by the Neo-Platonic Academy of Marsilio Ficino, which adopted a monistic interpretation of the Nature and proposed that an ultimate One lies behind all existence.5 Conversely, dualism between thought and reality had to be overcome.5 Classical symbolic expressions of dualism, like the opposites above/below, in/out, and in biology male/female, man/woman, were judged as mere appearance. The androgynous model represented the ideal reconciliation of the human being with the original Unity mentioned above. Steeped in this Neo-Platonic view, Renaissance art was guided by philosophy.5 Leonardo da Vinci’s drawing Androgynous is probably the most explicit representation of the androgynous model in this period. Androgynous characters can also be identified in the Leonardo’s most famous painting, Mona Lisa, and in St. John the Baptist. After Napoleon Bonaparte’s campaign in Egypt and Syria (1798–1801), the Egyptian philosophy and aesthetical principles were widely rediscovered and accepted with increasing interest in the Western countries. In 20th century, Jung postulated that both masculine and feminine components of the psyche are present in each individual.6 Accordingly, androgyny was considered as expression of the unified self. Today, the androgynous tendency can be easily recognized as a part of the pop culture, reflecting the success of the philosophical background described above. To be aware of this view of human nature may help us to better understand the aesthetical ideals of our period and, consequently, the requirements of our patients.

Extending the limits of the anterior tibial artery as the recipient vessel for around the knee and proximal lower extremity defect reconstruction using the free anterolateral thigh and gracilis flap

The aim is to describe a technique with orthograde dissection of the anterior tibial artery (ATA) used as the recipient vessel for the end‐to‐end (ETE) anastomosis in defect reconstruction around the knee and for proximal/middle third leg defects with free anterolateral thigh (ALT) and gracilis flaps.

Adipose Derived Stem Cells Reduce Fibrosis and Promote Nerve Regeneration in Rats: ADIPOSE STEM CELLS FOR NEURONAL SCAR REDUCTION

Peripheral nerve regeneration is critical and challenging in the adult humans. High level of collagen infiltration (i.e., scar tissue), in the niche of injury, impedes axonal regeneration and path finding. Unfortunately, studies focusing on the modulation of scar tissue in the nerves are scarce. To address part of this problem, we have evaluated the differentiated adipose derived stem cells (dASCs) for their antifibrotic and regenerative effects in a 10 mm nerve gap model in rats. Three different animal groups (N = 5) were treated with fibrin nerve conduits (empty), or seeded with dASCs (F + dASCs) and autograft, respectively. Histological analysis of regenerated nerves, at 12 weeks postoperatively, reveled the high levels of collagen infiltration (i.e., 21.5% ± 6.1% and 24.1% ± 2.9%) in the middle and distal segment of empty conduit groups in comparison with stem cells treated (16.6% ± 2.1% and 12.1% ± 2.9%) and autograft (15.0% ± 1.7% and 12.8% ± 1.0%) animals. Thus, the dASCs treatment resulted in significant reduction of fibrotic tissue formation. Consequently, enhanced axonal regeneration and remyelination was found in the animals treated with dASCs. Interestingly, these effects of dASCs appeared to be equivalent to that of autograft treatment. Thus, the dASCs hold great potential for preventing the scar tissue formation and for promoting nerve regeneration in the adult organisms. Future experiments will focus on the validation of these findings in a critical nerve injury model. Anat Rec, 301:1714–1721, 2018.

Reconstruction of gluteal deformities: a systematic review and experience of four cases.

