Head rotation and the perception of eyelid height and contour

PURPOSE

Effective visual perceptual processing is one of the many components of surgical competence. Human face identification is most efficient when viewed upright. However, it is not yet clear how this perception sensitivity impacts eyelid symmetry. This study investigates surgeons' and laypeople's accuracy and efficiency in perceiving eyelid asymmetry from different spatial perspectives.

METHODS

A prospective psychometric experiment was conducted where oculoplastic surgeons were recruited from the American Society of Ophthalmic Plastic and Reconstructive Surgery and the Brazilian Oculoplastic Surgery Society, and control participants were recruited via crowdsourcing (Amazon's Mechanical Turk). Standard illustrations of the human face with varying degrees of eyelid abnormality, laterality, gender and rotation were presented to participants who were asked to judge whether the eyelids were symmetric or asymmetric.

RESULTS

The survey was completed by 75 oculoplastic surgeons (49.33% male; mean age of 46.9±10.7) and 192 lay individuals (54.6% male; mean age 34.6±11.3 years). Among oculoplastic surgeons, deviation from upright was significantly associated with increased reaction time and decreased proportion correct (OR per 45° for peak 0.68, 95% CI 0.60 to 0.77, p<0.001; OR per 45° for ptosis 0.52, 95% CI 0.32 to 0.87, p=0.012; OR per 180° for aggregate responses 0.56, 95% CI 0.51 to 0.61, p<0.001). Oculoplastic surgeons demonstrated increasing accuracy and decreasing reaction time with additional trials for both peak and ptosis.

CONCLUSION

Oculoplastic surgeons perceive eyelid asymmetries more accurately and can better compensate for inverted sensory information. However, accuracy increases and reaction time decreases with additional trials, suggesting trainability and potential for improvement in inversion disability.

Adjuvant Hypofractionated Whole Breast Irradiation (WBI) vs. Accelerated Partial Breast Irradiation (APBI) in Postmenopausal Women with Early Stage Breast Cancer: 5Years Update of the HYPAB Trial

Therapeutical strategies in breast cancer are continuously updating. Recent researches assessed the possibility of irradiating only the surgical bed in selected patients (Partial Breast Irradiation, PBI). In 2014 we designed a study to evaluate toxicity and cosmesis of APBI using Volumetric Modulated Arc Therapy-Rapid Arc compared with hypofractionated whole breast irradiation (WBI). We present here the 5-years updated data. HYPAB was a single-institution randomized trial that recruited 172 patients from 2015 to 2018. Patients underwent conserving surgery and were randomized to either adjuvant WBI (40.5Gy/15 fractions with simultaneous boost to 48 Gy to tumoral bed) or APBI (30Gy/5 fractions), both delivered with VMAT-RA technique. Clinical evaluation was performed during the first visit, once a week during radiotherapy and during follow up. Cosmesis was assessed using the Harvard Scale for Breast Cosmesis. At the time of the analysis 161 patients were eligible, 53% in the WBI and 47% in the APBI group, with a median follow-up of 67 months. Most common late skin toxicities were G1 fibrosis (32%) and oedema (28%) and were higher in the WBI group; no G3 toxicities were observed. Cosmesis was rated poor in only 6 cases. 147 patients had no evidence of disease at the last follow-up, and no patients died of the disease. Mature results confirm the safety and efficacy of APBI in selected early stage breast cancer patients. Late toxicity is improved in the APBI arm at the cost of a slight increase in local relapse. Further studies are ongoing to better elucidate the use of APBI as a de-escalation approach.

Incidence of incisional hernias and cosmetic outcome after laparoscopic single-incision cholecystectomy: a long-term follow-up cohort study of 125 patients

Background

Studies have evaluated long-term occurrence of incisional hernia, cosmesis, and postoperative pain after single-incision laparoscopic cholecystectomy (SILC). However, the follow-up periods were rarely defined longer than 12 months. The authors performed a cohort study to evaluate hernia rate and cosmesis in a prolonged follow-up period.

Methods

All patients that underwent SILC at the University Hospital Brandenburg an der Havel Hospital between December 2008 and November 2014 were evaluated in terms of postoperative complications, and a follow-up telephone interview including the existence of hernias and chronic pain was performed. Cosmesis and the overall satisfaction of the scar was measured by POSAS (Patient and Observer Scar Assessment Scale).

Results

In total 125 patients underwent SILC. The single-incision approach was completed in 94.4%, an additional trocar was necessary in 3.2% (n=4) and a conversion to 4 trocar cholecystectomy was required in 2.4% (n=3). Intraoperative complications occurred in 0.8% and postoperative complication in 12.8% of all patients. Follow-up telephone interview was performed in 49.6% of 125 patients. The mean follow-up period was 138.9 months (11.6 years). Overall, in 3.6%, an incisional hernia was diagnosed. A total of 3.6% reported pain in the region of the umbilicus with a mean VAS (visual analog scale) of 2/10. The mean POSAS score was 7.8. Overall, 82.3% of this cohort rate their satisfaction of the scar with a 1/7, resembling the best possible result of the scar.

Conclusion

The present study demonstrates that SILC is a safe alternative in terms of incisional hernia rate and complications with a high satisfaction of the scar even after one decade after surgery. In comparison to shorter follow-up period and multiport laparoscopic cholecystectomy, our result is comparable.

Comparison of transoral endoscopic thyroidectomy vestibular approach and open conventional thyroidectomy regardıng inflammatory responses, pain, and patient satisfaction: a prospective study

Introduction

The application of transoral endoscopic thyroidectomy vestibular approach (TOETVA) is becoming widespread throughout the world. We primarily aimed to evaluate the severity of surgical trauma in TOETVA and conventional open thyroidectomy (COT) regarding the inflammatory response including the comparison of surgical stress markers [interleukin-6 (IL-6), C-reactive protein (CRP), white blood cell (WBC)].

Material and method

This non-randomized prospective study enrolled two groups with 20 patients each: COT group and TOETVA group. Patients aged 18-65 years with benign thyroid disease; with fine needle aspiration biopsy results of Bethesda III, IV or Bethesda V, VI (<1 cm nodule); thyroid volume <50 cm3; nodule diameter <4 cm; female gender without a previous neck, chin, and/or oral surgery; without vocal cord paralysis preoperatively; and patients in euthyroid state were enrolled to the study. Preoperative, postoperative second hour, first day, and second day CRP, WBC, and IL-6 levels were evaluated. Pain intensity was evaluated with the visual analog scale (VAS) score on the 2nd and 12th hour, 1st and 2nd days postoperatively.

Results

All the patients were female and mean age was significantly higher in the COT group. The operative time was significantly longer in the TOETVA group. No significant difference was found between the two groups regarding IL-6 levels. In the TOETVA group, postoperative second hour WBC value (p = 0.044) and first (p = 0.002) and second day (p = 0.005) CRP values were significantly higher. In the TOETVA group, the lower lip and lower chin VAS scores were significantly higher at 2nd and 12th hour, on the first and second days. The anterior neck VAS score was significantly higher in the TOETVA group at the second hour (p = 0.025). General and cosmetic satisfactions were similar at the 15th and 30th days in both groups.

Conclusion

The longer operative time and higher postoperative CRP level and VAS score in the chin and lower lip in the TOETVA group suggested that the method is not a minimally invasive technique compared to COT. However, the presence of similar total complication rates and early postoperative general and esthetic satisfaction that improves over time in both groups suggests that the clinical effect of increased magnitude of systemic inflammatory response in TOETVA might be temporary and acceptable.

Comparison of Early Postoperative Outcomes Between Totally Extraperitoneal and Lichtenstein Repair of Inguinal Hernia: A Prospective Randomized Study

Background: Surgical repair of inguinal hernia is among the most commonly performed surgical interventions in general surgery clinics, with minimal postoperative complications, less pain, and maximum cosmetic results. The aim of this study is to compare the outcomes of patients who underwent Lichtenstein repair (LR), which is currently the most commonly used open surgical procedure to repair inguinal hernias, and laparoscopic totally extraperitoneal (TEP) repair with regard to postoperative cosmesis, patient satisfaction, pain, and inflammatory response. Patients and Methods: The study consisted of male patients 18-65 years of age, who were operated for inguinal hernia with two different methods between February 2022 and January 2023 in the general surgery clinic of Elazig Fethi Sekin City Hospital. C-reactive protein (CRP), white blood cell, and interleukin 6 (IL-6) levels were observed to evaluate the inflammatory response in all patients. Visual Analog Scale and Verbal Rating Score systems were used to monitor the response to pain in the postoperative period. In addition, both groups were evaluated for patient satisfaction in cosmetic terms using the Vancouver Scar Scale and the Modified Stony Brook Scar Evaluation Scale. Results: Postoperative pain sensation in the TEP group was found to be significantly lower compared to the LR group. In terms of inflammatory response, IL-6 and CRP levels were found to be significantly higher in the LR group on postoperative day 1 and 2. Satisfaction with the cosmetic appearance of the surgical scar was significantly higher in the TEP group. Conclusion: TEP, which is a laparoscopic hernia repair method, is a safe surgical technique that can be preferred, especially in patients with less postoperative pain and higher cosmetic expectations. In terms of inflammatory response, significant difference is also in favor of TEP repair.

