Goals/Purpose

:

Anyone performing surgeries (with or without prosthesis) has faced many challenges when trying to overcome the burden of severe infections and/or complications derived from them. Although many protocols have been described and technology has helped us to reduce its impact, there still remain some obstacles that hinder an optimal cleansing solution[i]. Hypochlorous Acid (HOCl) has demonstrated a broad safety profile as well as effectiveness for wound care[ii]^,[iii], including various skin/mucosal infections and disorders (e.g. seborrheic dermatitis, atopic dermatitis-associated pruritus, acne vulgaris, diabetic foot ulcers, and hypertrophic scars/keloids)[iv]^,[v]. The scientific basis for its use relies on the Reactive Oxygen Species (ROS) formation by the respiratory burst, which is a natural immune pathway for pathogen destruction[vi]. Neutrophils and other cells of the innate immune system physiologically produce HOCl from H₂O₂ and Cl^- within phagosomes, through the granule enzyme myeloperoxidase[vii].

S-HOCl is different from Bleach!

HOCl molecule is an oxygen-dependent non-dissociated ion of chlorine, very unstable and hyperreactive at different pH; although it is one of the most powerful oxidants and the direct responsible of the microbicidal effect from chlorine-derived compounds[viii]. Recently a scientist[ix] discovered a process to Stabilize (S-HOCl) the molecule, which was patented and named a Cellular Antimicrobial Molecule (CAM) instead of a mere disinfectant (Figure 1).

Methods/Technique

:

S-HOCl concentrations at 500 ppm are effective to reach a 99.9% killing of most bacteria, fungus and virus, through exposures as short as 1 minute. Low-concentrated HOCl-based solutions have shown great efficacy to control common flu-like symptoms in viral and bacterial upper airway infections[x]^,[xi],[xii].

We are proposing the prosthesis pre-wash with a 500-ppm S-HOCl solution 5 minutes prior to its insertion; the pocket could be irrigated with S-HOCl as well. Besides, we add a 100-ppm S-HOCl solution directly to the fat harvesting canister (1/3 of the Lipoaspirate volume). Then, the processed fat graft can be injected without further washing.

Results/Complications

:

The current protocol has shown very promising results in terms of safety and infection control after 1 year of implementation. Neither infections, allergies, adverse effects, nor toxicological effects have been reported whatsoever. Still, a large case series, a cohort or even a multicenter clinical trial should be conducted to support our recommendations.

Conclusion

:

There is still a lot of confusion about the chlorine species and how they behave within different pH and physiological conditions. S-HOCl was developed to safely kill and control of numerous microorganisms’ growth at physiological conditions. Further studies are needed to support our protocol, which was supported by our experience and the current literature available. Furthermore, CAMs have arisen as a new category of ‘natural’ compounds for the post-antibiotic era.

[i] Norman G, Atkinson RA, Smith TA, et al. Intracavity lavage and wound irrigation for prevention of surgical site infection. Cochrane Database of Systematic Reviews. 2017. doi: 10.1002/14651858.cd012234.pub2

[ii] Del Rosso JQ, Bhatia N. Status Report on Topical Hypochlorous Acid: Clinical Relevance of Specific Formulations, Potential Modes of Action and Study Outcomes. J Clin Aesthet Dermatol. 2018 Nov;11(11):36-39. Epub 2018 Nov 1.

[iii] Gold MH, Andriessen A, Bhatia AC, et al. Topical stabilized hypochlorous acid: The future gold standard for wound care and scar management in dermatologic and plastic surgery procedures. Journal of Cosmetic Dermatology. 2020;19(2):270-277. doi:10.1111/jocd.13280.

[iv] Castillo DM, Castillo Y, Delgadillo NA, et al. Viability and Effects on Bacterial Proteins by Oral Rinses with Hypochlorous Acid as Active Ingredient. Brazilian Dental Journal. 2015;26(5):519-524. doi:10.1590/0103-6440201300388.

[v] Wongkietkachorn A, Surakunprapha P, Wittayapairoch J, Wongkietkachorn N, Wongkietkachorn S. The Use of Hypochlorous Acid Lavage to Treat Infected Cavity Wounds. Plastic and Reconstructive Surgery - Global Open. 2020;8(1). doi:10.1097/gox.0000000000002604.

