The primary principle behind laser hair removal is  selective photothermolysis  (SPTL), the matching of a specific  wavelength  of  light  and pulse duration to obtain optimal effect on a targeted tissue with minimal effect on surrounding tissue. Lasers can cause localized damage by selectively heating dark target matter,  melanin , thereby heating up the basal stem cells in the follicle which causes hair growth, the  hair follicle , while not directly heating the rest of the  skin . Light is absorbed by dark objects but reflected by light objects and water, so laser energy can be absorbed by dark material in the hair or skin, with much more speed and intensity than just the skin without any dark adult hair or melanin.


Melanin is considered the primary  chromophore  for all hair removal lasers currently on the market. Melanin occurs naturally in the skin and gives skin and hair their color. There are two types of melanin in hair.  Eumelanin  gives hair brown or black color, while  pheomelanin  gives hair blonde or red color. Because of the selective absorption of  photons  of laser light, only hair with color such as black, brown, or reddish-brown hair or dirty blonde can be removed. White hair, light blonde and strawberry blonde hair does not respond well.  Laser works best with dark coarse hair. Light skin and dark hair are an ideal combination, being most effective and producing the best results, but lasers such as the  Nd:YAG laser  are able to target black hair in patients with dark skin with some success. [ 6 ] [ self-published source? ] [ 7 ]


Hair removal lasers have been in use since 1997 and have been approved for "permanent hair reduction" in the United States by the  Food and Drug Administration  (FDA). [ 7 ] [ 10 ]  Under the FDA's definition, "permanent" hair reduction is the long-term, stable reduction in the number of hairs regrowing after a treatment regime. Many patients experience complete regrowth of hair on their treated areas in the years following their last treatment. This means that although laser treatments with these devices will permanently reduce the total number of body hairs, they will not result in a permanent removal of all hair. [ 7 ]


Laser hair removal has become popular because of its speed and efficacy, although some of the efficacy is dependent upon the skill and experience of the laser operator, and the choice and availability of different laser technologies used for the procedure. Some will need touch-up treatments, especially on large areas, after the initial set of 3–8 treatments.


IPL, though technically not containing a  laser , is sometimes incorrectly referred to as "laser hair removal". IPL-based methods, sometimes called "phototricholysis" or "photoepilation", use  xenon flash lamps  that emit full  spectrum   light . IPL systems typically output wavelengths between 400 nm and 1200 nm. Filters are applied to block shorter wavelengths, thereby only using the longer, "redder" wavelengths. IPLs offer certain advantages over laser, principally in the pulse duration. While lasers may output trains of short pulses to simulate a longer pulse, IPL systems can generate pulse widths up to 250 ms, which is useful for larger diameter targets. Some current IPL systems have proven to be more successful in the removal of hair and blood vessels than many lasers. [ 11 ] [ 12 ] [ 13 ]


A 2006 review article in the journal  Lasers in Medical Science  compared  intense pulsed light  (IPL), and both alexandrite and diode lasers. The review found no statistical difference in short-term effectiveness, but a higher incidence of side effects with diode laser-based treatment. Hair reduction after six months was reported as 68.75% for alexandrite lasers, 71.71% for diode lasers, and 66.96% for IPL. Side effects were reported as 9.5% for alexandrite lasers, 28.9% for diode lasers, and 15.3% for IPL. All side effects were found to be temporary and even pigmentation changes returned to normal within six months. [ 14 ]


Electrolysis  is another hair removal method that has been used for over 135 years. [ 15 ]  Like newer laser technology used properly and with several treatments, electrolysis can be used to remove 100% of the hair from an area and is effective on hair of all colors, if used at an adequate power level with proper technique. But the treatment is slow and tedious compared with typical newer laser hair removal.  More hair may grow in certain areas that are prone to hormone-induced growth (e.g. a woman's chin and neck) based on individual hormone levels or changes therein, and one's genetic predisposition to grow new hair.


A study conducted in 2000 at the ASVAK Laser Center in  Ankara , Turkey, comparing  alexandrite  laser and electrolysis for hair removal on 12 patients concluded that laser hair removal was 60 times faster, less painful and more reliable than electrolysis. The type of electrolysis performed in the study was  galvanic electrolysis , rather than  thermolysis  or a blend of the two. Galvanic current requires 30 seconds to more than a minute to release each hair whereas thermolysis or a blend can require much less. This study thus did not test the capability of all forms of modern electrolysis. [ 16 ] [ improper synthesis? ]


Shaving  is a technique in which one removes hair from the skin with a razor. Shaving, however, is only temporary and can lead to irritation of the shaved area.


Waxing  is another option for hair removal. This method is an efficient way of removing hair; it is longer-lasting than shaving but not permanent. The ancient Egyptians developed a similar mechanism, sugaring, in which one would mix oil and honey then apply it to the skin. [ 17 ] [ 18 ]


In some countries, including the U.S., hair removal is an unregulated procedure that anyone can do. In some places, only doctors and doctor-supervised personnel can do it, while in other cases permission extends to licensed professionals, such as regular nurses, physician assistants, estheticians, and/or cosmetologists. [ 19 ]


In Florida, the use of lasers, laser-like devices and intense pulsed light devices is considered medicine, and requires they be used only by a  physician  ( M.D.  or  D.O. ), a  physician assistant  under the supervision of a physician, or an advanced registered nurse practitioner under a protocol signed by a physician.  An electrologist working under the direct supervision and responsibility of a physician is also allowed to perform laser hair removal in the state of Florida. [ 20 ]


Several wavelengths of laser energy have been used for hair removal, from  visible light  to near- infrared   radiation . These lasers are characterized by their wavelength, measured in  nanometers  (nm): [ 21 ]


Pulse width (or duration) is one of the most important considerations. The length of the heating pulse relates directly to the damage achieved in the follicle. When attempting to destroy hair follicles the main target is the germ cells which live on the surface of the hair shaft. Light energy is absorbed by the melanin within the hair and heat is generated. The heat then conducts out towards the germ cells. As long as a sufficient temperature is maintained for the required time then these cells will be successfully destroyed. This is absolutely critical – attaining the required temperature is not sufficient unless it is kept at that temperature for the corresponding time. This is determined by the Arrhenius Rate Equation. [ 22 ]  To achieve these conditions the laser/IPL system must be able to generate the required power output. The main reason why hair removal fails is simply because the equipment cannot generate the desired temperature for the correct time.


Spot size, or the width of the laser beam, directly affects the depth of penetration of the light energy due to scattering effects in the dermal layer. Larger beam diameters or those devices that has a linear scanning [ 23 ] [ 24 ]  results in deeper deposition of energy and hence can induce higher temperatures in deeper follicles. Hair removal lasers have a spot size about the size of a fingertip (3–18 mm).


Fluence  or energy density is another important consideration. Fluence is measured in  joules  per square centimeter (J/cm 2 ). It's important to get treated at high enough settings to heat up the follicles enough to disable them from producing hair.


Epidermal  cooling has been determined to allow higher fluences and reduce pain and side effects, especially in darker skin. Three types of cooling have been developed:


In essence, the important output parameter when treating hair (and other skin conditions) is power density – this is a combination of energy, spot diameter and pulse duration. These three parameters determine what actually happens when the light energy is absorbed by the tissue chromophore be it melanin, hemoglobin or water, with the amount of tissue damaged being determined by the temperature/time combination.


Hair grows in several phases ( anagen ,  telogen ,  catagen ) and a laser can only affect the currently active growing  hair follicles  (early anagen). Hence, several sessions are needed to damage the hair in all phases of growth and force it to revert to a vellus non-colored small hair. [ 25 ]


Multiple treatments depending on the type of hair and skin color have been shown to provide long-term reduction of hair. Most people need a minimum of eight treatments. Current parameters differ from device to device but manufacturers and clinicians generally recommend waiting from three to eight weeks between sessions, depending on the area being treated. The number of sessions depends on various parameters, including the area of the body being treated, skin color, coarseness of hair, reason for  hirsutism , and sex.  Certain areas (notably men's facial hair) may require considerably more treatments to achieve desired results.


Laser does not work well on light-colored hair, red hair, grey hair, white hair, as well as fine hair of any color, such as  vellus . For darker skinned patients with black hair, the long-pulsed  Nd:YAG laser  with a cooling tip can be safe and effective when used by an experienced practitioner.


Typically the shedding of the treated hairs takes about two to three weeks. These hairs should be allowed to fall out on their own and should not be manipulated by the patient for certain reasons, chiefly to avoid infections. Pulling hairs after a session can be more painful as well as counteract the effects of the treatment.


Some normal side effects may occur after laser hair removal treatments, including itching, pink skin, redness, and swelling around the treatment area or swelling of the follicles (follicular edema). These side effects rarely last more than two or three days. The two most common serious side effects are acne and skin discoloration.


Some level of pain should also be expected during treatments. Numbing creams are available at most clinics, sometimes for an additional cost. Some numbing creams are available over the counter. Use of strong numbing creams over large skin areas being treated at one time must be avoided, since it can cause serious harm, and even death. [ 26 ]  Typically, the cream is applied about 30 minutes before the procedure. Icing the area after the treatment helps relieve the side effects faster. Ibrahimi and Kilmer reported a study of a novel device of diode handpiece with a large spot size which used vacuum-assisted suction to reduce the level of pain associated with laser treatment. [ 27 ]


Unwanted side effects such as hypo- or hyper-pigmentation or, in extreme cases, burning of the skin call for an adjustment in laser selection or settings. Risks include the chance of burning the skin or discoloration of the skin,  hypopigmentation  (white spots), flare of  acne , swelling around the hair follicle (considered a normal reaction),  scab  formation,  purpura , and  infection . These risks can be reduced by treatment with an appropriate laser type used at appropriate settings for the individual's skin type and treatment area.


Some patients may show side effects from an  allergy  to either the hair removal gel used with certain laser types or to a numbing cream, or to simply shaving the area too soon after the treatment.


Lip augmentation  is a cosmetic procedure that modifies the shape of the  lips  using fillers, such as  collagen  or implants. The procedure may be performed to increase lip size, correct asymmetry, create protrusion, or adjust the ratio of the top and bottom lips. The procedure typically involves surgical injection, though temporary non-surgical alternatives exist.


Swelling and bruising are common after lip augmentation, and irritation or allergic reaction may also occur. Lip augmentations can have undesired cosmetic effects, including scarring and lumping, and implants pose the risk of shifting underneath the lip or breaking through the skin.