Cosmetic Outcomes of Supraorbital Keyhole Craniotomy Via Eyebrow Incision: A Systematic Review and Meta-Analysis

Background  Supraorbital eyebrow craniotomy is a minimally invasive alternative to a frontotemporal craniotomy and is often used for tumor and vascular pathologies. The purpose of this study was to investigate how patient cosmetic outcomes are affected by technique variations of this approach. Methods  PubMed, Embase, and Scopus databases were systematically searched, and results were reported according to PRISMA guidelines. For the meta-analysis portion, the DerSimonian-Laird random effects model was used, and the primary end points were patient satisfaction and percentage of permanent cosmetic complications. Results  A total of 2,629 manuscripts were identified. Of those, 124 studies (8,241 surgical cases) met the inclusion criteria. Overall, 93.04 ± 11.93% of patients reported favorable cosmetic outcome following supraorbital craniotomy, and mean number of cases with permanent cosmetic complications was 6.62 ± 12.53%. We found that vascular cases are associated with more favorable cosmetic outcomes than tumor cases ( p  = 0.0001). Addition of orbital osteotomy or use of a drain is associated with adverse cosmetic outcomes ( p  = 0.001 and p  = 0.0001, respectively). The location of incision, size of craniotomy, utilization of an endoscope, method of cranial reconstruction, skin closure, use of antibiotics, and addition of pressure dressing did not significantly impact cosmetic outcomes ( p  > 0.05 for all). Conclusions  Supraorbital craniotomy is a minimally invasive technique associated with generally high favorable cosmetic outcomes. While certain techniques used in supraorbital keyhole approach do not pose significant cosmetic risks, utilization of an orbital osteotomy and the addition of a drain correlate with unfavorable cosmetic outcomes.

A new modified limited incision for superficial parotidectomy compared to modified Blair's incision

Background

Many incisions have been used to perform parotidectomy, but they result in a visible scar on the neck and may cause patient dissatisfaction by producing disfigurement sometimes.

Aim of Study

The aim of this study is to use a modified limited incision for superficial parotidectomy as an alternative to the classical incision, with no obvious scarring and without affecting the identification of the facial nerve, resulting in better cosmesis.

Patients and Methods

A prospective comparative study on 100 patients has undergone superficial parotidectomy using a modified limited incision and another 100 patients who have undergone superficial parotidectomy using the modified Blair's incision (control group) for variant benign pathologies. The surgeries were conducted in four hospitals (three private and one public) in Baghdad, Iraq, from January 2016 to September 2022. In both groups, the patients were followed up through outpatient visits to assess the cosmetic result of the incision and detect postoperative complications.

Results

All tumors were removed with no need for extending the skin incision. The cosmetic result of the incision was very satisfactory and only a nominal scar could be seen 6 months after surgery. Five percent of patients only developed postoperative complications.

Conclusion

A modified limited incision for superficial parotidectomy provides better patient satisfaction compared to a modified Blair's incision. The modified limited incision can be performed safely with a better cosmetic appearance of the surgical scar compared to the standard incision.

Cosmetic evaluation in type II congenital scoliosis with long-spanned curve: a case-matched comparison with adolescent idiopathic scoliosis

Background

There is an acknowledged discrepancy between radiographic and cosmetic parameters for patients with adolescent idiopathic scoliosis (AIS). However, no study has specifically evaluated cosmesis in patients with congenital scoliosis (CS). Therefore, the purpose of this study was to identify the cosmetic differences between patients with CS and case-matched patients with AIS and to investigate the correlation between radiological measurements and clinical cosmetic assessment indices.

Methods

A total of 37 adolescents with CS and 37 sex-, age-, and curve magnitude-matched patients with AIS were included. Cobb angle, shoulder height difference (SHD), coronal balance (CB), T1 tilt, first rib angle (FRA), clavicle angle (CA), clavicle-rib cage intersection (CRCI), and apical vertebra translation (AVT) were measured in the full X-ray of the spine. Shoulder area index 1 (SAI1), shoulder area index 2 (SAI2), shoulder angle (SA), axilla angle (AA), thoracolumbar area index (TLAI), and right and left waist angle difference (RLWAD) were measured on the clinical images from a posterior view. Hump index (HI) was measured in the forward bending photography. All patients completed the Scoliosis Research Society-22 (SRS-22) questionnaire.

Results

No significant difference was noted in the radiographic parameters between the AIS and CS groups (P>0.05). However, patients with CS exhibited significantly lower SAI1 (0.91 vs. 0.98; P=0.002) and SAI2 (0.85 vs. 0.95; P=0.001) than did the patients with AIS. The SRS-22 scores for self-image and mental health in patients with CS were significantly lower than those in patients with AIS (P<0.05). The correlation coefficients with statistical significance between radiographic and cosmetic measurements in patients with CS and those with AIS ranged from -0.493 to 0.534 and from -0.653 to 0.717, respectively. None of the correlation coefficients exceeded 0.8, indicating that the current radiological indices only exhibited a limited level of consistency with patients' cosmesis.

Conclusions

As compared with age-, gender-, and curve pattern-matched patients with AIS, patients with CS exhibited worse cosmesis and had clinically significantly lower SRS-22 scores despite having relatively small clinical differences. Although the radiographic parameters may not always align with clinical presentation, this discrepancy could be observed in both patients with CS and those with AIS.

Workflow and treatment results for computer-aided design and 3D-printed conformer therapy of congenital anophthalmia and microphthalmia

BACKGROUND/AIMS

To evaluate treatment with custom, three-dimensional (3D) printed conformers for socket expansion in congenital microphthalmia and anophthalmia (MICA).

METHODS

Retrospective analysis of prospective cohort from 2016 to 2020. All children received custom-made 3D-printed conformers increasing in size. We measured height, width, thickness, surface and volume of first and consecutive conformers, as well as horizontal palpebral fissure length (HPF) at start and follow-up visits. We analysed these parameters for severely (<45%) and moderately (>45%-75%) affected children, based on affected axial length on ultrasonography.

RESULTS

We included 18 cases (9 severe, 9 moderate) with a total of 174 conformers (88 severe, 86 moderate) and a mean follow-up of 2.8 years (range 1.3-4.8). The mean relative HPF increased from 77% to 93% with 16/17 cases reaching >80%, and 12/17 cases >90% symmetry. Horizontal and vertical conformer dimensions increased up to 10 months of treatment, with a steeper slope for the severe group (10.5% vs 5.5% for height and 9.0% vs 6.1% for width gain per treatment month, for severe and moderate MICA, respectively). After 10 months of treatment conformer height and width increased only slightly. No serious complications were observed.

CONCLUSION

3D-design and printing of solid conformers results in highly acceptable horizontal eyelid symmetry in the treatment of congenital MICA. The mean increase in conformer height and width in the first 10 months should be about 170% for moderate and about 200% for severe MICA. The presented conformer size formulas can aid ophthalmologists and ocularists to plan conformer treatment.

Factors associated with unsatisfactory cosmetic results in oncoplastic surgery

INTRODUCTION

Oncoplastic surgery (OS) has expanded the indications for breast-conserving surgery associated with an adequate aesthetic result. However, few studies have described the factors associated with unsatisfactory cosmetic outcomes from this surgical modality.

MATERIALS AND METHODS

This is a cross-sectional prospective study that included patients undergoing breast-conserving surgery (BCS) with or without OS. The patients self-evaluated the cosmetic results of the breasts posttreatment and had them photographed. The photos were analyzed by BCCT.core. Individual and treatment factors (local and systemic) for all patients were evaluated. These factors were dichotomized according to the use of OS and to the cosmetic result (satisfactory and unsatisfactory). Categorical variables were tested for association with surgical outcome using the chi-square test while numerical variables using the Mann-Whitney U test. Variables with p <0,2 were selected for multivariate analysis.

RESULTS

Of the 300 patients evaluated, 72 (24,0%) underwent OS. According to the patient self-evaluations, an unsatisfactory cosmetic result from OS was significantly associated with younger age at diagnosis, higher body mass index (BMI) at the time of evaluation, larger tumor size and greater weight of the surgical specimen. According to the BCCT.core, only the laterality of the tumor (left) was significantly associated with an unsatisfactory cosmetic result. In logistic regression, considering OS as a control variable, the risk of an unsatisfactory outcome according to patient self-evaluation was related to the tumor ≥ T2 odds ratio (OR) 1,85 (1,027-3,34) and age at diagnosis < 40 [OR 5,0 (1,84-13,95)]. However, according to the software, the variables were associated with an increased risk of an unsatisfactory outcome were the time interval between surgery and evaluation [OR 1,27 (1,16-1,39)], the presence of lymphedema [OR 2,97 (1,36-6,46)], surgical wound infection [OR 3,6 (1,22-11,16)], tumor location on the left side [OR 3,06 (1,69-5,53)], overweight [OR 2,93 (1,48-5,8)] and obesity [OR 2,52 (1,2-5,31)].

CONCLUSION

There is no standard methodology for breast cosmesis evaluation, which influences the factors associated with unsatisfactory results. Younger patients and those with increased BMI, left breast cancer and extensive resections tend to present with unsatisfactory cosmetic results when OS is performed.

Ultrasound-Guided Ethanol Ablation as a Primary Treatment for Thyroglossal Duct Cyst: Feasibility, Characteristics, and Outcomes

OBJECTIVES

To evaluate the feasibility, characteristics, and outcomes of ultrasound-guided ethanol ablation (US-EA) as a primary treatment for thyroglossal duct cysts (TGDCs).

STUDY DESIGN

Prospective case series.

SETTING

Single center study.

METHODS

The inclusion criteria were as follows: (i) patients with TGDC aged ≥18 years, (ii) benign TGDC in imaging and cytological examinations, and (iii) patients' need for nonsurgical scarless treatment. US-EA was used as the primary treatment strategy. The primary outcome variables were the volume reduction rate (VRR) and cosmetic score at the last follow-up.