[vi] Wang L, Bassiri M, Najafi R, Najafi K, Yang J, et al. Hypochlorous acid as a potential wound care agent: part I. Stabilized hypochlorous acid: a component of the inorganic armamentarium of innate immunity. J Burns Wounds. 2007 Apr 11;6:e5.

[vii] Winterbourn C.C., van Dalen C.J., Hampton M.B., Kettle A.J. Reactions of Myeloperoxidase and Production of Hypochlorous Acid in Neutrophil Phagosomes. In: Petrides P.E., Nauseef W.M. (eds) The Peroxidase Multigene Family of Enzymes. Springer, Berlin, Heidelberg. 2000.

[viii] Ono T, Yamashita K, Murayama T, Sato T. Microbicidal Effect of Weak Acid Hypochlorous Solution on Various Microorganisms. Biocontrol Science. 2012;17(3):129-133. doi:10.4265/bio.17.129.

[ix] Calderon JL. PATENT: Method of producing and Applications of composition of Hypochlorous Acid. Aquilabs SA Co. United States Patent Publication Application, US2009/0258083A1. Oct 15, 2009.

[x] Yu MS, Park HW, Kwon HJ, Jang YJ. The Effect of a Low Concentration of Hypochlorous Acid on Rhinovirus Infection of Nasal Epithelial Cells. American Journal of Rhinology & Allergy. 2011;25(1):40-44. doi:10.2500/ajra.2011.25.3545.

[xi] Yu MS, Kim B-H, Kang S-H, Lim DJ. Low-concentration hypochlorous acid nasal irrigation for chronic sinonasal symptoms: a prospective randomized placebo-controlled study. European Archives of Oto-Rhino-Laryngology. 2016;274(3):1527-1533. doi:10.1007/s00405-016-4387-5.

[xii] Cho H-J, Kim C-H. In response to Improved outcomes after low-concentration hypochlorous acid nasal irrigation in pediatric chronic sinusitis. The Laryngoscope. 2016;126(10). doi:10.1002/lary.26090.

Goals/Purpose:

With advancements in device technology, non-surgical and minimally invasive options have gained increasing popularity for improving the appearance of skin fine lines and wrinkles. While laser resurfacing and peeling agents remain the gold standard, several alternative treatments are under investigation. Microneedling is a minimally invasive technique in which several small needles are applied to the skin in a repetitive motion, resulting in controlled microinjury. This process may stimulate the tissue rejuvenation with the formation of new tissue and blood vessels. This study used a microneedling device currently FDA-approved to improve the appearance of acne scars in adults aged 22 and older. The purpose of this study was to assess the efficacy and tolerability of the microneedling device on men and women with fine lines and wrinkles of the face and neck.

Methods/Technique:

This single-center, prospective study enrolled 35 male and female subjects between the ages of 44 and 65. Each subject received a microneedling (Bellus Medical) treatment over the entire face and neck once every month for four months (four treatments total) at microneedle depths between 1.0 and 2.5mm. Subjects followed up one month and three months post-treatment. At every visit, both standard photography and VISIA Complexion Analysis were performed. Additional non-invasive skin measurements, namely, high-resolution ultrasonography, optical coherence tomography (OCT) 3D imaging, transepidermal water loss (TEWL) and BTC 2000, were taken. Microbiopsies, 0.33mm in diameter, were collected near the left alar base prior to the first treatment, before the fourth treatment and three months post-treatment to evaluate the effect of microneedling on tissue histology and gene expression. Subjects completed the Subject Global Aesthetic Improvement Scale and a satisfaction questionnaire based on a live assessment of his or her face compared to pre-treatment photographs.

Results/Complications:

32 subjects (93.75% female, 6.25% male) completed four treatments and the one- and three-month post-treatment follow-up visits. One patient was withdrawn from the study due to non-compliance and two subjects were lost to follow-up. All subjects experienced pinpoint bleeding during treatment and moderate erythema post-treatment. However, these reactions are anticipated and resolved within days of treatment.