Around 1900,  surgeons  tried injecting  paraffin  into the lips without success. [ 1 ]  Liquid  silicone  was used for lip augmentation, starting in the early 1960s but was abandoned thirty years later due to fears about the effects of silicone on general health and long term aesthetic outcome. [ 2 ]  About 1980, injectable  bovine   collagen  was introduced to the  cosmetic surgery  market and became the standard against which other  injectable  fillers were measured. [ 3 ]  However, that collagen does not last very long and requires an  allergy  test, causing the patient to wait at least three weeks before another appointment, after which more waiting is required to see cosmetic results.


The aim of lip augmentation is to provide an aesthetic, symmetric, and healthy appearance for the patient. Naturally, the face is not perfectly symmetric, and if the asymmetry is too big - with lip augmentation, the asymmetry can be corrected. [ citation needed ]


The ideal upper / lower lip ratio is around 1:1.6, [ 4 ]  and this ratio is also achievable by lip augmentation.


In the late 1990s, with the huge popularity of surgical rejuvenation and concomitant increase of  cosmetic surgery  procedures worldwide, more substances, along with  biocompatible  materials commonly used in other medical applications for years, became available to  surgeons  for use in augmenting thinning or misshapen lips into more plump and attractive features.


Some of the first widely used lip augmentation substances were:


Since 2000, more products and techniques have been developed to make lip augmentation more effective and patient friendly. The relative ease of many injections is due to surgeons using tiny 30 and 31 gauge (about as thick as a dozen human hairs)  needles  that are used to inject the very sensitive lips. [ citation needed ]  Nonetheless,  topical  anesthesias are often used for lip augmentation procedures. [ citation needed ]


Some of these new techniques and substances include:


Several studies have found fat grafting of the lip to be one of the best methods of maintaining a semi-permanent fuller and softer lip. [ 11 ]  When the lips are overfilled, the results can be comic, often supplying fodder to  tabloid  newspapers and offbeat websites. This look is sometimes mockingly called a 'trout pout.' Overaggressive injections can lead to lumpiness while too little can result in ridges.


Common reactions can range from redness, swelling or  itching  at the injection site(s). Other possible complications include  bleeding , uneven lips,  movement  of the implants or extrusion, when an  implant  breaks through the outermost surface of the skin. The usual, expected  swelling  and  bruising  can last from several days to a week. [ citation needed ] [ 12 ]


Some patients are allergic to the common local anesthetics like  lidocaine  and probably should not consider lip injections. Some react badly to the skin test that patients must take before receiving collagen. Other patients who should forego procedures to the lip include those who have active skin conditions like  cold sores , blood  clotting  problems,  infections , scarring of the lips or certain diseases like  diabetes  or  lupus  that cause slower healing. Patients with facial  nerve  disorders, severe  hypertension  or recurrent  herpes simplex   lesions  should also eschew lip augmentation. As in all surgeries,  smokers  complicate completion of their procedure as well as the speed of  healing .


Fat transfer can last longer than other injected materials but can have lumping or scarring effects. The length of time a fat transfer may last in the lips is often determined by how much the area moves and how close it is to a major blood supply. In addition, the donor fat must be harvested from another area of the patient's body which leaves another—albeit tiny—surgical  wound . However, donor fat harvesting techniques have become extremely well refined. [ 13 ]


Cosmetic surgery providers often advise their patients that many options now exist for improving the appearance of the lips. Most practitioners also admit that successful lip augmentation is highly dependent on the skill of the provider, with that skill stemming from many years of experience injecting the lips of many types of patients. Moreover, the surgeon must master various injection techniques. [ citation needed ]


With many injectables, the benefit to the patient is an immediate return to normal, usual activities. [ citation needed ]  A few surgeons offer a procedure known as surgical flap augmentations in which small sections of skin near the lips or inside the mouth are excised and added to the lips. But the technique does not add volume and achieves only a slight outward protrusion of the lips. [ 14 ]


A  lip lift  is the most common  plastic surgery  procedure that modifies the cosmetic appearance of the  lips , by reshaping them to increase the prominence of the  vermilion border  and to enhance the facial area above the lips into a more aesthetically pleasing shape. In corrective praxis, a lip lift procedure is distinguished from  lip enhancement , the augmentation of the lips, which can be affected with a non-surgical procedure.


There are surgical and non-surgical techniques for effecting lip lift and lip augmentation to the lips. The surgical techniques include incisions below the  nose  and in the periphery of the lips area of the face, the perioral area; other techniques effect the surgical incisions from inside the mouth.


The  aesthetic ideal  of a mouth with youthful lips—shaped like a lozenge—features an upper lip with a pronounced  Cupid's bow , and much fullness to each lip; however, such an ideal physiognomy declines with age, and the lips shrink and lose anatomic definition, as the lips sag, which affects the aesthetics of the smile, by revealing less of the teeth during a relaxed smile. [ 1 ] [ 2 ]  The  American Society of Plastic Surgeons  reported 3.2 million cosmetic surgery procedures performed to mature patients, aged 55 years and older, in 2008. The patient demand for facial rejuvenation indicates that most requests do not include the mouth, which results in a surgical outcome that is aesthetically deficient. [ 1 ] [ 3 ] [ 4 ] [ 5 ] [ 6 ]
In the 1980s, when  collagen , originally the principal filler for the lips, proved limited in effecting permanent correction, plastic surgeons then developed surgical techniques for lifting and augmenting the lips, and correcting aesthetic defects and deformities. [ 7 ]


A systematic review regarding "non-filling" procedures for lip augmentation classified lip lift techniques in four surgical categories: the direct lip lift (DLL), indirect lip lift (ILL), corner of the mouth lift (CML), and the V–Y lip advancement (VYLA). [ 8 ]


The "gull-wing lift" is an effective surgical technique for increasing the prominence (display) of the vermilion coloring of the lips, by removing  skin  (and other tissues) as required, either directly from or from above the white line of skin that borders onto, and sets off, the vermilion of the lips (the white roll). The incisions remove tissue and significantly alter the shape of the lips by moving up the vermilion from both peaks of the Cupid's bow outwards to the commissures, the corners of the mouth. Incisions are also made below the lower lip to increase the projection of the vermilion of the lower lip. This gull-wing lip lift usually requires an OR time of approximately 20 minutes; post-operatively, the swelling of the lips subsides at 1–2 weeks and the tightness subsides at 2–4 months. Asymmetry, under-correction, and  hypertrophic scarring  are possible complications. [ 1 ]


A technical variant of the gull-wing lip lift is the sub-nasal lip lift (bull-horn lip lift), which involves the removal of either an ellipse or a curved-edge ellipse of tissue from under the nose. The skin then is raised, and sutured to lift the lip and expose more of the upper-lip vermilion. [ 2 ] [ 9 ]  Depending upon the indications of the patient, this technique can increase the drooping the corners of the mouth (commissures); thus, the sub-nasal lip lift often includes a corner-lift surgical step. [ 6 ]  In the corner lift procedure (external angle oral  commissuroplasty ), triangles of tissue are resected from above the commissures, thereby elevating the corners of the mouth. [ 3 ]  A descending wedge of tissue can also be removed to add contour to the Cupid's bow or to reduce bulky lips. [ 2 ]


Another variation is the thread lift, in which a square stitch is placed from one nostril to the other and down to the peaks of the Cupid's bow. This variation has fallen out of favor because the results are short-lived. [ citation needed ]


Another variation is the double duck lip lift, in which the columella of the nose is not incised. [ citation needed ]


Another variation of the procedure consists of a lenticular excision of the white skin surrounding the upper oral commissure in order to lift this part of the lips. This technique has also been dubbed the "Smile Lift". [ citation needed ]


Another variation of the procedure is for a surgeon to make an incision inside the mouth to loosen the mucosa and vermilion, which are then advanced and secured, leaving a portion of scar tissue inside the mouth which may take 2–4 months to heal. [ 3 ]  Yet another technique uses a "W" incision inside the mouth to create several "V" flaps, which are then used in a V-to-Y plasty technique to advance the vermilion of either or both lips. [ 3 ]  This procedure leaves no exposed areas inside the mouth, but can be painful and has a lengthy recovery period. [ 5 ]


Although surgeons report patient satisfaction with these techniques to be "high," no one variation has been sufficiently applauded to become the standard procedure. [ 7 ]  Most of these methods result in an increase in the amount of vermilion visible. Quantitative data exists for the V-Y lip augmentation, for which statistically significant increases in upper vermilion height and surface area have been measured. [ 7 ]  A systematic review regarding "non-filling" procedures for lip augmentation published in 2014 showed that philtrum length decreases with Indirect Lip Lift techniques, but not with V-Y lip augmentation.


Complications which may arise from lip lift surgery include:


Because of this, patients must be on bed rest for at least a week. In particular, the technique of removing skin at or directly above the white roll has been singled out as resulting in unfavorable scarring and stiffness in the lips. [ 2 ] [ 4 ] [ 10 ]


Advancements and improvements in non-surgical fillers available for lip enhancement has reduced demand for the lip lift procedure. [ citation needed ]


Liposuction , or simply  lipo , is a type of  fat-removal procedure  used in  plastic surgery . [ 1 ]  Evidence does not support an effect on weight beyond a couple of months and does not appear to affect  obesity -related problems. [ 2 ] [ 3 ]  In the United States, liposuction is the most common  cosmetic surgery . [ 4 ] [ 5 ]


The procedure may be performed under general, regional, or local  anesthesia . It involves using a  cannula  and negative pressure to suck out fat. [ 4 ]  As a  cosmetic procedure  it is believed to work best on people with a normal weight and good skin elasticity. [ 4 ]


While the suctioned fat cells are permanently gone, after a few months overall body fat generally returns to the same level as before treatment. [ 2 ]  This is despite maintaining the previous diet and exercise regimen. While the fat returns somewhat to the treated area, most of the increased fat occurs in the abdominal area.  Visceral fat —the fat surrounding the internal organs—increases, and this condition has been linked to life-shortening diseases such as  diabetes ,  stroke , and  heart attack . [ 2 ]


There are two different uses for liposuction:


Cosmetic liposuction is used to change the body's contour or shape, to aesthetically improve the appearance of body parts and contour. It should not be used for  weight loss . [ 6 ]  Benefits from cosmetic liposuction appear to be of a short-term nature with little long-term effect. [ 2 ]  After a few months fat typically returns and redistributes. [ 2 ]  Liposuction does not help  obesity -related metabolic disorders like  insulin resistance . [ 3 ]


Reconstructive, medically necessary liposuction is used to treat  lipedema , [ 7 ]  to remove excess fat in the chronic medical condition  lymphedema , [ 8 ]  and to remove  lipomas  from areas of the body. [ 9 ] [ 10 ]