RESULTS

We enrolled 28 patients with TGDC. The median TGDC volume at baseline was 6.7 mL. The median procedure time of the US-EA was 6.5 minutes. The median volumes of the cyst aspirate and injected ethanol were 4.0 and 2.0 mL, respectively. Overall, 18, 8, and 2 patients underwent 1, 2, and 3 treatment sessions, respectively. There were no complications. The median VRR was 96.2%, and the treatment success rate was 96.4%. The World Health Organization cosmetic score decreased from 4 (baseline) to 1 (after treatment) in all patients. The subjective grade for cosmetic satisfaction was satisfactory or highly satisfactory in all patients. The VRR, treatment success rate, and the number of treatment sessions did not differ as functions of the characteristics of the TGDC, including the initial volume, septation, debris, or viscosity of the cyst fluid.

CONCLUSION

US-EA was feasible, safe, and effective in patients with TGDC. Therefore, US-EA can be used as a primary treatment for TGDC, evading general anesthesia and surgical scar.

Detailed Sub-study Analysis of the SECRAB Trial: Quality of Life, Cosmesis and Chemotherapy Dose Intensity

AIMS

SECRAB was a prospective, open-label, multicentre, randomised phase III trial comparing synchronous to sequential chemoradiotherapy (CRT). Conducted in 48 UK centres, it recruited 2297 patients (1150 synchronous and 1146 sequential) between 2 July 1998 and 25 March 2004. SECRAB reported a positive therapeutic benefit of using adjuvant synchronous CRT in the management of breast cancer; 10-year local recurrence rates reduced from 7.1% to 4.6% (P = 0.012). The greatest benefit was seen in patients treated with anthracycline-cyclophosphamide, methotrexate, 5-fluorouracil (CMF) rather than CMF. The aim of its sub-studies reported here was to assess whether quality of life (QoL), cosmesis or chemotherapy dose intensity differed between the two CRT regimens.

MATERIALS AND METHODS

The QoL sub-study used EORTC QLQ-C30, EORTC QLQ-BR23 and the Women's Health Questionnaire. Cosmesis was assessed: (i) by the treating clinician, (ii) by a validated independent consensus scoring method and (iii) from the patients' perspective by analysing four cosmesis-related QoL questions within the QLQ-BR23. Chemotherapy doses were captured from pharmacy records. The sub-studies were not formally powered; rather, the aim was that at least 300 patients (150 in each arm) were recruited and differences in QoL, cosmesis and dose intensity of chemotherapy assessed. The analysis, therefore, is exploratory in nature.

RESULTS

No differences were observed in the change from baseline in QoL between the two arms assessed up to 2 years post-surgery (Global Health Status: -0.05; 95% confidence interval -2.16, 2.06; P = 0.963). No differences in cosmesis were observed (via independent and patient assessment) up to 5 years post-surgery. The percentage of patients receiving the optimal course-delivered dose intensity (≥85%) was not significantly different between the arms (synchronous 88% versus sequential 90%; P = 0.503).

CONCLUSIONS

Synchronous CRT is tolerable, deliverable and significantly more effective than sequential, with no serious disadvantages identified when assessing 2-year QoL or 5-year cosmetic differences.

Dermolipoma in an Unusual Location: A Case Report and Literature Review

A healthy nine-year-old Japanese male presented with a history of inferonasal conjunctival mass that was noted to increase in size in a few years' time. Initial examination revealed a 10-mm soft yellowish inferonasal conjunctival mass with a whitish surface. The rest of the examination findings were unremarkable. A computed tomographic scan was done and showed a conjunctival mass that was not connected posteriorly to the orbital fat but had the same density as the orbital fat. Complete surgical excision was performed, and pathologic evaluation of the excised specimen revealed a dermolipoma. The patient was subsequently followed up to monitor for any postoperative complications. Three months following the operation, there was no recurrence of the tumor, and the patient had an excellent cosmetic outcome.

Are Radiation Target Volumes for Postmastectomy Radiation Therapy Too Large? Initial Report of the Complication Avoidance of Reconstruction Implant Radiation Therapy (CARIT) Study

Following mastectomy for breast cancer, women may choose implant-based reconstruction for many reasons, such as cosmesis, self-identity, and the ability to wear particular items of clothing. However, postmastectomy radiation therapy (PMRT) can compromise these cosmetic goals, including as much as a 40% loss of implant rate. To minimize the risk of radiation toxicity, it is important to consider how clinical target volumes (CTVs) can be optimized in PMRT to preserve the implant and reduce complications. Typically, guidelines from organizations such as the Radiation Oncology Group are used, which include regions previously encompassed by tangential fields. This includes all structures below the pectoralis muscle, such as the chest wall, where the risk of recurrence is negligible; this technique often requires incidental inclusion of portions of the lung and heart plus circumferential radiation of the implant. We present the preliminary single institution case series of a technique of complication avoidance of reconstruction implant radiation therapy, called CARIT, where the chest wall, and a large proportion of the implant, is not irradiated. In a retrospective review of 30 cases in which CARIT has been attempted, it was found that 24% of patients treated required a second surgery due to Baker grade III/IV capsular contracture. Using the Modified Harvard Harris Cosmetic Scale, 66.5% of patients had cosmetic outcomes rated as "good" or "excellent". CARIT could offer a technique to reduce complications in postmastectomy implant-based reconstruction patients, with our next steps focusing on improving dosimetry, and formally comparing the cosmesis and tumor control aspects with commonly used techniques.

Subpectoral biceps tenodesis with BicepsButton fixation in the young population: which technique works best?

BACKGROUND

Injuries of the long head of the biceps (LHB) tendon are a prevalent source of anterior shoulder pain and are commonly treated with tenodesis. Not only a stable fixation of the LHB but also anatomic restoration of the length-tension relationship plays a central role in providing satisfactory functional and cosmetic outcomes, especially in young patients. We report the clinical outcomes of 2 different subpectoral tenodesis techniques using unicortical button fixation.

METHODS

Patients aged ≤ 50 years who were treated between April 2015 and January 2020 with 1 of the 2 following subpectoral tenodesis techniques were retrospectively selected and enrolled to undergo a follow-up examination at least 2 years after surgery: subpectoral in situ tenodesis followed by resection of the intra-articular portion leaving a residual tendon stump in the bicipital groove (group I) vs. tenotomy followed by resection of the stump and subpectoral tenodesis (group II). Patients who underwent concomitant rotator cuff repair, subsequent shoulder surgery, or contralateral biceps surgery were excluded. Clinical outcomes were evaluated using the LHB score and the Constant-Murley Score (CMS), as well as measurements of isometric elbow flexion and forearm supination strength. Sonographic evaluation included assessment of the integrity of the LHB and tenodesis, examination for signs of inflammation within the sulcus or around the tendon, and measurements of the distalization of the myotendinous junction of the LHB compared with the nonoperative side.

RESULTS

A total of 34 patients comprising group I (24 men; mean age at time of surgery, 40.3 years; mean follow-up period, 57.2 months) and 24 patients comprising group II (19 men; mean age at time of surgery, 39.8 years; mean follow-up period, 51.9 months) were evaluated. The total CMS, as well as the scores for each CMS subcategory, did not reveal significant differences between the groups. The overall LHB score was on average 10 points higher in group I (mean, 94 points) than in group II (mean, 84 points) (P = .016). Regarding the LHB score subcategories, group I showed significantly better results for patient-dependent cosmesis (mean, 15 points in group I vs. 12 points in group II; P = .005) and examiner-dependent cosmesis (mean, 14 points in group I vs. 10 points in group II; P = .001). This finding was substantiated by a significantly higher distalization of the myotendinous junction in group II (mean, 3.0 cm in group I vs. 3.8 cm in group II; P = .030).

CONCLUSION

This study shows that subpectoral in situ tenodesis of the LHB followed by arthroscopic resection of the intra-articular portion provides higher LHB scores and better cosmetic outcomes compared with proximal intra-articular tenotomy followed by subpectoral tenodesis.

Bézier curves as a total approach to measure the upper lid contour: redefining clinical outcomes in palpebral surgery

AIMS

To define and quantify the upper lid contour by adapting Bézier curves with a newly developed software in normal subjects, assessing their reliability.

METHODS

Fifty eyes of 50 healthy patients with no ocular pathology were included in this study from October 2020 to November 2020. All measurements were performed on Bézier curves adjusted to the upper lid contour. An original software was used to measure the radial and vertical midpupil-to-lid margin distances (MPLD), temporal-to-nasal (T/N) ratios, contour peak location and grade of superposition (GS) and asymmetry (GA) indexes. We calculated differences in the variables measured regarding age, gender or the side of the eye being assessed.

RESULTS

The mean Bézier curve showed an excellent level of inter-rater reliability (intraclass correlation coefficient of 0.99). The median GS index of each eyelid to the mean Bézier curve was 95.4%, 8.5 IQR, and the median GA index was 3%, 3.4 IQR. The mean contour peak location was -0.35 mm, SD 0.45. Overall, the mean central MPLD was 4.1 mm, SD 0.6. No significant differences were found between male and female patients in variables derived from Bézier curves.

CONCLUSION

Bézier curves may become a very useful tool for the assessment of upper lid contour, contour peak and symmetry. GS and GA indexes, along with the T/N area ratio are potential outcomes for this purpose. All current variables can be obtained just from one single Bézier curve measurement. Our results offer an in-depth exhaustive description of these variables and their distribution in the normal population.