Dermal and epidermal density in the cheek was increased 101.86% and 19.28%, respectively, at three months post-treatment (dermal density- p<0.001, epidermal density- p=0.0078). Elasticity in the face increased 28.2% from baseline at three months post-treatment (p= 0.0039). In the face, attenuation coefficient increased 15.65% and 17.33% from baseline one month (p<0.001) and three months (p=0.0012) post-treatment, respectively. In the neck, only a 7.99% increase at one month post-treatment was statistically significant (p= 0.014). Blood flow was significantly increased in the face and neck 100 uM below the skin surface at three months post-treatment, but significantly decreased at a depth of 500 uM.

At three months post-treatment, the relative intensity of dermal collagen type 3 was increased nearly three-fold compared to baseline (p=0.02). Additionally, 7 of 12 samples extracted at the three-month follow-up visit showed an increase in dermal muscle formation on trichrome staining. TNF-alpha expression was increased immediately prior to the final microneedling treatment (p=0.01), but no statistically significant change was noted three months post-treatment.

At three months post-treatment, 71.9% of subjects saw an improvement in at least one of the following parameters in the treatment area- number of fine lines and wrinkles, size of fine lines and wrinkles, size of pores, skin texture, skin tone, or skin clearness. When asked three months post-treatment, 65.6% of subjects would recommend microneedling to others.

Conclusion:

The results from this study illustrate the safety and tolerability of four treatments using a microneedling device to improve the appearance of fine lines and wrinkles on the face and neck. Both non-invasive skin measurements and microbiopsy data demonstrated changes in skin architecture in both the face and neck after treatment. The treatments were well-tolerated by all subjects, with only slight discomfort reported by a few patients, particularly when treating over the nose and forehead. There were no adverse events related to the device or treatment during the course of the study. Additionally, subject satisfaction was high, and a majority of participants would recommend this treatment to others. Further studies will evaluate the feasibility and efficacy of these treatments on other body regions, including the dorsal hand.

Goals/Purpose

:

In the ever-present quest to attain the ideal body image, new advancements in device technology offer patients, both men and women, more treatment options than ever before to meet their aesthetic expectations for body contouring. Liposuction remains the gold standard for fat removal and improved contour. Despite its proven efficacy, there remains a large number of patients who are surgically averse, preferring non-surgical alternatives. Currently, there are five leading non-invasive body contouring options indicated for lipolysis: cryolipolysis, radiofrequency (RF), high-intensity focused ultrasound (HIFU), low level laser therapy (LLLT) and hyperthermic laser treatment.

The purpose of this study was to evaluate the safety and efficacy of a 1060 nm diode laser for non-invasive fat reduction of the abdomen region.

Methods/Technique

:

This multi-center study protocol enrolled 30 male and female subjects between the ages of 25-62. Individuals were asked to refrain from making major changes in their diet or lifestyle during the course of the study. Exclusionary criteria included pregnancy, nursing in the last six months, prior liposuction to the treatment area in past twelve months, immunosuppression, implants in the treatment area, use of medications that induce photosensitivity, skin disorders, tattoos in the treatment area, severe laxity, use of anticoagulants, abdominal hernia, unstable weight within the past 6 months, use of retinoids, and a history of poor scar formation. Each subject received a single study treatment with a 1060 nm diode laser with the power set between 1.2 and 1.4 W/cm². Baseline photos and ultrasound images were taken and compared to those at 6 and 12 weeks post treatment. Subjects were followed up at 6 and 12 weeks post treatment. Subjects completed a satisfaction questionnaire at the study exit.

Results/Complications

:

29 subjects completed one treatment and the necessary 6 and 12-week follow‐up visits to be included in these results. One subject was lost to follow up. Three blinded evaluators could correctly identify the pre‐treatment image compared to the post‐treatment image in an average of 64% of subjects. Subject satisfaction was high, with 70% stating they were satisfied to very satisfied on a five-point Likert Scale. Subject comfort was also high, as the average pain score reported using the Wong Baker, where 0 is no pain and 10 is the worst pain imaginable, was 3.1 out of 10. All but two subjects tolerated the entire treatment at maximum power (1.4 W/cm²); for one subject, the machine was turned off and restarted, and for another subject, the power was temporarily brought down to 1.2 W/cm². The ultrasound images compared between baseline to 12 weeks showed an average reduction in the abdominal adipose layer of 8.2%. 72% of subjects would recommend this treatment to a friend.