Many articles refer to liposuction as "cosmetic" and not reimbursable by medical insurance companies. Most of this information is outdated. If the documentation supports the liposuction for a medical reason ( lipedema ,  lymphedema ,  lipomas ) as reconstructive, and not investigational, experimental, or unproven, the claim is medically necessary and should be reimbursed. [ 11 ]  While most insurance companies may initially deny the claim, many can be won upon appeal if the documentation and patient's need supports the criteria for  reconstructive surgery . [ 12 ] [ 13 ] [ 14 ]


The techniques and terms listed below: tumescent, lymph-sparing, Tumescent Local Anesthesia (TLA), Water-Assisted Liposuction (WAL), Power-Assisted Liposuction (PAL), Laser-Assisted Liposuction (LAL) all apply to reconstructive, medically necessary liposuction. [ citation needed ]


In general, fat is removed via a  cannula  (a hollow tube) and  aspirator  (a suction device). Liposuction techniques can be categorized by the amount of fluid injected, and by the mechanism by which the cannula works. If the removed fat is used as filler for the face, lips, or breasts, knowledge of the precise technique used to remove the fat is indicated. [ 15 ]  There are numerous types of liposuction. Some can be described as techniques or modalities. These techniques of liposuction are categorized depending upon the type of energy used for the liquifaction of fat. Often surgeons will use two or more of the different techniques below in the same session. [ citation needed ]


This is the most generic term for liposuction. In the CPT manual it is referred to as "suction-assisted lipectomy" and includes codes: 15876–15879. [ 16 ]


This does not address a particular technique but the diameter of the cannula, a stainless steel tube which is inserted into subcutaneous fat through a small opening or incision in the skin. The outside diameter of micro-cannulas range from 1 mm to 3 mm. [ 17 ]


This technique does not require a particular wand and is most often performed with either tumescent liposuction or WAL (below). It refers to the specific surgical technique, the skill of the surgeon, and the extensive training that is unique to removing lipedema fat. [ 18 ]  Because the scope is different for removal of lipedema fat versus cosmetic contouring, if lymph-sparing is not addressed in the surgical operative notes, a medical necessity review committee could determine that the procedure poses “a risk to the lymph system.” [ 19 ] [ 20 ] [ 21 ]


This may be referenced either way above, but the technique is the same. [ 22 ]  This is an anesthesia technique recommended for lymph-sparing liposuction surgery. Tumescent Liposuction refers to the use of anesthesia during liposuction. The word “tumescent” means swollen and firm. By injecting a large volume of very dilute lidocaine (local anesthetic) and epinephrine (capillary constrictor) into subcutaneous fat, the targeted tissue becomes swollen and firm, or tumescent. This technique does not require a special or specific type of wand. [ 17 ] [ 18 ]


Referred to as "a vibrating cannula" in research studies, PAL uses a specific type of wand that creates an up and down, vibrating-like motion of the cannula to acquire greater fat removal. When compared to simple suction-assisted liposuction, PAL requires less energy for the surgeon to operate while also resulting in greater fat removal. It is commonly used for difficult, secondary, scarred areas, and when harvesting large volumes of fat for transfers to other areas. [ 23 ] [ 24 ]


Note that techniques can be combined; for instance one could refer to the procedure as "lymph-sparing, tumescent liposuction using a vibrating (PAL) microcannula to treat lipedema." [ citation needed ]


A specific technique and wand commonly used for patients who require lymph-sparing liposuction for lipedema. The lipedema fat is removed using a fan-shaped jet of water, which includes the anesthetic. In contrast to tumescent liposuction above, where the anesthetic solution is injected separately and beforehand, the WAL wand both injects the solution and suctions the fat. BodyJet is a Water-Assisted Liposuction system. [ 25 ]


This rare and unique term for liposuction for lipedema is used in a specific paper by Campisi,  Fibro-Lipo-Lymph-Aspiration With a Lymph Vessel Sparing Procedure to Treat Advanced Lymphedema After Multiple Lymphatic-Venous Anastomoses: The Complete Treatment Protocol . This term emphasizes the uniqueness of the reconstructive procedure versus the cosmetic procedure. Everything about the surgical suction application via cannula is different from standard suction lipectomy. The goal of FLLA is to relieve symptoms such as pain, ameliorate disability, improve function and quality of life, and halt disease progression. [ 26 ]


Only small blunt cannulas are used, great care is used to not injure lymphatic which are already abnormal and increased risk of injury. Only the longitudinal orientation of cannulas is used at critical junctures. Preoperatively critical lymphatic structures are scanned and marked. FLLA surgery is significantly more time-consuming than cosmetic surgery often requiring 4–5 hours per body part; much larger aspirate volume is removed versus cosmetic suction lipectomy.


The benefit to lymphatics function comes not only from the removal of subcutaneous adipose tissue, but also the all components of the loose connective tissue including removing fibrosis in the interstitial space. [ 27 ]


Ultrasound-assisted liposuction techniques used in the 1980s and 1990s were associated with cases of tissue damage, usually from excessive exposure to ultrasound energy. [ 28 ]  Third-generation UAL devices address this problem by using pulsed energy delivery and a specialized probe that allows physicians to safely remove excess fat. [ 29 ]  UAL is beneficial in people with a particular skin tone, in liposuction of areas that are more difficult to remove fat, that include treatment of gynecomastia, or areas where secondary liposuction is being performed. [ 30 ]


Referred to as Smart Lipo, this technique uses laser technology to coagulate and tighten the skin and boost collagen performance. [ 31 ]  Uses include "cankles", debulking surgery for elephantiasis nostras [ 32 ]  and lipedema. [ 33 ]


Sold under the brand name of CoolSculpting, cryolipolyis is not a type of liposuction but rather a non-surgical fat reduction procedure that freezes fat cells; it is an FDA-approved, non-invasive procedure that uses cooling to disrupt fat cells underneath the dermis. [ 34 ]  This freezing energy crystallizes and eventually kills targeted fat cells without harming the surrounding healthy tissue. The body's metabolic processes work to remove the dead fat cells. [ 35 ] [ 36 ]  Coolsculpting is not recommended for those with lipedema, lymphedema or other conditions that affect the lymphatic system. Comparing fat freezing to liposuction, [ 37 ]  which requires immediate removal of larger quantities of fat, needs anesthesia with a higher potential for scarring and subsequent significant recovery period.


The model  Linda Evangelista  reportedly was left unrecognisable after a cryolipolysis procedure. [ 38 ]


Radiofrequency-assisted Liposuction, also known as RFAL, is a new procedure that is being done by thermal energy to promote skin tightening and remove unwanted fat. In this technique, radio waves of specific frequency are used to melt fat. [ 39 ]


Doctors disagree on the issues of scarring with not suturing versus resolution of the swelling allowed by leaving the wounds open to drain fluid. Suturing is more common with a large cannula. [ 24 ]  Since the  incisions  are small, and the amount of fluid that must drain out is large, some surgeons opt to leave the incisions open, while others  suture  them only partially, leaving space for the fluid to drain out. [ 40 ]


Liposuction is considered very safe, though not all liposuction surgery is equal. Small volume liposuction (<1,000 cc) done awake is different from large volume liposuction (>5,000 cc, in some cases 10,000 cc) done with anesthesia and a hospital stay. [ 41 ]


Suction-assisted lipectomy (aka liposuction) were identified [ when? ]  from the Tracking Operations and Outcomes for Plastic Surgeons database maintained by the  American Society of Plastic Surgeons  (ASPS). [ 42 ]  The ASPS maintains a registry of plastic surgery cases called TOPS (Tracking Operations & Outcomes for Plastic Surgeons) which is the largest database of plastic surgery cases. The TOPS database is only voluntary, not available to the public, and does not follow cases long-term or get testimony and experience of patients, only from doctors who profit from doing liposuction. [ 43 ]


Based on this database, no deaths were found in about 4,500 cases done by plastic surgeons 2009–10. However, non-plastic surgeons are not included in this. [ 44 ]


In a 2015 study, 69 of 4,534 patients (1.5 percent) meeting inclusion criteria experienced a postoperative complication. Their conclusion was that: Liposuction by board-certified plastic surgeons is safe, with a low risk of life-threatening complications. Traditional liposuction volume thresholds do not accurately convey individualized risk. The authors' risk assessment model showed that volumes above 100 ml per unit of body mass index confer an increased risk of complications. [ 45 ]  An example is the case of  Aarthi Agarwal , a Bollywood actress who died six weeks after liposuction surgery after going into cardiac arrest. [ 46 ]


A spectrum of complications may occur due to any liposuction. Risk is increased when treated areas cover a greater percentage of the body, incisions are numerous, a large amount of tissue is removed, and concurrent surgeries are done at the same time. To address safety issues, in 2009 the American Society of Plastic Surgeons (ASPS) published  Evidence-Based Patient Safety Advisory: Liposuction . This 17-page document addresses key safety issues and offers recommendations. [ 42 ]
In addition, the increase in tumescent and lymph-sparing techniques have had a positive impact on diminishing complications. [ 47 ]  In a 2009 paper, the author found from a series of 3,240 procedures, no deaths occurred, and no complications requiring hospitalization were experienced. In nine cases, complications developed that needed further action. The conclusion was that liposuction using exclusively Tumescent Local Anesthesia (TLA) is a proven safe procedure provided that the existing guidelines are meticulously followed. [ 48 ] [ 18 ]


Serious complications include  deep vein thrombosis ,  organ perforation , bleeding, and  infection . [ 49 ]  As of 2011, death was reported to occurs in about one per ten thousand cases. [ 50 ]


To obtain liposuction at lower cost or at a shorter wait may encourage  medical tourism . The  Dominican Republic  has been a popular destination for US medical tourists, because it is fairly close. Since 2003, the  CDC  has reported adverse events after  cosmetic surgery , particularly due to liposuction in combination with gluteal fat transfer,  abdominoplasty , and  breast augmentation . During 2009–2022, 93 U.S. citizens died after cosmetic surgery in the Dominican Republic, and 90% of autopsy-confirmed deaths were due to  embolism ; in 55% due to  fat embolism  and in 35% due to  pulmonary venous thromboembolism . [ 51 ]


Relatively modern techniques for body contouring and removal of fat were first performed by a French surgeon, Charles Dujarier, but a 1926 case that resulted in the amputation of the leg of a French dancer due to excessive tissue removal and too-tight suturing set back interest in body contouring for decades. [ 54 ] [ 55 ]