Efficacy and Tolerance of IMRT Boost Compared to IORT Boost in Early Breast Cancer: A German Monocenter Study

The aim of this retrospective study is to compare the two boost subgroups, IORT or IMRT, in terms of overall survival (OS), progression-free survival (PFS), cosmesis, and acute and late toxicity. It shall be shown whether and which of the boost techniques offers better results with respect to the facial points, since there are already many studies on applying boost to the tumor bed after/during breast conserving surgery, and there are few which compare the different techniques. For this comparison, two subgroups of 76 patients each (n = 152), treated between 2002 and 2015, were enrolled in the study. In one subgroup, the 9 Gy boost was intraoperatively administered after complete removal of the primary tumor, while the other subgroup received the boost of 8.4 Gy percutaneously and simultaneously integrated into the tumor bed after breast conserving surgery. Both subgroups have subsequently undergone whole breast irradiation (WBI) of 50.4/50 Gy in 1.8−2 Gy per fraction. OS and the incidence of late toxicity did not differ between the two subgroups and no risk factor was found regarding PFS. Acute toxicities initially occurred significantly less (p < 0.001) in the IORT subgroup; however, after WBI took place, this difference vanished. Therefore, boost application by means of IORT or IMRT can be considered equivalent.

Hemodialysis Arteriovenous Access Cosmesis Scale (AVACS): A new measure for vascular access

RATIONALE AND OBJECTIVE

This study aimed to develop a cosmesis scale to evaluate the cosmetic appearance of hemodialysis (HD) arteriovenous (AV) accesses from the perspective of the patient and clinician, which could be incorporated into clinical trials.

STUDY DESIGN

Using a modified Delphi process, two AV access cosmesis scale (AVACS) components were developed in a four-round Delphi panel consisting of two surveys and two consensus meetings with two rounds of patient consultation.

SETTING AND PARTICIPANTS

The Delphi panel consisted of 15 voting members including five interventional or general nephrologists, five vascular surgeons, three interventional radiologists, and two vascular access nurse coordinators. Four patients experienced with vascular access were involved in patient question development.

ANALYTICAL APPROACH

For a component to be included in the AVACS, it had to meet the prespecified panel consensus agreement of ⩾70%.

RESULTS

The clinician component of the AVACS includes nine questions on the following AV access features: scarring, skin discoloration, aneurysm/pseudoaneurysms and megafistula appearance. The patient component includes six questions about future vascular access decisions, interference with work or leisure activities, clothing choices, self-consciousness or attractiveness, emotional impact, and overall appearance.

LIMITATIONS

Delphi panel methods are subjective by design, but with expert clinical opinion are used to develop classification systems and outcome measures. The developed scale requires further validation testing but is available for clinical trial use.

CONCLUSIONS

While safety and efficacy are the primary concerns when evaluating AV access for HD, cosmesis is an important component of the ESKD patient experience. The AVACS has been designed to assess this important domain; it can be used to facilitate patient care and education about vascular access choice and maintenance. AVACS can also be used to inform future research on developing new techniques for AV access creation and maintenance, particularly as relates to AV access cosmesis.

Postauricular Incision Versus Modified Blair Incision in Parotidectomy: A Systematic Review and Meta-Analysis

OBJECTIVE

The mainstay of first-line treatment of parotid tumors is adequate surgical removal. The present study was conducted to compare the differences between parotidectomy with postauricular incision (PI) and modified Blair incision (MBI).

DATA SOURCES

A systematic search of PubMed, Embase and the Cochrane Library was performed.

METHODS

The data of interest and study characteristics were extracted from the included studies. Statistical analysis was performed with Comprehensive Meta-Analysis software (version 3; BioStat, Englewood, NJ). Dichotomous data and continuous data were analyzed by calculating the risk difference and the mean difference with the 95% confidence interval respectively.

RESULTS

Four retrospective studies were included in the present meta-analysis. The pooled results revealed that the cosmetic satisfaction score was higher in the PI group (MD = 2.67; 95% CI, 2.12 to 3.23) and that intraoperative blood loss was lower in the PI group (MD =  -55.35; 95% CI, -100.33 to -10.36). The operative duration (MD  =  -5.15; 95% CI, -24.06 to 13.75), tumor size (MD  =  -.07; 95% CI, -.27 to .13) and incidences of common postoperative complications were comparable between the two groups.

CONCLUSIONS

According to these findings, the use of PI in parotidectomies may be one of the options for improving cosmetic outcomes. This technique may be considered if oncological safety can be secured.

Patient engagement in cosmetic designing of prostheses: current practice and potential outcome benefits

BACKGROUND

Making a prosthesis for an individual with limb loss is a highly personalized process. A currently unexplored area is whether there are tangible benefits in greater patient engagement during the cosmetic designing of their prostheses. We examined the current clinical practice of engaging patients in prosthetic cosmetic designing and identified factors associated with patient outcomes.

METHODS

One hundred and four prosthetists and 28 prosthesis users were surveyed in this cross-sectional study. The questionnaires covered aspects of prosthetic prescription and fabrication, users' perceived level of engagement, and self-reported outcomes. Regression analyses were used to examine the associations between patients' perceived levels of engagement during the design process, satisfaction, and other outcomes.

RESULTS

Seventy-five percent of the prosthesis users reported being offered at least one cosmetic option during the making of their prostheses, which corroborated with 82.7% of the prosthetists reporting that they typically engage their patients in this aspect of their practices. Patients who were offered at least one cosmetic design option reported significantly greater satisfaction ( P = 0.027) than those who were not offered such an option. Patients' level of satisfaction regarding the look of their prostheses was significantly correlated with their perception that their prostheses empower them in daily activities (r = 0.415, P = 0.028).

CONCLUSION

Engaging patients in the cosmetic designing of their prostheses is a widely accepted practice. Patients who are more satisfied with the look of their prostheses perceived higher levels of empowerment. Prosthetic practitioners should consider the potential outcome benefits of higher level engagement for users of prosthetic devices.

High Dose Rate Brachytherapy in non - melanoma skin cancer - systematic review

Non-melanoma skin cancers (NMSC's) are the most common malignancies worldwide. Millions of new cases every year present challenge to healthcare systems. Recent years brought numerous new data concerning High Dose Rate (HDR) brachytherapy as treatment option for NMSC's. International guidelines do not recognize brachytherapy as a method of choice given lack of randomized trials, however many prospective and retrospective studies show promising results. Aim of the study was to present the efficacy of HDR brachytherapy, with analysis of its safety and adverse effects based on review of the English published medical full-text papers. Literature review of thirteen articles published between 1999 and 2021 was performed. Pubmed and Google Scholar databases were searched on October 2021 using keywords: ((Basal cell carcinoma) OR (squamous cell carcinoma) OR (non-melanoma skin cancer)) AND (HDR brachytherapy). Fourteen full text English articles with follow up over 1 year and study group over 50 patients were included into analysis. In analyzed material 2403 patients received High Dose Rate brachytherapy. Local control varied between 71 and 99%.Dominant reported cosmetic effect was good or very good. Results were cross-referenced with recent meta-analyses comparing brachytherapy to surgical excision, Mohs microsurgery and external beam radiotherapy. Radiodermitis is the main adverse effect of radiation treatment during and after radiotherapy. HDR brachytherapy emerges as potentially non-inferior treatment method providing very good reported cosmetic outcomes.

Methods of Esthetic Assessment after Adjuvant Whole-Breast Radiotherapy in Breast Cancer Patients: Evaluation of the BCCT.core Software and Patients' and Physicians' Assessment from the Randomized IMRT-MC2 Trial

Simple Summary

To validate the BCCT.core software, the present analysis compares the esthetics assessment by the software in relation to patients’ and physicians’ rating in breast cancer patients after surgery and adjuvant radiotherapy. Agreement rates of the different assessments and their correlation with breast asymmetry indices were evaluated. The assessments of the software and the physicians were significantly correlated with all asymmetry indices, while for patients’ self-assessment, this general correlation was first seen after 2 years. Only a slight agreement between the BCCT.core software and the physicians’ or patients’ assessment was seen, while a moderate and substantial agreement was detected between the physicians’ and the patients’ assessments. The BCCT.core software is a reliable tool to measure asymmetries, but may not sufficiently evaluate the esthetic outcome as perceived by patients. It may be more appropriate for a long-term follow-up, when symmetry seems to increase in importance.

Abstract

The present analysis compares the esthetics assessment by the BCCT.core software in relation to patients’ and physicians’ ratings, based on the IMRT-MC2 trial. Within this trial, breast cancer patients received breast-conserving surgery (BCS) and adjuvant radiotherapy. At the baseline, 6 weeks, and 2 years after radiotherapy, photos of the breasts were assessed by the software and patients’ and physicians’ assessments were performed. Agreement rates of the assessments and their correlation with breast asymmetry indices were evaluated. The assessments of the software and the physicians were significantly correlated with asymmetry indices. Before and 6 weeks after radiotherapy, the patients’ self-assessment was only correlated with the lower breast contour (LBC) and upward nipple retraction (UNR), while after 2 years, there was also a correlation with other indices. Only a slight agreement between the BCCT.core software and the physicians’ or patients’ assessment was seen, while a moderate and substantial agreement was detected between the physicians’ and the patients’ assessment after 6 weeks and 2 years, respectively. The BCCT.core software is a reliable tool to measure asymmetries, but may not sufficiently evaluate the esthetic outcome as perceived by patients. It may be more appropriate for a long-term follow-up, when symmetry appears to increase in importance.