Conclusion

:

The results from this study highlight the safety and efficacy of a single treatment using a 1060nm (±10nm) diode laser to improve the appearance of unwanted fat in the abdomen. Quantitative ultrasound data demonstrated a significant reduction in adipose layer thickness of the abdomen at the 12-week follow up visit (8.2%). Additionally, treatment was associated with high satisfaction, with the majority of subjects reporting they were “satisfied” or “very satisfied” with their results. The treatment was well tolerated among all subjects, with only minimal discomfort reported. Though the majority of subjects experienced trace to moderate erythema and edema immediately post-treatment, these events are considered anticipated clinical responses and were only transient in nature. There were no long-term side effects or reports of adverse events during the study duration, providing further evidence to support the device’s safety in the indicated population. With the non-invasive device market continuing to expand and advance, the results of this study confirm the safe and effective application of the 1060nm (±10nm) diode laser for the improvement of unwanted fat in the abdomen and flanks. Future studies are evaluating the efficacy of multiple treatments in a single region.

Goals/Purpose

:

The aesthetic significance of the periorbital region of the human face has been appreciated since ancient times. The widespread popularity of techniques such as glabellar chemodenervation, brow lift, and blepharoplasty speaks directly to the importance that patients place on this region of the face. In the plastic surgery literature, most of what is considered an aesthetically pleasing outcome is based on instinctive analysis of the aesthetic surgeon, rather than on patient assessments, public opinions, or other objective means of evaluation.

We tested a commercially available artificial intelligence system trained and validated using the Amsterdam Dynamic Facial Expression Set, which contains highly standardized images of different emotional expressions. Using machine learning, this artificial intelligence system can analyze image data and provide an objective measure of facial expression, generating a relative breakdown of each of the 7 basic emotions as well as the action units associated with these emotions. We employed this system to measure the impact of the brow lift and associated rejuvenation procedures on the appearance of emotion while the patient is in repose.

Methods/Technique

:

We retrospectively identified all patients who underwent bilateral brow lift for visual field obstruction between 2006 and 2019. We excluded those patients without postoperative photos, ones with post operative photos without resolution of bruising, those with less than 6 weeks of post op photos, those with concomitant diagnoses such as facial paralysis, those with any Botox injection within the last 6 months prior to the pre or post operative photos, and patients who underwent complex head and face reconstructive procedures in addition to brow lift.

Images were analyzed using a commercially available facial expression recognition software package (FaceReader™, Noldus Information Technology BV, Wageningen, Netherlands). The data generated from the software reflected the proportion of each emotion expressed for any given facial movement and the action units associated.

Results/Complications

:

A total of 52 cases were identified after exclusion. We excluded 1 patient with unilateral brow lift, 2 patients with facial paralysis, 1 patient with multiple facial reconstruction procedures, 7 with less than 6 weeks post-operative photos or significant bruising in the last available postoperative photo, 3 patients with Botox injection, and 2 with no standardized postoperative photos. The endoscopic brow lift approach was used in 50 patients and the direct approach was used in 5 patients. 50 patients also had concurrent upper eyelid blepharoplasties, 9 had upper eyelid ptosis repair, 4 had canthopexies, 5 had facelifts, 5 had fat grafting to the face, and 14 had lower eyelid blepharoplasties. Average age at presentation was 61.6 years old (range: 36.5-86 years). Post-operative photos were obtained on average 53 weeks after the brow lift (range: 42 days to 11 years).

Emotion detected:

Preoperatively, the angry emotion was detected on average of 13.06%, the happy emotion averaged 1.68%, sad emotion averaged 13.06%, the scared emotion averaged 3.53%, and the surprised emotion averaged 0.97% among all the patients.

Postoperatively, the angry emotion decreased to 5.42% when averaging among all the patients (p=0.009). The happy emotion increased to 9.35% (p=0.0013), while the sad emotion decreased to 5.42%. The scared emotion remained relatively the same at 3.4%, and the surprised emotion increased to 2.01%, however, these were not statistically significant.

The action unit (AU) changes correspond to what can be expected after brow lift surgery, with less brow lowering AUs and more brow raiser AUs.

Conclusion

:

This study proposes a paradigm shift in the clinical evaluation of brow lift and other facial aesthetic surgery, implementing an existing facial emotion recognition system to quantify changes in expression associated with facial surgery. The use of software such as these opens the way to simple, real time, and objective evaluations of outcomes that are relevant for both surgeons and patients.