Liposuction evolved from work in the late 1960s from surgeons in Europe using techniques to cut away fat, which were limited to regions without many blood vessels due to the amount of bleeding the technique caused. [ 54 ]


In the mid-1970s in Rome, Arpad Fischer and his son Giorgio Fischer created the technique of using a blunt  cannula  linked to suction; they used it only to remove fat on the outer thighs. [ 56 ]  In 1977, Arpad Fischer and Giorgio Fischer reviewed 245 cases with the planotome [ clarification needed ]  instrument for treating  cellulite  in the lateral  trochanteric  (hip-thigh) areas. There was a 4.9 per cent incidence of  seromas , despite incision-wound suction  catheters  and compression dressings; 2 per cent of the cases developed  pseudocysts  that required removal of the capsule ( cyst ) through a wider incision (>5 mm (0.20 in)) and the use of the panotome. [ 57 ] [ 58 ]  The Fischers called their procedure liposculpture. [ 59 ]


Yves-Gérard Illouz  and Fournier extended the Fischers' work to the whole body, which they were able to use by using different sized cannulae. [ 54 ]  Illouz later developed the "wet" technique in which the fat tissue was injected with saline and  hyaluronidase , which helped dissolve tissue holding the fat, prior to suctioning. [ 54 ]   Lidocaine  was also added as a local anesthetic. [ 54 ]  Fournier also advocated using compression after the operation, and travelled and lectured to spread the technique. [ 54 ]  The Europeans had performed the procedures under general anesthesia; in the 1980s, American dermatologists pioneered techniques allowing only local anesthetics to be used;  Jeffrey A. Klein  published a method that became known as "tumescent" in which a large volume of very dilute lidocaine, along with  epinephrine  to help control bleeding via  vasoconstriction , and  sodium bicarbonate  as a  buffering agent . [ 54 ]


In 2015, liposuction surpassed  breast augmentation surgery  as the most commonly performed cosmetic procedure in the US. [ 60 ]


Lipotuck  is a procedure trademarked in 2006, by Dr.  A. H. Ahmadi . The procedure is a single cosmetic surgery combining  abdominoplasty  (a.k.a. a " tummy tuck ") and  liposuction .


Some abdominoplastic procedures, while removing flesh from the abdomen, do nothing to correct for shaping around hips, thighs, and " love handles ." Alternatively, the desired look can be achieved through multiple procedures: tummy tuck first, liposuction after. [ 1 ]  Lipotuck adds to a more traditional "tummy tuck" procedure with significant liposuction to the abdomen, hips, and thighs. This procedure is engineered to create flattering curves according to traditional notions of female beauty. [ 2 ]  Lipotuck also includes a repositioning of the patient's belly button, as the excess skin removed generally includes the original one. [ citation needed ]


One plastic surgeon in Australia describes Lipotuck as a procedure that "tends to be safer" because it uses  tumescent liposuction , a procedures that "numbs and softens the fat," which "avoid[s] bleeding." [ 3 ]  Lipotuck is also more routine, and can be done as an  outpatient procedure . [ 3 ]  Lipotucks can have the risk of  seroma , which happens when some fluid collects in the surgical area that requires a small incision to drain afterwards. [ 3 ]


The  American Society of Plastic Surgeons  does not currently recognize the term "Lipotuck" as an FDA-approved brand name for specific plastic surgery treatments. [ 4 ]  However, the term was successfully trademarked in 2006 by A. H. Ahmadi, a cosmetic surgeon in  Sugar Land, Texas . [ 5 ]


The Lipotuck procedure is commonly used by plastic surgeons around the world; many procedures now use a combination of abdominoplasty, liposuction, and buttock contouring. [ 6 ] [ 7 ]  Practitioners have also begun to offer "mommy makeovers," which generally include a combination of liposuction and abdominoplasty among other enhancements, most commonly  breast augmentation . [ 8 ]  These have been called the "mommy makeover trifecta." [ 8 ]


Marionette lines  (melomental folds) are long vertical lines that laterally circumscribe the  chin . [ 1 ]  They are important landmarks for the general impression of the face. Marionette lines appear with advancing age, but some people never get them, depending on facial structure and anatomy. They tend to appear as the  ligaments  around the mouth and chin relax and begin to loosen and sag, and fatty tissues of the cheek deflate and descend during the aging process. It can be difficult to get rid of them, but they can be minimized with facelifts that lift  cheek  tissue away from the area of the mouth combined with synthetic facial fillers, or with facial fillers alone. [ 2 ]


MyFreeImplants  is the largest website used by women to find donations, particularly from men, via  crowdfunding  for  breast augmentation . [ 1 ] [ 2 ]


The women frequently converse with their donors. [ 3 ]


The site has been criticized by professional organizations including the  British Association of Aesthetic Plastic Surgeons  (BAAPS) for tasteless marketing and trivializing a significant surgical procedure. [ 4 ]


It has also been criticized for providing a platform for men to ask for sexual favors. [ 5 ]


Nasal reconstruction using a paramedian forehead flap  within  oral and maxillofacial surgery , is a  surgical  technique to reconstruct different kinds of nasal defects. [ 1 ]  In this operation a reconstructive surgeon uses skin from the forehead above the eyebrow and pivots it vertically to replace missing nasal tissue. Throughout history the technique has been modified and adjusted by many different surgeons and it has evolved to become a popular way of repairing nasal defects.


The tint of forehead skin so exactly matches that of the face and nose that it must be first choice. Is not the forehead the crowning feature of the face and important in expression? Why then should we jeopardize its beauty to make a nose? First, because in many instances, the forehead makes far and away the best nose. Second, with some plastic juggling, the forehead defect can be camouflaged effectively.


Probably the first  nasal reconstructions  using a forehead flap were performed by  Sushruta  in India during 600 to 700 BC. [ 3 ]  The method was introduced in Europe in the 15th century. The first English description of the Indian midline forehead  rhinoplasty  was published in the Madras Gazette in 1793  [ 3 ]  and later Carpue, an English surgeon, published his experience with two successful median forehead flaps in 1816. The classic median forehead flap supplied by paired supratrochlear vessels was popularized in the United States by Kazanjian in 1947, however, this flap was not optimal because it was not long enough. To solve the problem of the short median forehead flap, its design was modified so that central forehead tissue could be transferred on a unilateral paramedian blood supply. [ 3 ]


A forehead flap is usually required if the nasal defect is larger than 1.5 cm, requires replacement of support or lining, or if it is located within the infratip or columella. [ 4 ]  If the defect is small and superficial it can be resurfaced with a skin graft or it can heal by  secondary intention . [ 4 ]  Limited alar defects can be resurfaced using a nasolabial flap, however, the amount of tissue available from the nasolabial area is limited and the flap is thicker, less vascular, and hair bearing in males. [ 4 ]


Nasal defects mostly result from excision of (malignant) skin tumours as basal cell carcinoma, squamous cell carcinoma, malignant melanoma, keratoacanthoma, lentigo maligna, lymphoma, and sweat gland carcinoma. [ 5 ]  Other acquired nasal defects are usually caused by trauma, burns or sepsis.


The forehead flap is known as the best donor site for repairing nasal defects because of its size, superior vascularity, skin color, texture and thickness. [ 1 ] [ 3 ] [ 4 ]  Especially the color and texture of the forehead skin matches exactly with the skin of the nose. This is why the forehead flap is used so much for nasal reconstruction.


Vascularisation of the scalp and forehead is supplied by the supraorbital,  supratrochlear , superficial temporal, postauricular and occipital vessels. [ 1 ] [ 4 ] [ 6 ]  All these vessels are lined vertically and permit safe and effective transfer of the forehead flap on multiple individual vascular pedicles. [ 1 ] [ 6 ]  The pedicle is the anatomic part that resembles the stem of the flap. The perfusion of the paramedian forehead flap comes from three sources: randomly, through the frontalis muscle and through the supratrochlear artery. [ 1 ]  Because the forehead flap is an axial flap with a pedicle containing its dominant vessel, the pedicle can safely be narrowed to 1 to 1.2 cm. [ 1 ]


Four types of flap design are historically described in literature: the median forehead flap, oblique forehead flap, sickle flap and vertical paramedian forehead flap. [ 4 ]  However, the vertical paramedian forehead flap based on the ipsilateral or contralateral supratrochlear vessels has become standard, because it has a low turning point, making it easy to reach the defect without using hair-bearing scalp. [ 1 ] [ 4 ]  Also,  primary closing  of the proximal forehead is possible as a result of the narrow pedicle. [ 4 ]


Lateral nasal defects are usually closed with an ipsilateral paramedian forehead flap. Central nasal defects can be reconstructed using either a right- or left-sided forehead flap. The ipsilateral pedicle is closer to the defect than the contralateral pedicle, therefore the flap can be made shorter when using the ipsilateral side. [ 1 ] [ 4 ]  Some experts suggest that a contralateral flap is easier to rotate, but this difference is minimal. [ 1 ]  The only problem with the contralateral flap is the extra length needed, not the difficulty of the technique.


Most foreheads are at least 5 cm long, when measured from eyebrow to hairline. [ 1 ]  This is usually enough to resurface the entire nose using a vertical paramedian forehead flap design. [ 1 ] [ 3 ]  Still, there are some short foreheads. A forehead is called short when it is shorter than 4.5 cm. When using the forehead flap on a short forehead, there are multiple ways to get the length that is needed. [ 1 ] [ 3 ]  First, the turning point of the flap can be moved down, so that the base of the flap is closer to the nasal defect and a shorter flap can be used to reach the nasal defect. [ 1 ]  Second, the distal end of the flap can be placed within the hairline. [ 1 ]  The reconstructed nose will then have some hair on it, but it can be plucked, depilated or lasered.


Aesthetic regions are used to describe the normal features of the face. These regions (forehead, cheeks, eyelids, lips, nose and chin) are defined by skin quality, border outline, and three-dimensional contour. [ 4 ]  The nose has nine aesthetic subunits, which are most important for reconstruction of the nose. These subunits are: the tip, dorsum, alae, sidewalls, columella, and soft triangles. For an optimal aesthetic result, scars should be positioned between nasal subunits. If enlarging the defect will make the aesthetic result better, normal tissue within the subunit can be safely removed. [ 3 ]


For reconstructing any nasal defect, the contralateral side should be used as a guide. Templates of the defect should be made based on the healthy contralateral side. This is important for defining dimension, outline, and landmark position. [ 4 ]  If more than 50% of a convex nasal subunit (tip, ala nasi) is missing, resurfacing the entire nasal subunit is better than only resurfacing the defect. [ 3 ]  Ideally, nasal reconstruction is performed on a stable platform. Support and shaping by soft tissue sculpting should be accomplished before pedicle division. [ 4 ]  Concha, septum or rib  cartilage  grafts should be used for creating enough support and a good shape.