Hypofractionated Whole Breast Irradiation and Boost-IOERT in Early Stage Breast Cancer (HIOB): First Clinical Results of a Prospective Multicenter Trial (NCT01343459)

Background and purpose: To investigate intraoperative electron radiation therapy (IOERT) as a tumor bed boost during breast conserving surgery (BCS) followed by hypofractionated whole breast irradiation (HWBI) on age-correlated in-breast recurrence (IBR) rates in patients with low- to high-risk invasive breast cancer. Material and methods: BCS and IOERT (11.1 Gy) preceded a HWBI (40.5 Gy) in 15 fractions. Five-year IBR-rates were compared by a sequential ratio test (SQRT) with best evidences in three age groups (35−40 y and 41−50 y: 3.6%, >50 y: 2%) in a prospective single arm design. Null hypothesis (H0) was defined to undershoot these benchmarks for proof of superiority. Results: Of 1445 enrolled patients, 326 met exclusion criteria, leaving 1119 as eligible for analysis. After a median follow-up of 50 months (range 0.7−104), we detected two local recurrences, both in the age group >50 y. With no observed IBR, superiority was demonstrated for the patient groups 41−50 and >50 y, respectively. For the youngest group (35−40 y), no appropriate statistical evaluation was yet possible due to insufficient recruitment. Conclusions: In terms of five-year IBR-rates, Boost-IOERT followed by HWBI has been demonstrated to be superior in patients older than 50 and in the age group 41−50 when compared to best published evidence until 2010.

Conservative treatment of a scoliosis patient after two heart surgeries in early childhood - A case report

Introduction

This is a case report of a juvenile female patient with scoliosis following two heart surgeries for congenital heart disease (CHD).

Patient presentation, management and outcome

Initially, the premenarchial female was 9 years old and had a Tanner stage 2–3 with a single thoracic curve of 65° Cobb. Because of the high risk for progression, immediate brace treatment was proposed as the father declined surgery. The patient received intensive treatment according to the Schroth Best Practice® programme and a Gensingen Brace® designed for large thoracic curves. Over the 18 months following the initial visit, she received two additional braces. As a result, the progression of the main curve was prevented. The patient continues to maintain an improved cosmetic result and is currently at a Risser 2.

Conclusion

Surgery performed for CHD in rare cases may lead to stiff spinal deformity as a consequence of that surgery. Progression of a severe and stiff curve was prevented during the most vulnerable phase of the pubertal growth spurt with an improved clinical result. Therefore, we assume that the patient may have a normal life in adulthood with minor restrictions only. Supported by pattern-specific high correction exercises and braces, these typical single thoracic curves can be re-compensated to a more balanced appearance, less prone to progression in adulthood.

Clinical implications

Because of the relative high risks of spinal fusion and the long-term unknowns of such an intervention, high-impact conservative treatment should be implemented first before surgical correction is considered.

Brace treatment for patients with scoliosis: State of the art

Background

Physiotherapy, brace applications or surgery are the treatment options utilised to manage patients with scoliosis. Many different brace applications are used, and the success rates of orthoses vary.

Objectives

Brace applications can have detrimental impacts on the patient leading to physical discomfort, psychological discomfort, and in some instance the use of braces may even be painful. Therefore, future developments in this field should be aimed at improving the success rate and reducing physical distress experienced by the patient while using brace applications. The purpose of this article is to provide recommendations with respect to the most appropriate bracing approach in general.

Method

A narrative review of the scientific literature was carried out to substantiate the statements made in this article.

Results

The most important braces provided for the treatment of patients with scoliosis and the treatment results that can be achieved are presented and discussed, taking into account the most recent systematic reviews. A wide range of success rates have been found for the different brace applications.

Conclusion

Given that brace application may impact the patient leading to physical discomfort and psychological distress, good quality management in brace application for patients with scoliosis is needed to ensure the best possible outcome and the least stressful management.

Clinical implications

Safety in brace application for patients with scoliosis needs improvement. The use of standardised and reliable computer aided design (CAD) libraries and appropriate patient information based on published guidelines is suggested.

Association of Visual Appearance on Outcomes After Hallux Valgus Surgery

BACKGROUND

In this study, our aim was to determine the effect of cosmetic improvement on patient satisfaction and functional scores in hallux valgus (HV) surgery.

METHODS

Preoperative foot photographs of 105 patients who had undergone chevron osteotomy for HV between 2016 and 2018 were taken. The patients were divided into 2 groups. Twenty-four months after surgery, the preoperative foot photographs were shown to patients in group 1 (n = 52) but not to patients in group 2 (n = 53). The groups were then compared using the visual analog scale (VAS), the American Orthopaedic Foot & Ankle Society Hallux Metatarsophalangeal-Interphalangeal (AOFAS Hallux MTP-IP), and the 36-Item Short Form Health Survey (SF-36) scores. Both groups were evaluated radiologically with preoperative and postoperative hallux valgus angles and intermetatarsal angles.

RESULTS

There was no difference between the 2 groups in terms of radiologic parameters either pre- or postoperatively, or AOFAS Hallux MTP-IP scores postoperatively. However, for group 1, the VAS was lower (0.4±0.8 vs 1.8±1.6, P = .003) and both the SF-36 physical functioning (88.3±18.1 vs 79.1±23.2, P = .017) and SF-36 mental health scores were higher (78.8±19 vs 69.2±16.3, P = .022).

CONCLUSION

Visualizing improvement in the cosmetic appearance of the foot appears associated with patients' perception of subjective pain and functional improvement. We recommend that preoperative foot photographs be taken and recorded.

LEVEL OF EVIDENCE

Level III, case-control study.

Total eyelid complex sparing orbital exenteration for mucormycosis

Orbital exenteration is a radical surgery which involves complete removal of the orbital contents along with all or parts of the eyelid. However, the eyelid complex can be totally spared in cases of necrotising disease such as mucormycosis without compromising on exposure, or fear of devascularisation of the lids. We describe a total eyelid complex preserving orbital exenteration. Preservation of the total eyelid complex has the potential to speed up the healing process and provide dynamic functional and cosmetic rehabilitation.

Case series of shrinking hydroxyapatite orbital implants

BACKGROUND

An orbital implant is used after enucleation or evisceration surgery to replace the volume lost and to aid in prosthesis fitting and movement. Different materials have been used through the years. The authors noted that with bone-derived hydroxyapatite orbital implants, some patients lose their orbital volume.

METHODS

The operating theatre record was searched to find patients who had their hydroxyapatite orbital implant removed at Dunedin Hospital, New Zealand, between 2011 and 2015. The original implant size and size at removal were noted. Histological results were noted. Medical notes were reviewed.

RESULTS

A total of six patients had hydroxyapatite orbital implants removed during this time. Four patients had implants that were smaller than their original sizes. All specimens had fibrovascular infiltration noted, three had chronic inflammatory cells and one had osteoclastic activity.

CONCLUSIONS

Bone-derived hydroxyapatite orbital implants can reduce in size, and this may occur due to osteoclastic activity. The surgeon must consider this scenario when choosing the type of implant to be used after enucleation or evisceration.

Use of Lateral Oncoplasty for Multiquadrant Giant Fibroadenoma: A Novel Approach

Giant fibroadenomas are uncommon benign lesions, defined as fibroadenomas of >5 cm in size and/or weighing more than 500 g. They can distort the shape of the breast and cause asymmetry, so they should be excised. Here, we report two cases of giant fibroadenoma, where wide local excision and reconstruction with lateral oncoplasty were done. Compared to all previous reports of patients with giant fibroadenoma, where the lump was excised either through a submammary incision or by round block technique depending on the location of the tumour, we used the lateral oncoplasty technique in both patients. Lateral oncoplasty is a new reconstructive option to maintain cosmesis and symmetry after the excision of giant fibroadenomas in the outer and central quadrants of the breast. It is a good option for reconstruction in cases where the defect is very large and facilities for conventional flap surgeries are not available.

Laparoscopic cholecystectomy with two incisions: an improved, feasible and safe technique with superior cosmetic outcomes

OBJECTIVE

Conventional laparoscopic cholecystectomy (CLC) is usually performed with four incisions. Minimally invasive surgery for gallbladder disease with less pain and smaller scars has become increasingly popular. This study reported a new, two-incision laparoscopic cholecystectomy (TILC) using conventional instruments.

METHODS

In this prospective study, 43 patients were recruited to undergo TILC and were compared with 43 historical cases undergoing CLC. We evaluated operative time, postoperative pain, cosmesis and complications.

RESULTS

There was no significant difference in gender, age, body mass index, bile duct damage, blood loss and postoperative hospital stay between the two groups. The mean operation time was longer with TILC than with CLC, but the difference was not statistically different. Postoperative pain scores were significantly lower with TILC than with CLC. The mean cosmetic satisfaction score was significantly higher with TILC than that with CLC. There was no significant difference in the incidence of complications between the two groups.

CONCLUSION

Our work demonstrates that TILC generates less postoperative pain and significantly improved cosmesis for patients. TILC is a safe and feasible alternative to CLC.

Cosmetic outcomes following wide local excision of impalpable breast cancer: is radioguided occult lesion localization using iodine-125 seeds better than hookwire localization?

BACKGROUND

Hookwire localization (HWL) is the gold standard for localizing impalpable tumours for breast conserving surgery. An alternative technique, radioguided occult lesion localization using iodine-125 seeds (ROLLIS), has been associated with lower re-excision rates. This paper investigates if cosmetic outcomes differ in women undergoing breast conserving surgery with HWL or ROLLIS.

METHODS

Women who had ROLLIS or HWL guided excision for impalpable breast cancer within a multicentre randomized controlled trial (RCT) (ANZCTR 12613000655741) were recruited. Exclusions were level 2 oncoplasty and mastectomy. Cosmetic outcome was calculated using BCCT.core, the Hopwood Body Image Scale and estimated percentage breast volume excised. Chi-squared analysis was used to determine the difference between the intervention groups.