Goals/Purpose

:

Many patients are concerned about emotional expression after onabotulinum toxin A injection. We sought to investigate the effect of injection on expression using artificial intelligence.

Methods/Technique

:

Fifty-two female subjects (“expressors”) were recorded while viewing video clips intended as a mood induction procedure that stimulates surprise and anger emotions. The subjects were then injected with 25 units of onabotulinum toxin A in the glabellar region. All video clips from time periods before injection and 1 month after injection from the 10 maximal expressors were extracted and shown to a group of 31 “perceivers” who rated the facial expressions for intensity (Likert 1-7) and identity of emotion (percent correct emotion identified). The video expressions detected within each clip were analyzed using a commercially available facial expression recognition software package (FaceReader™, Noldus Information Technology BV, Wageningen, Netherlands). The data generated from the software reflected the proportion of each emotion expressed for any given facial movement and the action units associated.

Results/Complications

:

Glabellar paralysis significantly diminished mean perceived intensity of anger (50.4% relative reduction, p<0.001) and surprise (20.6% relative reduction, p<0.001). For anger videos before and after botox injections, angry emotions detected by the software decreased from 13.71% to 1.47% (p=0.062), and surprise emotions decreased from 5.08% to 4.2% (p=0.75). For surprise videos before and after botox injections, angry emotions detected decreased from 7.67% to 1.84% (p=0.75), and surprise emotions increased from 5.95% to 7.65% (p=0.125).

Conclusion

:

This study provides the first proof of concept for the use of a machine learning software application to objectively quantify facial expression before and after botox injections. The software results are consistent with human raters in detecting changes in anger, but give the opposite effect in term of surprise.

Goals/Purpose

:

Delivering competent care to transgender patients becomes especially critical as plastic surgeons continue to pioneer transgender surgery. When transgender patients access care, effective communication rooted in correct pronouns, terminology, and vocabulary ensures a safe environment by healthcare staff and establishes an understanding of transgender patients healthcare needs. This study’s aim is to explore the feasibility of improving knowledge of transgender-related care and increasing comfort and competence for health care providers with the use of a short, efficient, single-session training program.

Methods/Technique

:

We delivered training to professionals involved in post-op care for trans surgical patients and to medical students. The training sessions were given over one hour in one session. The format of the training was didactic with practice-based examples. To measure self-perceived ability and ease in providing care to transgender patients we measured outcomes before training and after training to determine self-perceived comfort and competence ranging from not competent/comfortable to very competent/comfortable To measure objective competence, we used a 6 item multiple-choice questionnaire. For analysis to determine the change on subjective and objective comfort/competence after training, two cohorts were established of surveyors consisting of high comfort/competence and low comfort/competence. We conducted McNemar's test to analyze paired proportions with a significance of p<.05. To determine if baseline comfort or competence predicted any positive change in objective competence after training, Pearson’s Chi-Squared Test with a critical value of .05 was conducted. Analyses were conducted using JMP Pro, Version 15 ( SAS Institute, Inc., Cary, NC, 1989-2019).

Results/Complications

:

96 healthcare providers completed our training and submitted pre-training evaluations and post-training surveys. Subjectively, the training increased the percentage of providers that self-reported as very comfortable ( 73%, 95%, p<.05) and very competent ( 41%, 93%, p<.05) in caring for transgender patients. In subjects who reported high competence before training, our workshop increased the percentage of providers ( pre-training=83%, post-training=92%, p<.05) who received at least an 80% in the objective questionnaire. Self-perceived low comfort providers at baseline showed a greater increase in the percentage of providers who objectively got a higher score after training compared to self-perceived high comfort providers. ( low comfort=42%, high comfort] 35%, p=.55). Self-perceived low competence providers at baseline showed a greater increase in the percentage of providers who objectively got a higher score after training compared to self-perceived high competence providers ( low competence=40%, high competence= 30%, p=.05).

Conclusion

:

Our short, single-session training session improved the comfort and competence of providers even in providers who reported subjective high competency at baseline. Providers who reported low comfort and low competence had better improvements in objective competence after our training session. The implementation of a short, interactive seminar like our workshop can be used to improve how care is delivered to transgender patients with improved provider knowledge of gender identity, gender expression, goals of care, sexual orientation, and transgender barriers. A nurturing provider-patient relationship built on trust is essential for the success of transgender surgical interventions that require patient compliance with invasive regimens preoperatively and postoperatively.