A second repair can sometimes be required; causes are recurrence of cancer, new cancer or new trauma. A second flap can be harvested from the contralateral forehead after a prior vertical flap. [ 1 ]  If an oblique or angled flap was used during the first surgery, the second repair becomes more difficult. On one side the pedicle is destroyed and on the other side the forehead is scarred. [ 1 ]  This is another reason to use the unilateral paramedian forehead flap design.


The donor defect after using a paramedian forehead flap is limited to the central-lateral forehead. The defect is closed as much as possible using a T-shaped scar. [ 1 ]  The adjoining tissues are pulled together vertically and horizontally. Often there is a persisting defect depending on the size of the flap. Any possible resultant defect is high in the forehead and left to heal by secondary intention. [ 1 ]  Eyebrow malformation can occur, but is usually avoided if this method is used correctly.


The two most used forehead flap techniques are the two stage and three stage forehead flap. [ 1 ] [ 3 ] [ 4 ]  The forehead consists of multiple layers; skin, subcutaneous tissue, frontalis muscle with fascia and a thin areolar layer. [ 1 ] [ 4 ]  Traditionally, the forehead flap is transferred in two stages, where the flap is thinned during the first stage to improve the aesthetic result, possibly jeopardizing its vascularity and increasing chance for flap necrosis. To overcome this problem, Menick [ 1 ] [ 3 ] [ 4 ]  described a three-stage forehead flap technique, [ 1 ]  where initially the flap is transferred containing all tissue layers, making it an extremely safe technique. Only during the second stage, the flap - which now acts as a delayed flap - can safely be thinned aggressively according to aesthetic needs. [ 1 ] [ 3 ] [ 4 ]  During the final stage the pedicle is severed, the flap is thinned further and pedicle and flap are trimmed and inset. This three stage flap is especially useful for reconstructing large defects, complex contour deformations, or lining defects, while the two stage flap is used for smaller and superficial defects. [ 1 ] [ 4 ]


Before surgery all important landmarks and reference points must be identified and marked. Important landmarks are the hairline, frown lines, location of the supratrochlear vessels, outline of the defect, nasal and lip subunits. [ 1 ]  Then templates are made using the intact side of the nose to make a precise symmetric reconstruction of the nose. The template resembling the defect is placed just under the hairline and the vascular pedicle is drawn downwards into the medial eyebrow. The pedicle is based on the supratrochlear vessels and can be 1.2 cm wide. [ 1 ]  This way the flap design has been made.


The flap is incised and elevated from distal to proximal. [ 1 ] [ 3 ]  Distally, the frontalis muscle and subcutaneous tissue are excised, this is done for 1.5 to 2 cm. [ 1 ] [ 3 ]  Then more downwards the disscection goes through the muscle and over the  periosteum . [ 1 ]  When reaching the brow, all of the skin borders are incised and the flap is carefully released. [ 1 ]  As soon as the flap reaches the defect without tension further incision of the flap is stopped and the flap is inset into the area of the defect. [ 1 ] [ 3 ] [ 4 ]  This is done using a single layer of fine suture. [ 1 ]


The second stage is three to four weeks later, when the flap is well healed at the recipient site. [ 1 ]  At this stage the pedicle is divided, the inferior forehead is reopened and the proximal pedicle replaces the medial brow by an inverted V. The nose side of the pedicle is elevated superiorly with 2 mm of subcutaneous fat. [ 1 ]  If needed the recipient site can be altered to reach a better aesthetic result. The scar is eventually sculpted between the nasal subregions to create a satisfying aesthetic result. [ 1 ] [ 4 ]


The flap is incised and elevated over the periosteum from distal to proximal. [ 1 ]  The flap consists of skin, subcutaneous tissue, fat and frontalis muscle and is not thinned. When reaching the brow, all of the skin borders are incised and the flap is carefully released. [ 1 ]  The full-thickness flap is then sutured into the defect without tension.


Three to four weeks later, when the full thickness forehead flap is well healed at the recipient site, the second stage begins. The skin of the flap and 3–4 mm of subcutaneous fat is elevated. [ 1 ] [ 3 ]  The underlying excess of soft tissue is then excised and the remaining healed tissue is sculpted in an ideal nasal subunit. The flap is then resutured to the recipient site.


This stage is completely identical to the second stage of the two stage forehead flap.


For an optimal aesthetic result a difficult nose reconstruction is often followed by revision surgery. [ 4 ]  There are different types of revisions: minor revisions, major revisions and reoperations. [ 4 ]  Revisions are done not sooner than eight months after completion of the primary forehead flap technique.


The goal of nasal reconstruction is to look as normal as possible after reconstruction. [ 7 ]  The results of nasal reconstruction using the paramedian forehead flap are quite good, although some patients report functional difficulties. Airway passage difficulties, mucosal crusts, dry mucosa, and difficulties with smelling are uncommon. [ 5 ]  A minority of the patients reported snoring more often or having a spontaneous nose bleed more often. [ 5 ]  Difficulties with phonation are not likely to occur. The majority of patients are satisfied with function of the nose after reconstruction. [ 5 ]


Ideally, standardized semistructered interviews are used to assess aesthetic outcome after nasal reconstruction. Studies using these interviews showed that generally patients are very satisfied with the result although they reported aggravating of their nasal appearance compared to before surgery. [ 5 ]  Patients were especially satisfied with flap color match and shape of the nasal tip. [ 5 ]  Remarkably, patients scored subjective aesthetic outcome significantly higher compared to a professional panel. [ 8 ]


In comparison to the two stage flap, the three stage flap technique has shown better results, lower revision rates and more possibilities for use of skin grafts for lining. [ 4 ]  Most likely this is because of the reliable vascularisation of the three stage flap.


Because of the flap's rich perfusion, flap necrosis is unlikely to occur. If it happens the result of severe  ischemia  is normally caused by excessive tension on the flap, a misidentification of past injury, nearby scar formation, fanatic inset to the recipient site or exaggerated flap thinning. [ 4 ]  To solve the problem, to keep the underlying cartilage from infecting and to stop the situation from getting worse, it is better to excise dead tissue at an early stage than to wait watchfully allowing the injury to heal secondarily  [ 4 ]


It is unlikely for the operation area to get infected. In this situation failure in aseptic techniques or necrosis of the lining are the main causes. Early discovery of infection is very important so complete  debridement  can take place before underlying cartilage is exposed. Chronically infected cartilage is cured by reelevating the flap and excising the infected parts. [ 4 ]


In some patients a new tumor develops in the skin injured by the sun or an old cancer can redevelop. In a few cases the result of the first reconstruction was not good enough. When this takes place the next step is to take away the old flap and redo the reconstruction. A second flap can be taken from the contra lateral side in most instances  [ 1 ]


The defect created at the donor site is usually positioned at the central/lateral forehead. The defect can be closed by pulling the different sides of the wound together in vertical and horizontal direction. [ 1 ]  If there is a resulting defect after closure it is situated high in the forehead and it closes by secondary healing. In spite of the fact that, as a result, the eyebrow could be distorted, this is usually avoided. [ 1 ]  As a result of a large initial defect, the flap has to be larger and the bigger the forehead defect will be. When there is a large resultant forehead defect it logically lies closer to the eyebrow. That is why there is a significant risk of superior eyebrow malposition, especially if a horizontal or oblique oriented forehead flap is used. [ 1 ]  Then the solution is to close the remaining defect with a skin graft. However a skin graft is esthetically inferior and will always look like a shiny, irregularly pigmented, mismatched piece of skin. Alternatively, secondary placement of a  tissue expander  in the forehead can be used to correct the eyebrow malposition and to excise the skin graft and primarily close the forehead defect.


Negative-pressure wound therapy  ( NPWT ), also known as a  vacuum assisted closure  ( VAC ), is a  therapeutic  technique using a  suction  pump, tubing, and a  dressing  to remove excess  exudate  and promote healing in acute or  chronic wounds  and  second- and third-degree burns . The therapy involves the controlled application of sub-atmospheric pressure to the local wound environment using a sealed wound dressing connected to a vacuum pump. [ 1 ] [ 2 ] [ 3 ]  The use of this technique in wound management started in the 1990s and this technique is often recommended for treatment of a range of wounds including  dehisced  surgical wounds, closed surgical wounds, open abdominal wounds,  open fractures , pressure injuries or  pressure ulcers ,  diabetic foot ulcers ,  venous insufficiency ulcers , some types of  skin grafts , burns, sternal wounds. It may also be considered after a clean surgery in a person who is obese. [ 1 ] [ 4 ] [ 5 ]


NPWT is performed by applying a  vacuum  through a special sealed dressing. The continued vacuum draws out  fluid  from the wound and increases blood flow to the area. [ 1 ]  The vacuum may be applied continuously or intermittently, depending on the type of wound being treated and the clinical objectives. Typically, the dressing is changed two to three times per week. [ 3 ]  The dressings used for the technique include foam dressings and gauze, sealed with an  occlusive dressing  intended to contain the vacuum at the wound site. [ 1 ]  Where NPWT devices allow delivery of fluids, such as saline or  antibiotics  to irrigate the wound, intermittent removal of used fluid supports the cleaning and drainage of the wound bed. [ 6 ]


In 1995,  Kinetic Concepts  was the first company to have a NPWT product cleared by the US  Food and Drug Administration . [ 7 ]  Following increased use of the technique by hospitals in the US, the procedure was approved for reimbursement by the  Centers for Medicare and Medicaid Services  in 2001. [ 8 ]


General technique for NPWT is as follows: A  dressing  or filler material is fitted to the contours of a wound to protect the  periwound  and the overlying foam or gauze is then sealed with a transparent film. [ 9 ]  A drainage tube is then connected to the dressing through an opening of the transparent film. Tubing is connected through an opening in the film drape to a canister on the side of a  vacuum pump . [ 10 ]  This turns an open wound into a controlled, closed wound with an airtight seal while removing excess fluid from the wound bed to enhance circulation and remove wound fluids. [ 11 ]  This creates a moist healing environment and reduces  edema . [ 9 ] [ 10 ]


There are four types of dressings used over the wound surface:  foam  or  gauze , a transparent film, and a non-adherent (woven or non-woven) contact layer if necessary. Foam dressings or woven gauze are used to fill open cavity wounds. Foam can be cut to size to fit wounds. Once the wound is filled, then a transparent film is applied over the top to create a seal around the dressing. The tubing is then attached and connected to the pump.