RESULTS

Analysis was performed for 123 participants (66 ROLLIS and 57 HWL). The cosmetic outcome determined by BCCT.core for all participants was good with no significant difference between the ROLLIS and HWL groups. When reviewing the number of patients who experienced either a good or excellent result, there was a significantly higher number of patients in the ROLLIS group (n = 53, 82%) compared to the HWL group (n = 42, 74%, P = 0.02. There were no differences in Hopwood Body Image Scale or estimated percentage breast volume excised between groups. There was a reduction in the frequency of re-excision in the ROLLIS group (n = 3, 4.5%) versus HWL group (n = 8, 14%); however, this was not significant (P = 0.06).

CONCLUSION

Pre-operative localization of impalpable breast lesions using either ROLLIS or HWL resulted in a good cosmetic outcome with no significant difference between localization techniques.

Fractional ablative carbon dioxide laser treatment of facial scars: Improvement of patients' quality of life, scar quality, and cosmesis

BACKGROUND

Disfiguring facial scars can be a massive burden on patients' psychosocial health and severely impact patients' self-esteem.

AIMS

The aim of this study was to analyze whether ablative fractional carbon dioxide laser (CO2-AFL) treatment can positively influence facial scarring and quality of life (QoL) while improving the aesthetic appearance.

PATIENTES/METHODS

Patients with facial scars who had received CO2-AFL treatment between May 2019 and May 2020 were included in a retrospective study. The post-interventional course and patient and/or observer reported outcomes were inquired before and three months after treatment. Primary outcomes were changes in the Patient and Observer Scar Scale (POSAS) and QoL (Short Form (SF) 36). In addition, two independent examiners evaluated the aesthetic outcome by comparing initial scarring with the post-intervention results using photographs.

RESULTS

A total of 16 patients with facial scars were included. Most of the scars were caused by burns (43.8%) or trauma (31.3%). The post-interventional course was uneventful. Overall POSAS scores improved decisively for both observers (n=2) and patients (n=16) (p<0.001 and p<0.001). Also, there was an improvement in QoL with an increase in emotional well-being (p=0.043) and social functioning (p=0.01). Furthermore, the aesthetic outcome was significantly enhanced (p=0.001) after treatment.

CONCLUSION

The CO2-AFL offers a safe and effective treatment for disfiguring facial scars. We have shown that improvement of scar appearance and scar quality was meaningful to the patient, with a significant impact on a patient's life quality. Based on these findings we suggest including the CO2-AFL in the facial scar treatment concept.

Cosmetic Outcomes Following Breast-Conservation Surgery and Radiation for Multiple Ipsilateral Breast Cancer: Data from the Alliance Z11102 Study

BACKGROUND

Diagnoses of multiple ipsilateral breast cancer (MIBC) are increasing. Historically, the primary treatment for MIBC has been mastectomy due to concerns about in-breast recurrence risk and poor cosmetic outcome. The Alliance Z11102 study prospectively assessed cosmetic outcomes in women with MIBC treated with breast-conserving therapy (BCT).

PATIENTS AND METHODS

Z11102 was a multicenter trial enrolling women with two or three separate sites of biopsy-proven malignancy separated by ≥ 2 cm within the same breast. Cosmetic outcome was a planned secondary endpoint. Data were collected with a four-point cosmesis survey (1 = excellent, 4 = poor) and the BREAST-Q (scored 0-100). All patients undergoing successful breast-conserving therapy were treated with whole-breast radiation. Associations were assessed with Chi square or Fisher's exact tests as appropriate.

RESULTS

Cosmetic outcome data for 216 eligible women who completed therapy are included in this analysis. Of the 136 patients who completed the survey 2 years postoperatively, 70.6% (N = 96) felt the result was good or excellent, while 3.7% (N = 5) felt the result was poor. We found no significant differences in patient-reported cosmetic outcomes when stratifying by patient age, number of lesions (two or three), number of incisions, number of lumpectomies, or size of largest area of disease. Mean satisfaction score on the BREAST-Q was 77.2 at 6 months following whole-breast radiation and 73.7 at 3 years following surgery.

CONCLUSIONS

BCT performed for MIBC results in good or excellent cosmesis for the majority of women. From a cosmetic perspective, BCT is a valid surgical approach to women with MIBC.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01556243.

A Comparative Analysis of Surgical Scar Cosmesis Based on Operative Approach for Radical Prostatectomy

Objective: Recent developments in minimally invasive approaches to radical prostatectomy (RP) for localized prostate cancer have improved oncological outcomes, but may also affect surgical scar cosmesis, an important component of survivorship and patient quality of life. Our aim was to evaluate surgical scar appearance based on operative approach to RP using a validated tool for evaluating psychosocial impact of scar appearance. Methods: Men between the ages of 45 and 80 were surveyed on an online crowdsourcing platform. Well-healed surgical scars after open, multiport (MP) robotic (transperitoneal and extraperitoneal), and single-port (SP) robotic RP were digitally rendered on stock photos to control for patient appearance. Respondents evaluated images using the SCAR-Q© psychosocial impact domain. Additionally, different RP scars were ranked by appearance and assigned 10-point appearance scores. Results: Two hundred thirty-four surveys were included for analysis (completion rate 84.2%). The median age was 54 (IQR: 49-61) and 35% (85/234) had previous abdominal surgery, of which 45% (38/85) was robotic or laparoscopic. SP scars had better psychosocial impact scores (median 100 out of 100 vs 69 and 58) than MP and open, respectively (both p < 0.001). SP scars were consistently ranked higher by appearance (median rank 1, IQR: 1-1) than MP (2, IQR: 2-3) and open (3, IQR: 3-4) (p < 0.001). SP without assistant port had the highest appearance score (median 9, IQR: 7-9) among all scars (p < 0.001). Conclusion: SP scars scored highest on psychosocial impact and were consistently ranked highest in appearance. These findings may be informative for optimizing both cosmetic appearance and quality of life for patients undergoing RP.

Minimally invasive video-assisted thyroidectomy in Asian patients: experience from Singapore

BACKGROUND

Minimally invasive video-assisted thyroidectomy (MIVAT) although well established in Europe has not yet gained widespread acceptance in Asia. We describe our learning experience in the first reported series of 105 cases from Singapore.

METHODS

A retrospective analysis of outcomes in 105 patients who underwent MIVAT from April 2011 to 2018 was performed. The inclusion criteria were - symptomatic benign thyroid pathologies and follicular lesions or neoplasms needing a hemi-thyroidectomy. A thyroid lobe volume less than 35 mL was used as cut-off. Patients underwent surgeon-performed thyroid ultrasound with biopsy of solid nodules. All cases were operated by one surgeon using standard Miccoli technique with energy device used in all cases.

RESULTS

From a total of 424 patients with nodular goitres undergoing thyroidectomy, 105 (24%) symptomatic eligible patients underwent the MIVAT procedure (M:F - 23:82). The mean incision lengths at start and completion were 1.7 cm (range 1.5-2 cm) and 2.4 cm (range 2-2.7 cm), respectively. Mean operating time was 97 min (range 59-160 min). There were four conversions (3.8%) in the first 25 cases and four patients (3.8%) experienced transient hoarseness with full recovery. Visual analogue pain scores at 6 and 24 h post-operatively were 2.7 and 1.1, respectively. Scar satisfaction was reported as excellent (75%), satisfactory (23%) and poor (2%).

CONCLUSION

Although technically more demanding, MIVAT is a safe and useful operation in a thyroid surgeon's armamentarium. The limitation of goitre size, however, allows only a small percentage of symptomatic patients to undergo this procedure.

Long-term patient-rated cosmetic and satisfactory outcomes of early breast cancer treated with conventional versus hypofractionated breast irradiation with simultaneous integrated boost technique

To compare patient-rated cosmetic and satisfactory outcomes between conventional fractionation with simultaneously integrated boost (C-SIB) vs hypofractionation with SIB (H-SIB) in early breast cancer. Patients with stage I and II breast cancer who received breast-conserving surgery followed by radiation with SIB to tumor bed and completed questionnaire were included in this study. Radiotherapy was as follows: C-SIB arm = 50 Gy and 65 Gy in 25 fractions and H-SIB arm = 43.2 Gy and 52.8 Gy in 16 fractions to the whole breast and tumor bed, respectively. Single cross-sectional assessment of the breast cosmesis was done by patients and radiation oncologist at a follow-up visit. Breast cosmetic and satisfaction scores were collected using a four-point Harvard/NSABP/RTOG cosmesis criteria scale and a four-point Likert-type scale, respectively. Of a total of 114 patients (C-SIB = 57) and (H-SIB = 57) arms, a median time from radiotherapy completion to questionnaire response was 7.2 years. Patient-rated cosmetic outcome in C-SIB vs H-SIB was "excellent" in 40.3% vs 45.6%, "good" in 33.3% vs 42.1%, "fair" in 21.1% vs 10.5%, and "poor" in 5.3% vs 1.8% (P = .288). Corresponding satisfaction was "very satisfied" in 52.6% vs 57.9%, "satisfied" in 40.4% vs 35.1%, "neutral" in 7.0% vs 5.2%, and "unsatisfied" in 0% vs 1.8% (P = .683). Stage I and older age at radiotherapy were predictors for favorable (good or excellent) cosmesis and satisfaction, respectively. In early-stage breast cancer, H-SIB provided a trend for better cosmesis than C-SIB while maintaining satisfaction. The reduction in treatment duration and cost as well as favorable cosmesis outcomes encourages the use of H-SIB.