Goals/Purpose:

To evaluate the efficacy and safety of a single dose of abobotulinumtoxinA (50U, 75U, 100U or 125U) versus placebo in the treatment of moderate-to-severe glabellar lines, and to investigate the impact of dose escalation on duration of effect. The primary objective was to evaluate Month 1 composite investigator- and subject-assessed responder rate (≥2-grade improvement and glabellar line severity scale [GLSS] score 0 or 1) at maximum frown.

Methods/Technique:

In this 9-month, dose-escalating, double-blind Phase II study (NCT03736928), subjects received a single dose of abobotulinumtoxinA or placebo (randomized 4:1) for the treatment of moderate-to-severe glabellar lines. Stepwise enrollment was applied for the two highest dose levels to ensure safety. Assessments included investigator- and subject-assessed GLSS, time to onset, subject satisfaction (questionnaire; FACE-Q^1-3), aesthetic improvement and adverse events.

Results/Complications:

Each abobotulinumtoxinA dose group and the placebo group included ~80 subjects. The primary objective was met; the Month 1 composite 2-grade improvement responder rate was 80% (50U), 89% (75U), 90% (100U), and 95% (125U) compared with 3% (placebo), p<0.001. Median time to onset was 2 days; Month 9 responder rates (≥1-grade improvement, investigator-assessed) were 18% (50U), 26% (75U), 35% (100U) and 31% (125U). Aesthetic improvement was high. At Month 9, ≥89% of subjects reported natural-looking results, and ≥92% wanted to receive the same treatment again. Treatment-related adverse events were predominantly mild, transient, and similar across doses.

Conclusion:

AbobotulinumtoxinA was efficacious and well-tolerated across all doses, with rapid onset, duration up to 9 months and high subject satisfaction and aesthetic improvement.

References

1. Klassen AF, Cano SJ, Schwitzer JA, Baker SB, Carruthers A, Carruthers J, Chapas A, Pusic AL. Development and Psychometric Validation of the FACE-Q Skin, Lips, and Facial Rhytids Appearance Scales and Adverse Effects Checklists for Cosmetic Procedures. JAMA Dermatol. 2016;152(4):443-51.
2. Klassen AF, Cano SJ, Schwitzer J, Scott A, Pusic AL. FACE-Q scales for health-related quality of life, early life impact and satisfaction with outcomes and decision to have treatment: development and validation. Plast Reconstr Surg. 2015;135:375-86
3. Panchapakesan V, Klassen AF, Cano SJ, Scott AM, Pusic AL. Development and Psychometric Evaluation of the FACE-Q Aging Appraisal Scale and Patient-Perceived Age Visual Analog Scale. Aesthetic Facial Surgery, 2013; 33:1099-1109

Goals/Purpose:

Breast Implant Illness (BII) attributes symptoms of autoimmune illness, fatigue, myalgia, arthralgia, memory, and sleep disturbances to the presence of a breast implant prosthesis. In order to alleviate these symptoms, patients are electing to undergo explantation with capsulectomy. The purpose of this study was to evaluate the clinical effectiveness of explantation, capsulectomy, and mastopexy (E.C.M.) in patients presenting with BII, and prospectively analyze quality of life for patients following this procedure.

Methods/Technique:

Two hundred and thirty-two simultaneous explantation, capsulectomy, and mastopexy procedures were performed in 116 patients from 2014-2019. Fifty-six percent (n=65) of these patients presented with symptoms associated with BII. Prospective quality of life assessment was administered for all patients presenting with BII (100%). Inclusion criteria included a minimum postoperative follow-up of 6 months and completion of a practice-generated pre and post-operative patient reported outcomes (PRO) questionnaire. The PRO questionnaire consisted of 13 questions, where scoring was determined according to a 5-point Likert scale (1=extremely dissatisfied, 5=extremely satisfied for quality of life and breast aesthetics and 1=none, 5=very severe for symptoms). Clinical outcomes were analyzed including patient demographics, operative technique, breast implant specifications, complication rate and reoperation rate. Descriptive statistics were used to analyze patient demographics and clinical outcomes. Wilcoxon signed-rank test was performed to compare changes in quality of life scores.

