Ivan Ginev

Background/Objectives: Speech outcome is a major functional endpoint following primary palatoplasty. This study compared long-term speech outcomes after closed intravelar minimal-incision palatoplasty and the modified Veau–Wardill–Kilner procedure. Methods: This retrospective observational study evaluated speech using a standardized perceptual protocol adapted to the Bulgarian phonetic system across eight domains. Outcomes were compared between surgical groups, with additional analyses stratified by age and cleft type. Results: The minimal-incision group showed higher unadjusted proportions of normal speech intelligibility (29.4% vs. 17.6%, p = 0.020), normal resonance (73.2% vs. 54.9%, p = 0.001), and normal consonant articulation (37.8% vs. 19.0%, p < 0.001), whereas compensatory articulation was less frequent (49.6% vs. 65.5%, p = 0.008). Hypernasality, voice quality, and vowel articulation were comparable between groups. After adjustment for cleft type and age group, no significant association was observed between surgical technique and normal speech intelligibility (aOR 1.33, 95% CI 0.73–2.43; p = 0.357), whereas the minimal-incision technique was associated with higher odds of normal consonant articulation (aOR 1.79, 95% CI 1.01–3.18; p = 0.047) and normal resonance (aOR 1.73, 95% CI 1.02–2.94; p = 0.043). Conclusions: Both techniques were associated with broadly comparable long-term functional speech outcomes across most evaluated domains. After adjustment for cleft type and age group, differences remained in normal consonant articulation and normal resonance, whereas no significant adjusted association was observed for normal speech intelligibility. These findings should be interpreted cautiously given the historical treatment patterns, non-random distribution of cleft type between groups, and potential residual confounding.

Background: Breast implant illness (BII) is a constellation of non-specific systemic and local symptoms—including fatigue, joint pain, cognitive dysfunction, and autoimmune-like manifestations—attributed to silicone breast implants. Although BII remains a controversial clinical entity, accumulating evidence suggests symptom improvement following implant removal; however, causal mechanisms and optimal surgical strategies remain uncertain. Objective: The objective was to evaluate the prevalence of BII symptoms and the effect of explantation with en bloc total capsulectomy on symptom resolution in affected women. Methods: A prospective case series of 50 women who underwent explantation with total capsulectomy between 2023 and 2025 was conducted (Level IV evidence). The BII Questionnaire of the American Society for Aesthetic Plastic Surgery (ASAPS) was administered to assess preoperative and one-year postoperative symptom burden. Perioperative data—including implant characteristics, capsular findings, and imaging results—were analyzed. Symptom changes were assessed using descriptive statistics and nonparametric tests. Results: The mean age at explantation was 43 years, with a mean age at implantation of 31 years. Implants were predominantly placed in the retropectoral plane (80%). Intraoperative rupture was identified in 34 patients (68%). At one-year follow-up, a statistically significant reduction in symptom burden was observed, with an 81.7% decrease in mean symptom frequency (preoperative mean: 10.79 vs. postoperative: 1.97; p < 0.001). The most pronounced improvements were noted in chronic fatigue, cognitive impairment, and delayed wound healing. No surgical complications were recorded, and aesthetic outcomes were satisfactory among patients who underwent single-stage mastopexy. Conclusions: Explantation with en bloc total capsulectomy is associated with substantial symptom improvement in women presenting with BII. Although the precise pathophysiology of BII remains elusive, these findings support a patient-centered approach incorporating thorough preoperative evaluation and shared decision-making. Future research should prioritize the development of standardized diagnostic criteria, biomarker validation, and patient subgroup stratification to optimize clinical management and further advance the understanding of BII. Limitations: The absence of a control group precludes causal inference. Objective clinical and immunological assessments were not performed. Patient-reported symptoms were not corroborated by formal clinical evaluation. Most patients were self-referred, introducing referral and expectation bias. The sample size was small.

Large congenital melanocytic nevi (LCMN) of the face can pose significant functional, esthetic, and psychosocial challenges in childhood. In selected patients, staged excision offers a practical reconstructive strategy when primary closure is not feasible without distortion of nearby facial landmarks. We report the management of a child with a facial LCMN using a planned multistage surgical approach aimed at lesion removal while preserving contour and minimizing scar burden. The lesion was excised sequentially over three procedures, with careful attention given to relaxed skin tension lines and facial esthetic units. When required, adjunctive reconstruction was performed to optimize closure and support tissue healing. This approach allowed a gradual reduction in the nevus, improved tissue accommodation, and avoidance of excessive tension on the surrounding skin. Postoperative recovery was uncomplicated, and the final esthetic outcome was satisfactory for both the patient and parents. Staged excision was selected over tissue expansion and skin grafting because it allowed progressive lesion reduction while preserving adjacent facial landmarks and minimizing donor-site morbidity. This technical case highlights the importance of individualized surgical planning, preservation of facial esthetic units, and staged scar placement when managing large facial congenital melanocytic nevi in pediatric patients. The educational value of the report lies in illustrating the decision-making process used to balance lesion removal, esthetic outcomes, and long-term surveillance in a challenging facial location.