Mini-Laparoscopic Gynecological Surgery Using Smaller Ports Minimizes Incisional Pain and Postoperative Scar Size: A Paired Sample Analysis

Objective. The aim of this study was to assess postoperative incisional pain and cosmetic scores in mini-laparoscopic gynecological surgeries undertaken with different port sizes. Material and Method. In this prospective study, all women who underwent mini-laparoscopic gynecological surgery with 2.4-, 3-, and 5-mm lateral ports for benign gynecological conditions between March 2017 and April 2019 were included. The primary outcome was postoperative incisional pain at rest, walking, and after a provoked Valsalva maneuver assessed by numeric rating scale scores at 6 hours, 12 hours, 24 hours, and 3 days and 7 days after surgery. Secondary outcome measures included cosmetic scores of each port site (evaluated by using patient-observer scar assessment scale [POSAS]), operation time, and intra- and postoperative complications. Results. A total of 330 lateral port sites in 110 patients who underwent benign gynecological surgery via mini-laparoscopy were assessed for pain and cosmetic appearance. Pain scores at each time point were significantly lower for 2.4- and 3-mm ports than those for 5-mm ports; however, no significant difference was detected between 2.4-mm and 3-mm port sites (P = .6). The difference was more evident at 24 hours when routine analgesic drugs were stopped (P = .004). For POSAS scores, both 2.4-mm and 3-mm ports were superior to 5-mm port sites (P = .002); however, there was no significant difference between 2.4-mm and 3-mm port sites (P = .2). There were 2 port-related complications: one subcutaneous emphysema and one bleeding from a 5-mm trocar site 1 hour after surgery. Conclusion. Mini-laparoscopic gynecologic surgery using smaller ports resulted in decreased postoperative incisional pain and superior cosmetic appearance.

Residual thoracolumbar/lumbar curve is related to self-image after posterior spinal fusion for Lenke 1 and 2 curves in adolescent idiopathic scoliosis patients

OBJECTIVE

Although it is well known that major curve severity in adolescent idiopathic scoliosis (AIS) is inversely related to self-image, surgeons often encounter patients who complain of low self-image with preoperatively mild curves or postoperatively well-corrected main curves, suggesting the presence of other factors. This study examined factors contributing to self-image in AIS.

METHODS

A total of 86 consecutive patients who underwent posterior spinal fusion for AIS Lenke 1 or 2 curves and were followed for a minimum of 2 years were included in this study of patient self-image based on data that included scores reported on the Scoliosis Research Society survey (SRS-22r). The authors evaluated sex, BMI, Risser grade, age, angle of trunk rotation, Cobb angle of the main thoracic (MT) curve, Cobb angle of the thoracolumbar/lumbar (TL/L) curve, apical vertebral translation (AVT), T5-12 kyphotic angle, and clavicular angle. Univariate and multivariate general linear models were employed to identify preoperative and 2-year postoperative factors that impact self-image.

RESULTS

Univariate analysis revealed no significant correlation between preoperative MT curve Cobb angle and SRS-22r self-image score (p = 0.51), although patients with a higher MT curve AVT had a significantly worse preoperative self-image (p < 0.01). Two years postoperatively, larger Cobb angle of the TL/L curve (p = 0.01) and higher Risser grade (p = 0.03) resulted in significantly lower self-image scores. In multivariate testing, preoperative MT curve AVT remained significantly related to diminished self-image (p < 0.01). Two years later, higher TL/L curve (p < 0.01), Risser grade (p = 0.03), and MT curve AVT (p = 0.03) had significant associations with lower self-image scores.

CONCLUSIONS

Preoperative MT curve AVT appears more strongly related to self-image than does Cobb angle. Two years postoperatively, persistent TL/L region curvature and high Risser grade may also be associated with diminished patient self-image.

Survey on Willingness to Pay for Life-Saving Treatment, Functional Recovery, and Cosmesis in a Neuroscience Outpatient Clinic Setting in Singapore

BACKGROUND

Neurologic disorders impose a heavy burden on healthcare in Singapore. To date, no data on the willingness to pay (WTP) for neurologic treatments has been reported in the local population.

OBJECTIVES

We aimed to quantify the value of various health domains to neuroscience patients and their caregivers by comparing their WTP for different types of treatments.

METHODS

A questionnaire using a mixed open-ended and closed-ended contingent valuation method was developed to elicit WTP and self-administered by 112 visitors to a neuroscience outpatient clinic. The WTP for treatments in 3 health domains (advanced restoration of function, life extension, and cosmesis) was evaluated and compared. Subgroup regression analysis was performed to investigate the impact of demographic and socioeconomic factors.

RESULTS

Treatment that improved cosmesis had the highest median WTP of Singapore dollar (SGD) 35 000, followed by treatment that provided 1 year of life extension (SGD 20 000) and 1 year of advanced restored function (SGD 10 000; P < .001). Respondents with a university education were willing to pay as much as 2 to 3 times of those without across all health domains.

CONCLUSION

This is the first study to provide data on how different health domains are valued by neuroscience patients and caregivers in our population. Respondents valued treatment that restored or improved their physical appearances the most. These findings could contribute to future policies on the improvement of neuroscience care.

Transaxillary endoscopic excision of benign breast tumors, early institution experience

BACKGROUND AND AIM

Benign breast diseases are one of the most common diseases in females. An important goal in its treatment should be cosmesis, so a new minimally invasive technique has advanced. One of these techniques is the transaxillary endoscopic resection. The aim of this study was to assess the feasibility, safety, operative time, postoperative pain, hospital stay, and cosmetic outcome of this transaxillary approach.

METHODS

This study was carried out on 40 female patients presented with benign breast tumors in the surgical oncology unit at the General Surgery Department, Tanta University Hospital during the period from January 2018 to January 2019. The patients included in the study aged ≥18 years, had solitary or multiple benign breast tumors, located at any breast quadrant. The patients subjected to transaxillary endoscopic excision of the tumors.

RESULTS

The age of the patients ranged from 20 to 49 years with a mean age of 32 years. 60% of the lesions located in the upper half of the breast. Fibroadenoma was the most common finding in 80% of the patients, 60% of the patients had solitary tumor. The operative time ranged from 42 to 105 minutes with a mean of 61.4 minutes. 88.8% of the patients considered the cosmetic outcome excellent.

CONCLUSION

Endoscopic transaxillary excision of benign breast tumors is safe, feasible and has excellent cosmetic outcomes with high patient's satisfaction.

Single-Port Versus Conventional Laparoscopic Cholecystectomy: Better Cosmesis at the Price of an Increased Incisional Hernia Rate?

Background: The incidence of trocar site hernia (TSH) in single-port laparoscopic cholecystectomy (SPC) is still a debated issue. Aim of this retrospective study was to compare the incidence of postoperative hernia and cosmetic results among patients undergoing SPC and multiport laparoscopic cholecystectomy (MPC) performed at a single institution. Methods: A series of 60 SPC and 60 MPC patients operated on between July 2016 and May 2018 were compared. Primary endpoint was to assess the incidence of TSH at long term. All the patients were admitted as outpatients for physical examination and scar measurement. Secondary endpoints were the cosmetic results assessed by a cosmesis score (CS) and the body image questionnaire (BIQ). Results: After a median 18-month follow-up (range: 6-29 months), a hernia in umbilical trocar site was detected in 4 (7.1%) SPC patients and 1 (2%) MPC patient, the difference not being statistically significant (P = .216). BIQ was almost equivalent in SPC and MPC groups (5.15 versus 5.27; P = .518), respectively. Statistically significant differences in favor of SPC were found in CS (22.3 versus 19.72; P = .001) and in total length of scars (1.2 cm versus 4 cm; P < .001). Conclusions: SPC technique has proved to be safe and effective in experienced hands. Superior cosmesis of SPC over MPC is confirmed, but close attention to fascial closure is a vital component of SPC, and surgeons performing single-site surgery need to be aware of this increased potential for hernia formation.

A prospective comparison of subjective and objective assessments of cosmetic outcomes following breast brachytherapy

Purpose

We evaluated agreement between subjective and objective methods of cosmesis scoring in an accelerated partial breast irradiation (APBI) cohort.

Material and methods

Consecutive women treated with APBI using interstitial brachytherapy reported for clinical follow-up every 6 months. Single cross-sectional assessment of the breast cosmesis was done by a radiation oncologist (subjective method) using Harvard scale and by photographic assessment using BCCT.core (Breast Cancer Conservative Treatment. Cosmetic results, version 3.1) software (objective method) at 18-36 months post-APBI. The agreement between subjective and objective methods for the overall score as well as individual subjective/objective subdomains was computed using kappa statistics. ANOVA was used to test the correlation between objective indices and subjective subdomains.

Results

The agreement between the subjective (physician) and objective assessment was good with a kappa of 0.673. Overall, 77 (98.7%) patients were satisfied with the overall outcomes of breast conservation therapy. The kappa agreement between physician and patient scoring was 0.457 (95% CI: 0.240-0.674). Among the subjective subdomains, location of the nipple areola complex (NAC) had good agreement with both the overall subjective and objective score, with the kappa of 0.778 and 0.547, respectively. In the objective indices, BCE (breast compliance evaluation), LBC (lower breast contour), and UNR (unilateral nipple retraction) correlated significantly with the subjective subdomains: location of the NAC, breast size, and shape (p < 0.05 for all indices).

Conclusions

Good agreement exists for overall cosmetic outcomes measured by subjective and objective methods. Location of the NAC, breast size and shape are the most important parameters determining cosmetic outcomes irrespective of the method of assessment.

