Israel Medical Association Journal

Plastic and reconstructive surgery is a specialty that has an important place in the surgical field. Plastic surgeons cooperate with all surgical disciplines to solve complex multidisciplinary surgical cases. This issue of the Israel Medical Association Journal (IMAJ) covers some of the groundbreaking treatments being performed by plastic surgeons in Israel.

The articles show the wide and complex range of issues where plastic surgery is needed, including hospital-based breast reconstructions, oncologic resections, and innovative lymphedema surgery, as well as aesthetic procedures. The efforts of plastic surgeons have been especially highlighted due to the Iron Swords war, which started on 7 October 2023. Injuries included complex burns and amputations that required attention under fire. In addition, advances were achieved through cutting‑edge reconstructive microsurgical traumatic solutions. Together, these articles highlight how Israeli teams have leveraged experience in trauma, high‑volume civilian and military caseloads and innovative inspirations that have generated knowledge that may be broadly applicable to surgeons worldwide.

Burn injuries pose a significant challenge in mass casualty scenarios. They require rapid and effective intervention to optimize patient outcomes. In this case report, we present the management of three severely burned patients following the October 7th terrorist attack in Israel. Our objective is to highlight the role of NexoBrid® (MediWound Ltd, Yavne, Israel) enzymatic debridement [1] as a primary intervention and discuss the challenges encountered in a mass casualty setting.

During these challenging times, following the October 7th terrorist attacks and the ongoing Iron Swords war, there is a greater need to strengthen the Israeli Society of Plastic and Aesthetic Surgery. Prof. Josef Haik, chair of the Israeli Society of Plastic and Aesthetic Surgery, leads this effort. In addition, it is vital to highlight Israel's contributions to the global Plastic and Aesthetic Surgery community and to encourage collaboration with the nursing division for plastic surgery and burns. Our department is involved in presenting our findings and collaborating with colleagues. In this article, we outlined five main topics: the role of plastic surgery in wartime, reconstructive plastic surgery, aesthetic plastic surgery, microsurgery, and innovation in plastic surgery.

Background: Modern medicine has improved survival rates in burn care. However, this progress has led to a new challenge of sepsis, which has become the leading cause of death in burn patients, accounting for over 50% of mortality. The diagnosis and treatment of sepsis in the burn care unit pose significant challenges due to the hypermetabolic state of the patient, which can mask septic signs and symptoms. This situation underscores the urgent need for improved strategies in sepsis management in burn patients.

Objectives: To assess the predictors of morbidity and mortality among severe burn patients.

Methods: Rambam Health Care Campus is the referral center for burn patients in northern Israel. We reviewed 5 years of patient records, noting information regarding sepsis, laboratory results, infections, and overall morbidity and mortality. In addition, a comparative cohort of burn patient records without sepsis was compared.

Results: Thirty patients had recorded sepsis. Total and direct bilirubin were associated with higher mortality (P < 0.05). Elevated white blood cell count and platelet count at admission were also associated with mortality (P < 0.05). The most prominent burn areas were the arms, head, and legs. The leading cause of injury was fire, followed by an explosion. Burns of total body surface area ≥ 40% was associated with sepsis.

Conclusions: Sepsis is a complex challenge when diagnosing and treating burned patients. Identifying specific traits and prognostic factors is crucial to adequately treat these patients. Research in burn care and sepsis management is essential.

Background: Soft-tissue defects of the lower limb pose a reconstructive challenge. Soft tissue loss with exposed bone, tendon, or cartilage often requires free flap reconstruction. Dermal substitutes are used for treatment of extensive burns to replace damaged skin and may be ideal for lower limb reconstruction in selected cases.

Objectives: To present our experience with reconstruction of lower limb wounds using Integra® Bilayer Wound Matrix (Integra LifeSciences Corp., Plainsboro, NJ, USA) and MatriDerm® (MedSkin Solutions Dr. Suwelack AG, Billerbeck, Germany).

Methods: This single center retrospective study comprised 10 patients who underwent reconstruction of extensive tissue defects of the distal lower limbs with dermal matrices and split-thickness skin grafts.

Results: All patients were successfully reconstructed and resumed normal ambulation. Six patients had complete and four partial graft takes that was treated conservatively until full wound healing. Older patients with medical co-morbidities or history of wound infection were more likely to have partial graft take. One postoperative infection was recorded in the study.

Conclusions: Dermal substitutes are easy to apply and safe, show minimal donor site morbidity, provide good functional and aesthetic outcomes, and should be used for reconstruction of complex lower limb wounds.

Background: The forehead and scalp play a crucial role in the aesthetic appearance of the face. Extensive oncological resections that result in significant defects create challenges for reconstruction and require various surgical techniques.

Objective: To present the planning and surgical technique required for a simple, reproducible one-stage flap to reconstruct an extensive forehead defect.