Once the dressing is sealed, the vacuum pump can be set to deliver continuous or intermittent pressures, with levels of pressure depending on the device used, [ 10 ] [ 12 ] [ 13 ]  varying between −200 and −40  mmHg  depending on the material used and patient tolerance. [ 14 ]  Pressure can be applied constantly or intermittently. [ 10 ]


The dressing type used depends on the type of wound, clinical objectives and patient. For pain sensitive patients with shallow or irregular wounds, wounds with undermining or explored tracts or tunnels, gauze may be used, while foam may be cut easily to fit a patient's wound that has a regular contour and perform better when aggressive granulation formation and wound contraction is the desired goal. [ 15 ]


Contraindications  for NPWT use include: [ 16 ]


Negative pressure wound therapy is usually used with  chronic wounds  or wounds that are expected to present difficulties while healing (such as those associated with  diabetes ). [ 3 ]  Negative pressure wound therapy is approved by the  FDA  and numerous randomized controlled trials have been conducted on this technique, however, the evidence supporting how effective NPWT is compared to standard wound care dressings is not clear. [ 1 ]  Low-level evidence indicates that there may be a lower risk of death and less surgical site infections associated with NPWT compared to standard dressing care, however there may not be a difference in the risk of wound reopening when comparing the two approaches. [ 1 ]  NPWT may increase the risk of skin blistering compared to standard wound care. [ 1 ]  NPWT may be a more cost effective approach for closing wounds following a caesarean section in women who are obese, however, NPWT is not likely as cost effective for closing wounds associated with fracture surgeries. It is not clear if NPWT is cost effective for closing wounds associated with other types of surgery. [ 1 ]  NPWT has been used to treat non-trauma patients after abdominal surgery. [ 18 ]  Non-trauma patients are people who might need surgery for conditions such as abdominal infections or cancer. However, it is still not clear how safe and effective NPWT is for treating non-trauma patients with open abdomens. [ 18 ]


For treating diabetic ulcers of the feet, "consistent evidence of the benefit of NPWT" in the treatment of  diabetic ulcers  of the feet has been reported. [ 19 ]  Results for  bedsores  were conflicting and research on mixed wounds was of poor quality, but promising. [ 19 ]  There is no evidence of increased  significant complications . [ 19 ]  The review concluded "There is now sufficient evidence to show that NPWT is safe, and will accelerate healing, to justify its use in the treatment of diabetes-associated chronic leg wounds. There is also evidence, though of poor quality, to suggest that healing of other wounds may also be accelerated." [ 19 ]


The use of NPWT to enhance wound healing is thought to be by removing excess extracellular fluid and decreasing tissue edema, which leads to increased blood flow and stabilization of the wound environment. [ citation needed ]  A reduction in systemic (e.g. interleukins, monocytes) and local mediators of inflammation has been demonstrated in experimental models, while decreased matrix metalloproteinase activity and bacterial burden have been documented clinically. [ citation needed ]   In vivo , NPWT has been shown to increase fibroblast proliferation and migration, collagen organization, and to increase the expression of vascular endothelial growth factor and fibroblast growth factor-2, thereby enhancing wound healing. [ 20 ]


Otoplasty  ( Greek :  οὖς ,  oûs , "ear" +  πλάσσειν ,  plássein , "to shape") is a procedure for correcting the deformities and defects of the  auricle  ( external ear ), whether these defects are  congenital  conditions (e.g.  microtia ,  anotia , etc.) or caused by  trauma . [ 1 ]  Otoplastic surgeons may reshape, move, or augment the  cartilaginous  support framework of the auricle to correct these defects.


Congenital ear deformities occasionally overlap with other medical conditions (e.g.  Treacher Collins syndrome  and  hemifacial microsomia ).


Otoplasty  (surgery of the ear) was developed in  ancient India  and is described in the medical compendium, the  Sushruta Samhita  (Sushruta's Compendium,  c.  500 AD ). The book discussed otoplastic and other  plastic surgery  techniques and procedures for correcting, repairing and reconstructing ears,  noses , lips, and genitalia that were amputated as criminal, religious, and military punishments. The ancient Indian  medical  knowledge and plastic surgery techniques of the  Sushruta Samhita  were practiced throughout Asia until the late 18th century; the October 1794 issue of the contemporary British  Gentleman's Magazine  reported the practice of  rhinoplasty , as described in the  Sushruta Samhita . Moreover, two centuries later, contemporary practices of otoplastic praxis were derived from the techniques and procedures developed and established in antiquity by Sushruta. [ 2 ] [ 3 ]


In  Die operative Chirurgie  ( Operational Surgery , 1845),  Johann Friedrich Dieffenbach  (1794–1847) reported the first surgical approach for the correction of prominent ears — a combination otoplasty procedure that featured the simple excision (cutting) of the problematic excess  cartilage  from the posterior sulcus (back groove) of the ear, and the subsequent affixing, with sutures, of the corrected auricle to the  mastoid   periosteum , the membrane covering the mastoid process at the underside of the mastoid portion of the  temporal bone , at the back of the head. [ 4 ] [ 5 ]


In 1920,  Harold D. Gillies  (1882–1960) first reproduced the auricle by burying an external-ear support framework, made of autologous rib cartilage, under the skin of the mastoid region of the head, which reconstructed the auricle; he then separated this from the skin of the mastoid area by means of a cervical flap. In 1937, Dr. Gillies also attempted a similar pediatric ear reconstruction with an auricle support framework fabricated from maternal cartilage. This otoplasty correction technique proved inadequate, due to the problems inherent to the biochemical breakdown and elimination (resorption) of the cartilage tissue by the patient's body. [ citation needed ]


In 1964, Radford C. Tanzer (1921–2004) re-emphasized the use of autologous cartilage as the most advantageously reliable organic material for resolving  microtia  (abnormally small ears), because of its great  histologic  viability, resistance to shrinkage, and resistance to softening, and lower incidence of resorption.


The development of plastic surgery procedures, such as the refinement of J.F. Dieffenbach's ear surgery techniques, has established more than 170 otoplasty procedures for correcting prominent ears, and for correcting  defects  and  deformities  of the auricle; as such, otoplasty corrections are in three surgical-technique groups:


The external ear (auricle) is a surgically challenging area in terms of anatomy, composed of a delicate and complex framework of shaped cartilage that is covered, on its visible surface, with thin, tightly adherent, hairless  skin . Although of small area, the surface anatomy of the external ear is complex, consisting of the auricle and the external auditory meatus (auditory canal). The outer framework of the auricle is composed of the rim of the helix, which arises from the front and from below (anteriorly and inferiorly), from a crus (shank) that extends horizontally above the auditory canal. The helix merges downwards (inferiorly) into the cauda helices (tail of the helix), and connects to the lobule (earlobe). The region located between the crura (shanks) of the antihelix is the triangular fossa (depression), while the scapha (elongated depression) lies between the helix and antihelix. The antihelix borders in the middle (medially) to the rim of the concha (shell) and the concha proper, which is composed of the conchal cymba above (superiorly) and the conchal cavum below (inferiorly), which are separated by the helical crus, and meet the antihelix at the antihelical rim. The tragus (auditory canal lobule) and the antitragus (counterpart lobule) are separated by the intertragal notch; the auditory canal lobule does not contain cartilage, and displays varied morphologic shapes and attachments to the adjacent cheek and scalp.


The superficial temporal and  posterior auricular arteries  preserve the  arterial blood  supply of the external ear. The sensory innervation involves the front and back (anterior and posterior) branches of the  greater auricular nerve , and is reinforced by the auricular temporal and lesser occipital nerves. The auricular branch of the  vagus nerves  supplies a portion of the posterior wall of the external auditory canal. [ 15 ]


The support framework of the reconstructed auricle must be more rigid than the natural cartilage framework of a normal ear, in order for it to remain of natural size, proportion, and contour. If the reconstructed auricle framework were as structurally delicate as the cartilage framework of a natural auricle, its anatomic verisimilitude as an ear would gradually be eroded by a combination of the pressure of the tight skin-envelope in the temporal region of the head, and of the pressure of the progressive contracture of the surgical scar(s). [ 16 ]


In the practice of otoplasty, the term "prominent ears" describes external ears (auricles) that, regardless of their size, protrude from the sides of the head. The abnormal appearance exceeds the normal head-to-ear measures, wherein the external ear is less than 2 cm (0.79 in), and at an angle of less than 25 degrees, from the side of the head. Ear configurations, of distance and angle, that exceed the normal measures, appear prominent when the man or the woman is viewed from either the front or the back perspective. In the occurrence of prominent ears, the common causes of anatomic defect,  deformity , and abnormality can occur individually or in combination; they are:


Although most prominent ears are anatomically normal,  morphologic  defects, deformities, and abnormalities do occur, such as the:


The degrees of angle between the head and the ear, and the degrees of angle between the scapha and the concha, determine the concept of prominent ears. The study,  Comparing Cephaloauricular and Scaphaconchal Angles in Prominent Ear Patients and Control Subjects  (2008) reported that the comparisons of the head-to-ear angles and the scapaha-to-concha angles of a 15-patient cohort with prominent ears, with the analogous ear angles of a 15-person control group, established that the average head-to-ear angle was 47.7 degrees for the study group, and 31.1 degrees for the control group; and that the average scapha-to-concha angle was 132.6 degrees for the study cohort, and 106.7 degrees for the control group. [ 18 ]


The antihelix normally forms a symmetric Y-shaped structure in which the gently rolled (folded) crest of the root of the antihelix continues upwards as the superior crus, and the inferior crus branches forwards, from the root, as a folded ridge. The root of the inferior crus of the antihelix sharply defines the rim of the concha. Moreover, the inferior crus also forms the wall that separates the concha from the triangular fossa. The root and superior crus of the antihelix form the anterior wall of the scaphoid fossa, and the helix forms the posterior wall. The triangular fossa dips within the Y-arms of the superior and inferior crura. The corrugated contours of these auricular crests and valleys provide a pillar effect (support) that stabilizes the auricle. The vertical walls of the conchal cup translate to a semi-horizontal plane as the concha merges with the folded crest of the antihelix. The scapha–helix is nearly parallel to the plane of the temporal surface of the head. If the roll of the antihelix and its crest are effaced and flat, rather than rolled or folded, the steep pitch of the conchal wall continues into the un-formed antihelix and scapha and ends at the helix, with little interruption. Said planar orientation places the scapha–helix complex nearly perpendicular to the temporal plane of the head — because of which the ear appears prominent, thus, such an ear also lacks the stability provided by the pillar effect, and so allows the superior auricular pole to protrude. In the literature, effacement (deficiency) of the antihelical fold is the foremost subject of most discussions of the prominent ear, because it is an aurical deformity manifested as a spectrum of defects and deformities — ranging from an indistinguishable antihelix (with a confluent concavity, from antihelix to scapha and the helical rim projected outwards and forwards) to loss of definition solely of the superior antihelix (with prominence of the upper pole of the ear).