Background: Cleft lip with or without cleft palate (CL ± P) is a common congenital anomaly requiring a multidisciplinary team approach from birth into adulthood. Many patients undergo multiple secondary procedures on the lip, nose, and alveolus, representing a substantial long-term “burden of care” for families and health systems. The relationship between preoperative cleft severity and the cumulative number of surgical interventions into late adolescence remains insufficiently characterized. Methods: A retrospective cohort study was conducted on 166 patients with cleft lip ± cleft palate treated at a single tertiary cleft center. All patients underwent primary cheiloplasty, with or without concomitant gingivoperiosteoplasty (GPP), and had follow-up extending to a mean age of 18 years. Preoperative nasolabial deformity was graded into four categories (mild, moderate, severe, and very severe) using standardized photographic assessment. The primary outcome was the total number of cleft-related surgical interventions on the lip, nose, and alveolus, including the primary operation and all subsequent corrective procedures. Associations between preoperative severity and surgery counts were analyzed using the Kruskal–Wallis test and Bonferroni-adjusted pairwise comparisons. Results: All 166 patients underwent a primary procedure, either cheiloplasty alone (n = 86; 51.8%) or cheiloplasty combined with GPP (n = 80; 48.2%). A second surgical intervention was performed in 111 patients (66.8%), yielding 138 procedures, most commonly GPP with bone grafting (n = 54), corrective cheiloplasty (n = 48), GPP without graft (n = 23), and rhinoplasty (n = 12). A third intervention was performed in 48 patients (28.9%; 70 procedures), predominantly rhinoplasty and additional cheiloplasties, and a fourth intervention in 13 patients (7.8%; 17 procedures), mostly staged rhinoplasty and lip revisions. Overall, 56 patients (33.7%) had only one (primary) operation, 50 (30.1%) had two, 27 (16.3%) had three, 18 (10.8%) had four, 13 (7.8%) had five, and one patient (0.6%) had six surgical interventions. The total number of operations differed significantly across severity grades (Kruskal–Wallis p < 0.001). Patients with mild and moderate severity had significantly fewer surgeries than those with severe or very severe deformities (all p ≤ 0.023), whereas differences between mild vs. moderate and severe vs. very severe were not significant. Conclusions: In this cohort of patients with cleft lip followed to a mean age of 18 years, two-thirds required at least one secondary procedure, and nearly one-fifth underwent four or more surgeries. Higher preoperative severity was strongly associated with greater surgical burden, particularly when comparing mild or moderate deformities to severe and very severe clefts. These findings underline the importance of preoperative severity assessment for family counseling, expectation management, and the design of treatment protocols aimed at minimizing the long-term burden of care while preserving functional and esthetic outcomes.

Background: Oro-nasal fistula formation remains one of the most common complications following primary palatoplasty, while the influence of surgical technique on fistula incidence and characteristics remains controversial. This study aimed to compare the occurrence and features of oro-nasal fistulas after two primary palatal repair techniques. Methods: A retrospective comparative analysis was conducted in patients undergoing one-stage primary palatoplasty using either closed intravelar palatoplasty or a modified Veau–Wardill–Kilner pushback technique. Oro-nasal fistulas were evaluated according to presence, size, anatomical location, and functional impact. Secondary corrective procedures, including fistula repair and pharyngoplasty, were also analyzed. Results: Oro-nasal fistula formation was significantly associated with the surgical technique. Closed intravelar palatoplasty demonstrated a significantly lower fistula rate compared with the modified Veau–Wardill–Kilner technique. Cleft type and syndromic status were not independently associated with fistula development. Rates of secondary corrective procedures and pharyngoplasty were significantly lower in the intravelar group. Conclusions: Surgical technique plays a decisive role in oro-nasal fistula development after primary palatoplasty. Muscle-oriented repair with limited incisions is associated with reduced fistula formation and a lower need for secondary surgical interventions.

In the last decade, the term tertiary lymphoid structures (TLSs) has gained significant attention and is used to describe ectopic lymphoid organs that exhibit characteristics similar to secondary lymphoid organs (SLOs) and form in response to chronic inflammation. TLSs are closely related to cancer development and might serve as a predictive factor for patient prognosis. The relationship between tumors and TLSs is complex due to the influence of tumor-derived cytokines on the expression of TLS-derived cytokines and vice versa. Many articles have addressed TLSs and their significance in various carcinomas, and this study focuses on improving comprehension of the intrinsic mechanisms by which TLSs impact patient prognosis. This work is supported by data from our previous study on TLSs in patients with urothelial carcinoma of the bladder. However, literature data on the presence of TLSs in different neoplastic diseases remain scarce.