Abstract Background: The reconstruction of gluteal deformities remains a major challenge. The aim of this article is to provide a systematic review of the literature concerned, and to present a case series with representative defects from various zones. Methods: A review of the literature was performed using PubMed, EMBASE, and The Cochrane Library, in accordance with the PRISMA statement. Quality of evidence was rated according to GRADE. Patients with various buttock deformities were included and, depending on the defect, the reconstructive techniques applied consisted of lipoinjection, local fasciocutaneous flap, or pedicled gracilis muscle flap. Complications, patient’s pain assessment, impairment in everyday-life activities, aesthetic outcome, objective assessment of sensitivity, and recurrence were considered. Results: A total of 498 records were identified in the literature search. Of those, 12 studies met the PICOS (participants, interventions, comparators, outcomes, and study design) criteria. Overall, 41 patients were analysed, the evidence of which was of low quality. In this study, four patients (three female and one male) with a mean age of 44 ± 15 years were operated on between 2010–2014. The mean operation time was 83 ± 30 minutes. One patient required revision due to persistent seroma and recurrence, and one patient required neurolysis and gracilis denervation due to neuroma and scarring. After a mean follow-up of 40 ± 21 months, the results were functionally and cosmetically satisfactory. Conclusions: Reconstruction of buttock deformities using an integrated approach can lead to a long-lasting, functionally and aesthetically satisfactory result. However, evidence is limited due to the lack of good-quality studies.

Thoughts on "commentary on labia minora reduction techniques: a comprehensive literature review".

I would like to thank Dr Hunter for his thoughtful comments1 on our paper “Labia minora reduction techniques: a comprehensive literature review.”2 Dr Hunters commentary centers on the aspects related to the everyday practice of a labiaplasty surgeon, appropriately, as a veteran in this field, and in doing so, examines outcomes and complications reported with the different techniques included in our review. He further brings to our attention the motivations of the patients seeking labia minora reduction. Dr Hunter states that the vast majority of women seeking this surgery do so for aesthetic reasons. Interestingly, after reviewing the literature by performing a search on PubMed/Medline, I found five clinical studies reporting the motivations of patients requesting labia minora reduction. I included all …

Comparison of Anterolateral Thigh and Radial Forearm Free Flaps in Head and Neck Reconstruction.

Background: The radial forearm flap (RFF) and the anterolateral thigh flap (ALT) are commonly used for the reconstruction of head and neck soft-tissue defects. The aim of the study was to investigate and compare the surgical outcomes, complications and systemic condition of the patient after reconstruction of extensive head and neck defects with ALT or RFF following cancer extirpation. Patients and Methods: Between August 2011 and November 2013, a total of 36 patients affected by head and neck cancer (31 males and five females; mean age=64.7 years, range=40-86 years) underwent microsurgical reconstruction with 29 RFF and 10 ALT procedures. The surgical outcomes and complications among these two groups were retrospectively analyzed. Results: The success rate was 97% for the RFF group and 90% for the ALT group, with one total flap loss in each group. Donor-site complications occurred in 6% of the RFF group and in 7% of the ALT group. Seven RFF-treated patients (24%) and two treated with ALT (20%) experienced systemic complications. Statistical analysis confirmed no significant difference between the two groups regarding the variables investigated (p>0.05). Conclusion: In our experience, ALT and RFF demonstrated analogous practicability and reliability for the reconstruction of head and neck soft-tissue defects, with similar local and systemic complications and donor-site morbidity rates.

Hard Palate Melanoma: A Population-based Analysis of Epidemiology and Survival Outcomes

Background/Aim: Hard palate melanoma is an extremely rare and aggressive tumor arising from the mucosal epithelium of the oral cavity. The aim of this study was to analyze epidemiology, loco-regional treatment patterns and survival outcomes of this disease. Materials and Methods: The National Cancer Institutes Surveillance Epidemiology and End Results (SEER) database was searched for all cases of hard palate melanoma diagnosed between 1973 and 2012. The Kaplan–Meier method was used to calculate overall survival rate, log-rank test to compare survivals of different subgroups, and Cox hazard regression analysis to determine independent predictors of overall survival. Results: Overall, 83 patients were identified, 49 female and 34 males. The distribution among ages was: 13.3% <50 years, 38.6% between 50 and 69 years, 48.2% ≥70. Surgery alone was applied in 48.2% of patients, radiation therapy alone in 6%, and combination of surgery and radiation therapy in 33.7%. Overall 5-year survival was 26.3%. Survival with adjuvant radiation therapy was not longer than with surgery alone. Conclusion: Hard palate melanoma is a rare malignancy mostly affecting the elderly, with low overall survival. The main treatment is surgical resection, while adjuvant radiotherapy does not improve survival. The establishment of an international registry is warranted to better define treatment options.