The concha of the ear is an irregular hemispheric bowl with a defined rim. The normal scapha–helix surrounds the posterior part of the bowl (much as the brim of an inverted hat surrounds the crown). The pitch at which the scapha–helix projects from the conchal cup is determined:


If the posterior wall of the concha is excessively high, and the concha is excessively spherical, then there is an excessive angle and distance between the plane of the scapha–helix and the plane of the temporal surface of the head. Such protrusion usually is evenly distributed around the posterior conchal wall, however, the cephalad part of the concha can protrude disproportionately, another cause for a protruding upper pole. Similarly, the caudal part of the concha can project disproportionately, and cause a protruding lower auricular pole, therefore, these deformational features require special attention in the operating room.


Moreover, regarding the shape and projection of the ear, the importance of the concha must be considered in relation to the three-tiered configuration of the auricular cartilage framework, because the more delicate antihelix and helical complex are mounted upon the sturdier concha; therefore, changes in conchal size and shape greatly influence the overlying tiers, hence it is rare to see prominence of the ear that does not have a conchal element. The concha affects the prominence of the ear three-fold ways:


Understanding the first deformational element is well recognized, and, despite limited attention to the second element, once seen, it is easily understood. Therefore, understanding the third element leads to understanding the surgical-technical approach to correcting the isolated lower-pole and lobule prominence. The latter feature of conchal shape, while not the sole cause of lobular prominence, appears to play a key role. As the cartilage angle, between the concha cavum and the antitragus, becomes more acute (i.e. as the antitragus tips closer towards the concha), this supporting structure outwardly projects the lobule and the lower-third of the ear. This feature has a greater influence upon the lobule position than does the commonly described helical tail.


The combined effects of an effaced antihelix and a deep concha also contribute to severe auricular protrusion (a very prominent ear).


The occurrence of a prominent  mastoid process  tends to push the concha forward, which extends the auricle (external ear) away from the side of the head. The external ear is mounted upon the bony base of the underlying temporal bone, therefore, anomalies and asymmetries of the skeletal shape can cause either auricle, or both auricles, to become prominent. In relation to the protruding mastoid process, the most recognizable skeletal anomaly is the change in the position and in the projection of the auricle, as associated with non-synostotic  plagiocephaly  (the positional flattening of the side of the head, not caused by the inappropriate union of two bones). Hence, in the occurrence of a flattening of the skull (parallelogram deformation of the cranial vault), the side of the head afflicted with occipital plagiocephaly presents a prominent ear. In subtle cases, the prominent ear might be more readily evident in an elder patient, whose ears are asymmetrically positioned, reason for which the residual occipital flattening (occipital plagiocephaly), and mild facial asymmetry, are unapparent at first view. This effect, of the shape of the patient's head, upon the outward and extended position of the ear is notably indicated in the 1881 illustrations that describe the Ely otoplasty technique.


The undersized development of one side of a person's face, demonstrates the influence of skeletal development upon the position of the external ear on the head, as caused by the deficient morphologic development of the  temporal bone , and by the medial positioning of the  temporomandibular joint , the synovial joint between the  temporal bone  and the  mandible  (upper jaw). Moreover, in severe cases of hemifacial microsomia, without the occurrence of microtia (small ears), the normal external ear might appear to have been sheared off the head, because the upper half of the auricle is projecting outwards, and, at the middle point, the lower half of the auricle is canted inwards, towards the  hypoplastic , underdeveloped side of the face of the patient. A similar type of asymmetric development of the head and face features a relatively broad head, a narrow face, and a narrow  mandible ; when observed from the front perspective, the head and face of the person present a triangular configuration. Such wide-to-narrow skeletal sloping, from the head to the face, might create the bone promontory upon which rests and from which projects the upper anatomy of the auricle, which otherwise is an external ear of normal proportions, size, and contour.


The  cauda helicis  (tail of the helix) is bound to the fibrofatty tissues of the earlobe by a network of  connective tissue . The tail of the helix (cauda helicis), which projects outwards from the concha, carries the earlobe with it, causing it to protrude, which physical condition contributes to prominence of the lower pole of the auricle.


Given the  morphological  diversity of the earlobes found among men, women, and children, some earlobes are large, some earlobes are pendulous, and some earlobes are large and pendulous, but some are prominent because of the structure and form of the dense, interlacing connective tissue fibers that shape the earlobe anatomy independent of the tail of the helix (cauda helicis).


Functionally, the external ear is served by three ear muscles, the auricularis posterior muscle (rear ear-muscle), the auricularis superior muscle (upper ear-muscle), and the auricularis anterior muscle (front ear-muscle), the most notable of which is the  auricularis posterior muscle , which functions to pull the ear backwards, because it is superficially attached to the  ponticulus  (bridge) of the conchal cartilage, and to the posterior auricular ligament (rear ligament of the ear). The posterior muscle of the ear is composed of two to three  fascicles  (skeletal-muscle fibers contained in perimysium connective tissue), originates from the  mastoid process  of the  temporal bone  and is inserted to the lower part of the cranial surface of the concha, where it is surrounded by fibroareolar tissue deep within the temporal fascia. The  posterior auricular artery  irrigates the ear tissues with small, branch-artery blood vessels (rami). Likewise, the rear muscle of the ear is innervated with fine rami of the  posterior auricular nerve , which is a branch of the  facial nerve . Deep within these muscle and ligament structures lie the mastoid fascia and the tendinous origin of the  sternomastoid muscle . [ 19 ]


The corrective goal of otoplasty is to set back the ears so that they appear naturally proportionate and contoured without evidence or indication of surgical correction. Therefore, when the corrected ears are viewed, they should appear normal, from the:


The severity of the ear deformity that is to be corrected determines the advantageous timing of an otoplasty; for example, in children with extremely prominent ears, 4 years old is a reasonable age. In cases of  macrotia  associated with prominent ears, the child's age might be 2 years. Nonetheless, it is advantageous to restrict the further growth of the deformed ear. Regardless of the patient's age, the otoplasty procedure requires that the patient be under  general anaesthesia . [ 17 ]


Generally, for reconstructing an entire ear, or a portion of the rim cartilage, the surgeon first harvests a  costal cartilage  graft from the patient's rib cage, which then is sculpted into an auricular framework that is emplaced under the temporal skin of the patient's head, so that the skin envelope encompass the cartilage framework, the ear prosthesis. Once placed and anchored with sutures, the surgeon then creates an auricle (outer ear) of natural proportions, contour, and appearance. In the next months, in follow-up surgeries, the surgeon then creates an earlobe, and also separates the reconstructed auricle from the side of the head (15–18 millimetres (0.59–0.71 in)), in order to create a  tragus , the small, rounded projection located before the external entrance to the ear canal.


In the case of the patient encumbered with several congenital defects of the ear or who has insufficient autologous cartilage to harvest, it might be unfeasible to effect the corrections with grafts of rib cartilage. In such a case, the reconstructive Antia–Buch helical advancement technique may instead be used, wherein tissue is moved from behind the ear rim and then around and forward to repair the defective front of the ear rim. [ 20 ]  To perform the Antia–Buch helical advancement, the surgeon first designs the incision inside the helical rim and around the crus (shank) of the helix with ink. The surgeon then cuts the skin and the cartilage, but does not pierce the posterior skin of the ear. The helical rim then is advanced to allow the suturing (closure), and a dog-ear-shaped graft of skin is removed from the back of the ear. The closure of the sutures advances the crus of the helix into the helical rim. [ 21 ]


The ear defect or deformity to be corrected determines the otoplasty techniques and procedures to be applied: for example, a torn  earlobe  can be repaired solely with  sutures ; a slight damage to the rim of the auricle might be repaired with an  autologous  skin graft harvested from the scalp; and conversely, a proper ear reconstruction might require several surgeries. In the correction of infantile ear defects and deformities, the otoplasty usually is performed when the child is about six years old, as the healthy ear is almost adult-sized, and thus can act as a corrective template for the auricular reconstruction.


The otoplastic technique(s) applied to correct, reconstruct, or replace a deformed, defective, or a missing ear, is determined by the indications that the patient presents; some are:


Otoplastic surgery can be performed upon a patient under  anesthesia  —  local anesthesia , local anesthesia with  sedation , or  general anesthesia  (usual for children). In order to correct a lop ear with a small helix (the cartilage-supported outer rim of the auricle), an incision to one side of a flat cartilage piece leaves unopposed elastic forces on the opposite side, which permits the evolution of the ear contour; thus, a small incision on one side of the lop-ear cartilage, along the new anti-helical fold, can be a technical element of the corrective ear surgery. Yet, when done without an incision, the procedure is deemed an 'incisionless otoplasty', wherein the surgeon places a needle through the skin, to model the cartilage and to emplace the retention  sutures  that will affix the  antihelix  and  conchal bowl  areas.


Depending upon the auricular defect, deformity, or reconstruction required, the surgeon applies these three otoplastic techniques, either individually or in combination to achieve an outcome that produces an ear of natural proportions, contour, and appearance:


Repositioning the earlobe is the most difficult part of the otoplasty, because when an auricle that has been repositioned in its upper two-thirds, and that yet retains a prominent lobule (earlobe) will appear disproportionate to and malpositioned upon the head — as it did in the original, uncorrected deformity. The otoplastic technique most effective for lobular repositioning is the Gosain technique (or a variant), wherein the surgeon cuts the skin on the medial surface of the earlobe, and, in suturing it closed, takes a bite of the conchal undersurface to pull the earlobe towards the head.


Another prominent-earlobe correction technique is suturing the helical-cartilage tail to the concha, yet, because the tail of the helix does not extend much into the lobule, setting it back does not reliably correct the set back of the earlobe proper; other techniques involve skin excision and sutures, between the fibrofatty tissue of the lobule and the tissues of the neck.


Depending upon the pre-surgical degree of prominence of the upper-third of the auricle, the surgical creation of the antihelical fold might be inadequate to fully correct the position of the helical rim, near the root of the helix. [ 26 ]


The internal  sutures  usually are permanent (non-absorbable), but the surgical wound or wounds can be sutured with either absorbable sutures or with non-absorbable sutures that the plastic surgeon removes when the surgical wound has healed. Depending upon the deformity to be corrected, the otoplasty can be performed either as an  outpatient surgery  or at hospital; while the operating room time varies between 1.5 and 5 hours.