Background: Auricular carcinoma is a malignant neoplasm arising from the epithelial or adnexal tissues of the external ear, most commonly representing cutaneous squamous cell carcinoma, basal cell carcinoma, or, less frequently, melanoma, characterized by early cartilage invasion and regional spread due to the thin soft-tissue envelope of the ear. Such malignancies involve radical resection, producing wide defects, which require complex reconstructive approach. Case Presentation and Methods: We describe a 45-year-old male patient who presented with a basal cell carcinoma, affecting the lobulus of the ear and the retroauricular and mastoid region. He underwent successful tumor resection with clear resection margins in an ENT department with a subsequent referral to our department for reconstruction. This report presents a successful reconstruction of a large post-excisional defect, 10 × 10 cm in diameter, with mastoid process exposure. Temporal muscle flip flap and skin graft, along with the preservation of the external auditory canal with Z-plasty, were incorporated for reconstruction after subtotal auricular amputation due to BCC. It highlights the importance of a diligent long-term follow-up, the preservation of the canal, preventing meatal stenosis, and the reconstructive potential of the muscle flap in patients with mastoid bone exposure in a single stage. Conclusions: A temporalis muscle flap with skin graft coverage offers a reliable, vascularized solution for large post-oncologic auricular defects while preserving the external auditory canal. Z-plasty remains a critical technique for preventing meatal stenosis.

Background: Auricular carcinomas often require extensive surgical resection, resulting in complex three-dimensional defects,in some cases involving mastoid process exposure. Reconstruction aims to restore contour, protect underlying structures, and maintain patency of the external auditory canal (EAC). Case presentation and methods: We present a 45-year-old male patient, without comorbidities, who underwent subtotal auricular resection and wide retroauricular excision for basal cell carcinoma, resulting in mastoid bone exposure. Reconstruction was achieved using a temporal muscle flap covered by a skin graft, combined with a Z-plasty of the external auditory meatus to prevent postoperative stenosis. Recovery was uneventful, and 4 year follow-up demonstrated stable structural outcomes, preserved diameter of the meatus, without recurrence of the disease.The patient is prepared for autologous or prosthetic auricular reconstruction. Conclusion: A temporalis muscle flap with skin graft coverage offers a reliable, vascularized solution for large post-oncologic auricular defects while preserving the external auditory canal. Z-plasty remains a critical technique for preventing meatal stenosis.

Restoring the integrity of the calvaria due to diploic cavernous hemangioma removal possesses surgical complexity regarding the location of the tumor and the intricacy of the reconstruction method. We report a case of a 36-year-old male with a recurrent cavernous hemagioma, affecting the frontal bone. The patient had undergone surgical extirpation of the primary lesion six years ago in a different plastic surgery department with histological verification. He presented to our department with local recurrence at the same site. The lesion was completely resected, followed by calvarial reconstruction using autologous non-vascularized bone graft harvested from the iliac crest. Histology confirmed the recurrence of a benign cavernous hemangioma. Postoperative recovery was devoid of complications, and a follow-up CT scan after 6 months revealed no recurrence, with stable graft integration. A major insight of this manuscript includes the discussion of the benefits of using autologous bone in young patients instead of synthetic counterparts.

Background: Restoring the integrity of the lower eyelid presents a complex surgical challenge due to its lamellar structure and the high risk of complications. Among these, ectropion is the most frequent and troublesome outcome. Objective: This study aims to present a case of lower eyelid reconstruction following the excision of squamous cell carcinoma using Mohs micrographic surgery combined with the Mustardé cheek rotation flap technique, highlighting its advantages, limitations, and applicability in elderly patients. Case presentation: A 93-year-old female patient with right lower eyelid squamous cell carcinoma underwent Mohs micrographic surgery. The resulting defect was reconstructed using a Mustardé cheek rotation flap, chosen for its suitability in patients with adequate skin laxity. Patient-specific risk factors, including advanced age, a history of ischemic stroke, and class II heart failure (NYHA classification), were considered in the surgical planning stage. Results: The Mustardé cheek rotation flap provided a reliable closure with a favorable esthetic outcome and inconspicuous scarring, aligned with natural anatomical margins. The technique was technically straightforward in this patient owing to age-related skin laxity. No major postoperative complications were observed. Conclusions: The Mustardé cheek rotation flap represents a safe and effective reconstructive option for elderly patients with lower eyelid defects following tumor excision. This case illustrates the esthetic and functional benefits of the technique while emphasizing the need to tailor reconstruction strategies to patient comorbidities and defect characteristics.