Optimal wound closure techniques for thyroid and parathyroid surgery: A systematic review of cosmetic outcomes

OBJECTIVES

Cosmesis after surgical wound closure is an important outcome. This is relevant after thyroid and parathyroid surgery as anterior neck scars are visible and often of concern to patients. We aimed to investigate whether wound closure method influences cosmetic outcome in thyroid and parathyroid surgery, in particular using sutures, staples, steri-strips and glue.

DESIGN

We performed a systematic review of MEDLINE, PubMed, EMBASE, CINAHL and Cochrane focusing on wound cosmesis following thyroid and parathyroid surgery. Searches were conducted using combinations of the search terms: thyroid/parathyroid surgery, wound/skin closure and suture, staples, clips, glue and steri-strips, using appropriate MESH terms and Boolean operators.

MAIN OUTCOME MEASURES

Primary outcome was wound cosmesis. Secondary measures were also extracted.

RESULTS

Initial search found 304 papers and after systematic review, a total of 10 studies compared different closure methods and cosmetic outcomes. There were nine randomised controlled trials and one cohort study, with a total of 712 patients. Three studies compared staples vs glue; three compared sutures vs clips; two compared suture vs steri-strips and two studies for suture vs glue. In general, short-term cosmesis was better with subcuticular sutures compared to glue or clips, long-term cosmetic outcomes were not influenced by closure method.

CONCLUSIONS

We found closure with subcuticular suture or steri-strips produced superior short-term cosmetic outcomes. Although long-term cosmetic outcome is not influenced by closure method, given the superior cosmetic outcome and advantage of not needing removal, we recommend subcuticular sutures should be performed for wound closure in thyroid and parathyroid surgery.

Course of upper eyelid retraction in thyroid eye disease

AIMS

To evaluate the natural course of upper eyelid retraction (UER) in patients with thyroid eye disease (TED) and factors affecting its course.

METHODS

Retrospective non-interventional cohort study in a single tertiary institution from March 2006 to March 2015 on patients with TED with (1) unilateral or bilateral UER within 6 months from initial presentation, and (2) no prior interventions nor surgical treatment for their UER. Main outcomes and measures were mean margin reflex distance 1 (MRD1) and factors associated with UER improvement.

RESULTS

There were a total of 61 patients and 81 eyes (41 unilateral and 20 bilateral UER). Mean age was 42.3±15.1 years. Mean MRD1 decreased from 6.1 mm at presentation to 4.8 mm at 12 months, and 4.4 mm at 24 months. The proportion of eyes with normalisation of lid height increased from 0% at presentation to 22.2% at 6 months, 37.0% at 12 months and 49.4% at 24 months. Mean time to normalisation of MRD1 was 18.0±12.4 months. A positive family history of TED was found to be associated with a 6.2 times lower likelihood of normalisation. Change in exophthalmometry, clinical activity score and thyroid-stimulating immunoglobulin were significantly correlated to change in MRD1 (p<0.05). There was no correlation between change in MRD1 and thyroid-stimulating hormone receptor antibodies.

CONCLUSION

An improved knowledge of the natural history of UER in TED will allow us to better decide and evaluate the optimal management for such patients.

Comparison of single-incision and conventional laparoscopic cholecystectomy in terms of quality of life, body image, and cosmesis

Background

Clinical studies indicate that single-incision laparoscopic cholecystectomy (SILC) has many advantages over conventional laparoscopic cholecystectomy (CLC), such as improved cosmesis, reduced postoperative pain, and shorter hospital stay. The aim of this study was to compare quality of life, body image, and cosmesis between single-incision laparoscopic and conventional laparoscopic approaches in patients undergoing cholecystectomies.

Subjects and Methods

This retrospective study between SILC and CLC and was conducted among 58 patients undergoing SILC and CLC from January 2011 to March 2013 in Turkey. After the surgery, the EuroQol-5 Dimension Questionnaire (EQ-5D™), and body image questionnaire (BIQ) were administered to the patients.

Results

Differences between the early and late postoperative scores in the EQ-5D were statistically significant (P < 0.001). Differences between most BIQ areas favored SILC, especially regarding cosmesis (P = 0.016); SILC patients had higher satisfaction with their scar's appearance.

Conclusion

SILC is a promising alternative to traditional laparoscopic cholecystectomy in terms of quality of life, body image, and cosmesis in selected patients.

Description and Initial Experience with the "LIFT" (Less Incisions but Four Trocars) Technique for Laparoscopic Cholecystectomy

Background: Modifications to conventional laparoscopic cholecystectomy (LC) aim to reduce trauma to the abdominal wall and improve cosmetic outcomes. Although single-incision laparoscopic surgery (SILS) provides excellent cosmetic results, the procedure is technically demanding. Herein, we describe the LIFT technique ("Less Incisions but Four Trocars"), with four trocars but only one 3-mm visible incision, using conventional instruments. Methods: Retrospective study with the LIFT technique for cholecystectomy during 2017. Access to the abdomen is obtained with two trocars (11 and 5 mm) through the same intraumbilical skin incision, and two extraumbilical 3-mm trocars for a correct triangulation (one of them concealed below the bikini line). The results are compared with a series of patients operated on with LC by the same surgical team during 2016. Results: During the study period, 90 procedures were performed. Both techniques showed similar results in terms of surgical time, conversion rate, complications, and hospital length of stay. The patients operated on with the LIFT technique reported better cosmetic evaluation and less postoperative pain at 3 months compared with LC. Conclusion: The LIFT technique is a safe and feasible alternative for cholecystectomy that can provide a significant improvement from the cosmetical point of view, mostly for those patients who are especially concerned with their body image.

Different suturing techniques in thoracic incision: protocol for a feasibility randomised controlled trial

INTRODUCTION

Based on the principles of the ideal skin closure technique, we previously described a suture technique (wedge-shaped excision and modified buried vertical mattress suture (WE-MBVMS)) that could provide excellent outcomes for the most demanding surfaces. However, adequate clinical comparative evidence supporting improved outcomes is lacking. Thus, the purpose of this protocol is to establish the feasibility of conducting a fully randomised controlled trial (RCT) comparing the clinical effectiveness of WE-MBVMS with a buried intradermal suture (BIS) in closing thoracic incision.

METHODS AND ANALYSIS

This study is a feasibility RCT of WE-MBVMS and BIS in patients undergoing surgery for costal cartilage harvesting. Seventy-eight participants are expected to participate in the study and will be randomised in a ratio of 1:1 to WE-MBVMS or BIS. Trial feasibility will be assessed by the number of participants assessed for eligibility, recruitment rates, reasons for ineligibility or non-participation, time for interventions, withdrawal and retention at all follow-up points (3, 6 and 12 months), follow-up rates and reasons for withdrawing from the trial. In addition, clinical data regarding the cosmetic results of scars will be collected to inform the sample size for a fully powered RCT.

ETHICS AND DISSEMINATION

This study has been approved by The First Affiliated Hospital of Xi'an Jiaotong University Institutional Review Board (XJTU1AF2017LSK-120). The findings will be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR-INR-17013335; Pre-results.

Utility of a novel elastic traction system in endoscopic thyroidectomy via breast approach: initial experience with 34 patients

Objective To summarize our experiences in using an elastic traction, space-making technique for endoscopic thyroidectomy via breast approach in the treatment of early-stage differentiated papillary thyroid carcinoma. Methods A retrospective analysis was performed on patients who underwent endoscopic thyroidectomy via breast approach for thyroid carcinoma in our department. We used our self-developed "mini elastic traction space-maker" in a group of 34 patients; another 45 patients who underwent the procedure with the conventional CO2 insufflation method were enlisted as the control group. Results All patients had successful unilateral lobectomy and central lymph node dissection (CLND) surgeries. The adoption of the intraoperative elastic traction system increased the height of the subcutaneous working space (by 1 cm) and significantly decreased the times required for lobectomy and CLND compared with the controls (46.7 ± 4.7 min vs. 50.7 ± 4.9 min). However, there was no significant difference between the two groups in the set-up time to create the working space. Conclusions The elastic traction, space-making technique is a safe and feasible technique for endoscopic thyroidectomy via breast approach.

Application and use of subcutaneous stay sutures in anterior cervical spine surgeries with a transverse neck incision: A technical report

Objective/Purpose:

The objective of this study is to describe our experience with the use of stay sutures and transverse neck incision for anterior cervical spine surgeries involving multiple levels.

Summary of Background Data:

Transverse incisions on neck usually heal with minimal fibrosis resulting in cosmetically acceptable scars whereas vertical incision, although provides greater exposure, heals with extensive fibrosis resulting in ugly scars. Transverse incision is thus highly recommended. However, the fear of nonextensibility of transverse incision for multilevel fusion has led to the preference of vertical incision, development of techniques for identifying the optimal level of the incision, or has suggested the usage of two transverse incisions.

Materials and Methods:

Seventy-six patients underwent anterior cervical spine surgeries using a transverse neck incision for single or multilevel discectomy/corpectomy and fusion. Having divided the platysma, dissection was carried down to the anterior surface of the cervical spine between the carotid sheath laterally and the trachea and esophagus medially. Stay sutures were taken through the platysma and subcutaneous tissue, converting the transverse incision into a quadrilateral window providing access for as much as three-level corpectomy or five levels of fixation.

Results:

All the wounds healed with no evidence of wound-related complications, leaving a cosmetically acceptable scar.

Conclusion:

Using appropriately placed stay sutures, a transverse neck incision taken in the middle of the field of work can provide enough of a surgical window to perform multilevel fusion surgeries. Its simplicity and cost-effectiveness make it easily implementable, addressing the underlying pathology adequately with best possible cosmetic results.