For several days after the surgery, the otoplasty patient wears a voluminous, non-compressive dressing upon the corrected ear(s), and must avoid excessive bandage pressure upon the ear during the convalescent period, lest it cause pain and increased swelling, which might lead to the abrasion, or even to the  necrosis  of the ear's skin. After removing the dressing, the patient then wears a loose headband whilst sleeping for a 3–6-week period; it should be snug, not tight, because its purpose is preventing the corrected ear(s) from being pulled forward, when the sleeping patient moves whilst asleep. An overly-tight headband can abrade and erode the side surface of the ear, possibly creating an open wound. [ 21 ]  A dressing does not have to be worn if the patient was operated upon with the stitch method. [ 7 ]


Approximately 20–30 per cent of newborn children are born with deformities of the external ear (auricle) that can occur either  in utero  (congenitally) or in the birth canal (acquired). The possible defects and deformities include protuberant ears ("bat ears"); pointed ears ("elfin ears"); helical rim deformity, wherein the superior portion of the ear lacks curvature; cauliflower ear, which appears as if crushed; lop ear, wherein the upper portion of the auricle is folded onto itself; and others. Such deformities usually are self-correcting, but, if at 1 week of age, the child's external ear deformity has not self-corrected, then either surgical correction (otoplasty 5–6 years of age) or non-surgical correction (tissue molding) is required to achieve an ear of normal proportions, contour, and appearance.


In the early weeks of infancy, the cartilage of the infantile auricle is unusually malleable, because of the remaining maternal  estrogens  circulating in the organism of the child. During that biochemically privileged period, prominent ears, and related deformities, can be permanently corrected by molding the auricles (ears) to the correct shape, either by the traditional method of taping, with tape and soft dental compound (e.g.  gutta-percha latex ), or solely with tape; or with non-surgical tissue-molding appliances, such as custom-made, defect-specific splints designed by the physician. Therapeutically, the splint-and-adhesive-tape treatment regimen is months-long, and continues until achieving the desired outcome, or until there is no further improvement in the contour of the auricle, likewise, with the custom and commercial tissue-molding devices. [ 21 ]


The traditional, non-surgical correction of protuberant ears is taping them to the head of the child, in order to "flatten" them into the normal configuration. The physician effects this immediate correction to take advantage of the maternal estrogen-induced malleability of the infantile ear cartilages during the first 6 weeks of their life. The taping approach can involve either adhesive tape and a splinting material, or only adhesive tape; the specific deformity determines the correction method. This non-surgical correction period is limited, because the extant maternal estrogens in the child's organism diminish within 6–8 weeks; afterwards, the ear cartilages stiffen, thus, taping the ears is effective only for correcting "bat ears" (prominent ears), and not the serious deformities that require surgical re-molding of the auricle to produce an ear of normal size, contour, and proportions. Furthermore, ear correction by splints and tape requires the regular replacement of the splints and the tape, and especial attention to the child's head for any type of skin erosion, because of the cumulative effects of the mechanical pressures of the splints proper and the adhesive of the fastener tape.


Congenital ear deformities are defined as either malformations (microtia, cryptotia) or deformations, wherein the term "ear deformation" implies a normal chondrocutaneous component with an abnormal auricular architecture. The conditions are categorized as constricted ears, Stahl's ear deformity, and prominent ears, which derive from varied causes, such as the abnormal development and functioning of the intrinsic and extrinsic ear muscles, which might generate forces that deform the auricle; and external forces consequent to malpositioning of the head during the prenatal and neonatal periods of the child's life. A study,  Postpartum Splinting of Ear Deformities  (2005), reported the efficacy of splinting the ears of a child during the early neonatal period as a safe and effective non-surgical treatment for correcting congenital ear deformities. [ 28 ]  The study used a variety of physician-designed, physician-fabricated and commercially fabricated splints, such as a wire core segment in 6-French silastic tubing, self-adhering foam, temporary stopping with dental material, dental waxes, thermoplastic materials and other commercial ear-splint devices.


28. Merck, W.H. (2017)  "Ohrmuschelkorrektur ohne Hautschnitt - die Fadenmethode von Merck". In: K.Bumm (Herausgeber): Korrektur und Rekonstruktion der Ohrmuschel. Springer, 153–169.


Pediatric plastic surgery  is  plastic surgery  performed on children. Its procedures are predominantly conducted for reconstructive purposes, although some cosmetic procedures are performed on children as well. In children, the line between cosmetic and reconstructive surgery is often blurred, as many  congenital deformities  impair physical function as well as aesthetics.


Children make up roughly 3% of all plastic surgery procedures, and the majority of these procedures correct a congenital deformity. [ 1 ]  Cleft lip, syndactyly, and polydactyly are among the most common conditions treated with pediatric reconstructive surgery. Common pediatric cosmetic procedures include breast augmentation or reduction, auricular reconstruction, and rhinoplasty.


Reconstructive plastic surgery is performed on abnormal structures of the body that are the result of congenital defects, developmental abnormalities, trauma, infection, tumors or disease. While reconstructive surgery is most often undertaken to regain normal motor function or prevent current or future health problems, aesthetics is also considered by the surgical team. [ 2 ]


Several of the most common congenital birth defects can be treated by a plastic surgeon operating as an individual, or as a part of a multi-disciplinary team. The most common pediatric birth defects requiring plastic surgeon involvement include:


Cosmetic plastic surgery is defined as a surgical procedure undertaken to improve the physical appearance and self-esteem of a patient. These procedures are usually  elective .


While the majority of pediatric plastic surgery procedures done are reconstructive; there are those performed for cosmetic purposes. The most common procedures done for cosmetic benefit in children include: [ citation needed ]


Out of all procedures, nose reshaping generally has the most cases on an annual basis (4,313 procedures in 1996). However, children make up only 9% of the total caseload for all nose reshaping. On the opposite end of the spectrum, children requiring ear surgery accounted for 2,470 procedures in 1996, a total of 34% of all total ear surgeries.


While many of these procedures are done for purely cosmetic benefit, many plastic surgeons work on these features (giving them a more normal appearance), while performing a surgery to improve function as the result of a congenital deformity. [ 10 ]


With the unique challenges created in the field of plastic surgery, an increasingly popular trend has been to utilize the multi-disciplinary team approach in treatment.


Common conditions involving team treatment include:


Perforator flap surgery  is a technique used in  reconstructive surgery  where skin and/or  subcutaneous fat  are removed from a distant or adjacent part of the body to reconstruct the excised part. [ 1 ]  The vessels that supply blood to the flap are isolated perforator(s) derived from a deep vascular system through the underlying muscle or intermuscular septa. Some  perforators  can have a mixed septal and intramuscular course before reaching the skin. The name of the particular flap is retrieved from its perforator and not from the underlying muscle. [ 1 ]  If there is a potential to harvest multiple perforator flaps from one vessel, the name of each flap is based on its anatomical region or muscle. For example, a perforator that only traverses through the septum to supply the underlying skin is called a septal perforator. Whereas a flap that is vascularised by a perforator traversing only through muscle to supply the underlying skin is called a muscle perforator. [ 1 ]  According to the distinct origin of their vascular supply, perforators can be classified into direct and indirect perforators. Direct perforators only pierce the  deep fascia , they don't traverse any other structural tissue. Indirect perforators first run through other structures before piercing the  deep fascia . [ 1 ]


Soft tissue defects due to trauma or after tumor extirpation are important medical and cosmetic topics. Therefore, reconstructive surgeons have developed a variety of surgical techniques to conceal the soft tissue defects by using tissue transfers, better known as flaps. In the course of time these flaps have rapidly evolved from "random-pattern flaps with an unknown blood supply, through axial-pattern flaps with a known blood supply to muscle and musculocutaneous perforator flaps" for the sole purpose of optimal reconstruction with minimum donor-site  morbidity . [ 2 ]
Koshima and Soeda were the first to use the name “perforator flaps” in 1989  [ 3 ]  and since then perforator flaps have become more popular in reconstructive microsurgery. [ 1 ]  Thus perforator flaps, using autologous tissue with preservation of  fascia , muscle and  nerve   represent the future of flaps. [ 4 ]  The most frequently used perforator flaps nowadays are the deep inferior epigastric perforator flap ( DIEP flap ), [ 5 ] [ 6 ]  and both the superior and inferior gluteal (SGAP/ IGAP) flap, [ 7 ]  all three mainly used for  breast reconstruction ; the lateral circumflex femoral artery perforator (LCFAP) flap (previously named anterolateral thigh or ALT flap) [ 8 ]  and the thoracodorsal artery perforator (TAP) flap, [ 9 ]  mainly for the extremities and the head and neck region as a free flap and for breast and thoracic wall reconstruction as a pedicled perforator flap.


Perforator flaps can be classified in many different ways. Regarding the distinct origin of their blood supply and the structures they cross before they pierce the  deep fascia , perforators can either be direct perforators or indirect perforators. [ 10 ]  We will discuss this classification based on the perforators' anatomy below.


[ citation needed ]


Direct cutaneous perforators only perforate the  deep fascia , they do not traverse any other structural tissue. [ 10 ]


It is questionable whether these perforators are true perforators, because it might be more logical to not include these perforators. The surgical approach needed for direct perforators is slightly different from the one needed for indirect perforators. When direct perforators are not included, surgeons can focus on the anatomy of the perforator and the source vessel. [ 1 ]


Indirect cutaneous perforators traverse other structures before going through the  deep fascia . These other structures are deeper tissues, and consist of mainly muscle, septum or  epimysium . [ 10 ]  According to the clinical relevance, two types of indirect cutaneous perforators need to be distinguished. [ 1 ]  We will clarify these two types below. [ citation needed ]


Musculocutaneous perforators supply the overlying skin by traversing through muscle before they pierce the  deep fascia . [ 1 ]


A perforator which traverses muscle before piercing the  deep fascia  can do that either transmuscular or transepimysial. This latter subdivision is however not taken into account during the  dissection  of the perforator. Only the size, position, and course of the perforator vessel are considered then. [ 1 ]


When a flaps’ blood supply depends on a muscle perforator, this flap is called a muscle perforator flap. [ 1 ]


Septocutaneous perforators supply the overlying skin by traversing through an intermuscular septum before they pierce the deep fascia. These perforators are cutaneous side branches of muscular vessels and perforators. [ 1 ]