Methods: A cohort of six patients underwent reconstruction of large anterior forehead or scalp defects using a one-stage axial fasciocutaneous flap. All procedures were conducted under general anesthesia. The defects resulted from tumor resections. The sizes ranged from 5.5 cm to 11 cm. The flap was used to reconstruct various forehead and anterior scalp regions.

Results: All the flaps were successful. The aesthetic outcomes were favorable, and no significant complications were noted.

Conclusions: The extended forehead flap is a versatile option for safe, simple, and reproducible one-stage reconstruction of large forehead and anterior scalp defects that yields satisfactory aesthetic results.

Background: Merkel cell carcinoma (MCC) is a rare and aggressive neuroendocrine skin tumor with an increasing incidence in Western countries. Predominantly affecting older individuals, MCC represents less than 1% of malignant skin tumors.

Objectives: To characterize the clinical presentation, therapeutic interventions, and follow-up outcomes of MCC patients. To promote heightened clinical awareness regarding the early recognition and diagnosis of MCC.

Methods: We conducted a retrospective cohort study analyzing medical records of MCC patients at the Shaare Zedek Medical Center between 2015–2022. From 19 initially identified patients, 17 met the inclusion criteria. Data collection included demographic, epidemiological, clinical, and pathological characteristics.

Results: The study included 17 patients, predominantly of Jewish origin, with a mean age of 70.06 years; 58.8% female. Medical co-morbidities included 64.7% hypertension and 35.3% diabetes. MCC tumors were predominantly left-sided (58.8%), with varied locations including limbs, trunk, and face. Surgical treatment consisted of excision and primary closure (64.7%) or skin grafting (23.5%). The average tumor diameter was 3.41 cm clinically and 3.83 cm pathologically. Lymph node involvement occurred in 29.4% of cases; 23.5% showed metastatic disease at diagnosis, with metastases diffused in different body areas. Kaplan-Meier survival analysis showed no statistically significant differences across most variables, except for a significantly lower survival rate in patients with ischemic heart disease (P = 0.009).

Conclusions: Our study reveals unique characteristics of MCC, predominance of female patients, and a slightly younger average diagnosis age compared to existing literature. The 2-year survival rate in our cohort was 82%. The study underscores the importance of early detection and diagnosis of MCC, thereby enhancing clinical awareness and improving patient outcomes.

Background: The incidence of autologous breast reconstruction has been steadily increasing in recent years. Deep inferior epigastric perforator (DIEP) flap reconstruction is considered the gold standard for breast reconstruction despite its demanding technical expertise, time intensiveness, and rigorous postoperative monitoring.

Methods: We retrospectively collected data from 102 DIEP flaps utilized for breast reconstruction in 70 patients treated at private clinics between 2013 and 2024. All surgeries were performed by a single, experienced surgeon.

Results: The mean age at surgery was 42.2 ± 8 years. Immediate reconstructions were conducted in 34 patients (48%); 46% of patients had prior radiation therapy. Only one patient received adjuvant radiation therapy. Free DIEP flaps vascularized by one (53%), two (32%), or three (10%) perforators were preferentially anastomosed to the internal mammary vessels. One patient underwent a muscle-sparing procedure due to the absence of available perforators. Total flap failure occurred in four cases (3.9%), three occurred as a unilateral loss in patients who underwent bilateral reconstruction. Postoperative revisions of the microvascular anastomosis were performed in three patients, with successful flap salvage in two (67%). Fat necrosis was diagnosed in 26 breasts (25%), only a minority of cases required follow-up surgery. All patients were managed completely in a private clinic, with none requiring hospitalization in the public system.

Conclusions: Free DIEP flap breast reconstruction necessitates meticulous surgical planning, a well-coordinated surgical team, and close postoperative monitoring. Nevertheless, this surgery can be safely and effectively performed in a private clinic setting, with complication rates comparable to that of the public setting.

Background: Breast edema, characterized by fluid accumulation in breast tissue, is a common yet understudied complication following breast-conserving surgery (BCS) and radiotherapy for breast cancer. Its impact on physical and emotional well-being highlights the need for deeper exploration of its prevalence, risk factors, and clinical management.

Objectives: To evaluate the prevalence of breast edema following breast surgery, investigate its association with arm lymphedema, and explore links to surgical interventions.

Methods: We analyzed 105 breast cancer patients treated with BCS and axillary interventions, including sentinel lymph node biopsy (SLNB), lymph node sampling, or axillary lymph node dissection (ALND). Comprehensive evaluations included physical exams, arm circumference measurements, and a thorough review of patient demographics, medical history, and disease progression to assess the presence and severity of breast and arm lymphedema.

Results: Breast edema prevalence was 7.6%, with rates significantly influenced by surgical extent. None of the SLNB patients exhibited breast edema, compared to 23.5% of ALND patients. Significant predictors included arm lymphedema (OR 57.54, P = 0.024), body mass index (OR 0.65, P = 0.016), and tumor grade (OR 51.78, P = 0.040). Co-occurrence of breast and arm lymphedema was observed in 50% of cases.

Conclusions: Breast edema is a significant postoperative complication influenced by surgical extent and lymphatic disruption. Improved diagnostic methods, multidisciplinary care, and innovative surgical strategies are essential for mitigating this condition and enhancing patient outcomes.

Background: Breast reconstruction following oncological resection offers psychosocial benefits. Various factors influence patient reconstruction decisions, including ethnicity, socioeconomic status, and education. We investigated disparities in breast reconstruction among Bedouin and non-Bedouin women in the Negev region.

Objectives: To investigate the influence of ethnicity in breast reconstruction decisions between Bedouin and non-Bedouin women in Israel and to identify factors influencing the choice of reconstruction following oncological breast surgery.

Methods: In this retrospective cohort study, we examined women undergoing breast cancer surgery, with or without reconstruction, between 2015 and 2021 in a breast cancer referral center. Demographics and detailed medical data were collected from electronic health records. We analyzed the factors that influenced decisions regarding breast reconstruction.

Results: The study included 1415 patients who underwent breast resection. Age was a significant factor in breast reconstruction choices, with younger patients being more likely to choose reconstruction. Marital status and education level influenced the decision, whereas socioeconomic status and number of children did not. Ethnicity analysis highlighted distinct demographic and socioeconomic differences between Bedouin and non-Bedouin women. Despite these disparities, surgical choices did not differ significantly between ethnicities.

Conclusions: Significant disparities exist between Bedouin and non-Bedouin women in terms of sociodemographic factors. However, these disparities did not affect their breast reconstruction decisions. Age, marital status, and education level influenced the decision to reconstruct the breast.

Background: Abdominoplasties are among the most common procedures in aesthetic plastic surgery. The target audience are patients after massive weight loss who are left with excess skin and post-partum patients. Due to the efficacy of abdominoplasties in improving the abdominal contour, it became a mainstay procedure in plastic surgery. Claims have been made that abdominal surgeries can be safely combined with breast surgeries, and thereby decrease the risk associated with anesthesia for two separate procedures as well as the recovery period. The benefits of the combined procedures led to a surplus of patients seeking consultations.

Objectives: To examine the safety of the mommy makeover procedure compared to sole abdominoplasty.

Methods: Patients who previously underwent abdominoplasty by the senior author were divided into two groups based on whether breast surgery was performed in addition to the abdominoplasty. Groups were compared based on demographical, clinical, and surgical variables.

Results: The study cohort included 726 patients, of whom 15% underwent "Mommy-makeovers". Groups differed only in liposuction volume, resection weight and number of drains. Regarding surgical outcomes, surgical site infections were seen at a greater rate in the isolated abdominoplasty procedure. Further analyses accounting for potential confounders found no difference between the groups in terms of adverse events.

Conclusions: Mommy makeovers do not display a safety concern when compared to isolated abdominoplasties. Surgeons must consider various patient characteristics to ensure optimal results.

In the 1950s, ionizing radiation to the scalp was commonly used in Israel as a treatment for tinea capitis. Decades later, epidemiological studies identified an increased incidence of head and neck malignancies, particularly basal cell carcinoma, as well as intracranial tumors such as meningiomas among individuals who underwent this therapy in childhood. In addition to the oncologic risk, irradiated scalp skin presents significant reconstructive challenges due to chronic skin atrophy, hypovascularity, fibrosis, and impaired wound healing. In this study, we present our clinical experience with a modified, skin-sparing surgical protocol for managing reconstruction post excision of non-melanoma skin cancer of the scalp in patients previously irradiated for tinea capitis. The surgical strategy is tailored according to lesion size, depth, periosteal involvement, and scalp tissue quality. It incorporates components of the reconstructive ladder as appropriate. We present three representative cases highlighting key surgical challenges and considerations in this complex population.

Serotonin (5-hydroxytryptamin, 5-HT) is a vital monoamine neurotransmitter that modulates various physiological processes. Selective serotonin reuptake inhibitors (SSRIs) are commonly used for the management of depressive disorders. Prolonged administration of SSRIs may lead to reduced platelet aggregability due to the depletion of serotonin stores within platelets. However, the association between chronic SSRI use and the risk of postoperative bleeding remains a topic of debate, with no standardized guidelines for managing this risk in the field of plastic surgery. This literature review and case report highlights the importance of considering chronic SSRI use as a potential risk factor for postoperative bleeding in plastic surgery patients. Standardized guidelines for handling postoperative bleeding risk in patients using SSRIs are crucial for ensuring optimal surgical outcomes and patient safety.