Results/Complications:

Sixty-five patients were evaluated with a mean follow-up period of 23 months (6 mo to 5 yrs). Mean age and BMI were 42.3 years (26 – 62 yrs) and 24.6 kg/m², respectively. The primary breast implant procedure wasaugmentation (n=36, 55.4%) or augmentation-mastopexy (n=29, 44.6%). Multiple (≥ 2) previous breast procedures were performed in 27.7% (n=18) of patients prior to explantation. Average time from last implant surgery to the explantation procedure was 8 years 3 months (24 mo. to 20 yrs). All patients underwent bilateral explantation of submuscular (n=40, 61.5%) or subglandular implants (n=25, 38.5%), with capsulectomy, and simultaneous mastopexy. Mastopexy technique utilized was most commonly inverted “T” (n =49, 75.4%), followed by vertical (n = 16, 24.6%), based on a superior or superior medial pedicle. Silicone implants were explanted in 75.4% of patients (n=49) and saline in 24.6% (n=16). Mean fill volume of the implants explanted was 345 cc (250 – 550 cc). Mastopexy was coupled with simultaneous volume restoration though autologous fat grafting in 38.5% (n = 25) of patients, where the mean volume of fat transferred was 200 cc (range 120 - 300 cc). Of the 130 breast procedures performed, the complication rate was 3.1% (n=4), consisting of hypertrophic scarring (n=2 breasts), loss of nipple sensation (n = 1 breast), and areolar asymmetry (n=1 breast) with a reoperation rate of 2.3% (n=3).

Patient reported outcomes demonstrated a significant improvement in all quality of life domains, including physical well-being (p<0.005), psychological well-being (p<0.005), and sexual well-being (p<0.005) (Figure 1a). Patient satisfaction with regard to aesthetic outcomes also significantly improved, including overall breast appearance (p<0.005), breast shape (p<0.005), and breast size (p<0.005). With respect to BII symptoms, fifty-six patients (86.1%) noted reduced pain, myalgias/arthralgias, and fatigue after E.C.M (Figure 1b). However, nine patients (13.8%) reported no improvement in their presenting symptoms after explantation. Although, 96.9% of patients (n=63) would repeat the surgery, and 98.5% (n=64) would recommend the procedure to others suffering from BII. Sixty-two patients (95.4%) reported that they were satisfied or extremely satisfied with the aesthetic appearance of their breasts post-explantation.

Conclusion:

The emergence of patients presenting with “breast implant illness” has continued to increase in recent years. As a result, patients request breast implant removal and look to plastic surgeons to alleviate symptoms. This study presents an effective treatment paradigm to manage implant removal through simultaneous explantation, capsulectomy, and mastopexy with significant improvements in various quality of life domains. In patients for whom explantation is indicated and replacement was not an option secondary to BII concerns, ECM can be performed simultaneously with acceptable complication and reoperation rates, as well as improvement in overall breast aesthetic.

Goals/Purpose: Lateral canthopexy is a commonly used adjunct to lower blepharoplasty to support the lower lid during healing and to decrease the risk of lower lid retraction. Definitions of what constitutes a lateral canthopexy varies between authors. This ambiguity is further confounded by several technical approaches with unclear anatomic detail of the structure being grasped to tension the lower lid. The superficial lateral canthal tendon, inferior retinaculum, and orbicularis oculi muscle are described as targets for lateral canthopexy. The aim of this anatomic study is to elucidate which anatomic component of the lateral canthal area permits greater mobility and control of lower lid position during lateral canthopexy.

Methods/Technique: Four fresh cadaveric hemifaces were dissected utilizing 2.5x loupe magnification to define the lateral canthal area, with specific attention to identify the structure of the lateral canthal complex. Lateral canthopexy was then performed by selectively grasping the 1) lateral palpebral raphe (LPR), 2) superficial lateral canthal tendon (SLCT), 3) lateral canthal tendon (LCT), or 4) the lateral edge of the inferior tarsal plate (LEITP) and the excursion of the lower lid margin was assessed and recorded videographically. The insertions of the three components of the lateral canthal complex were then divided. Lateral canthoplasty was then performed by selectively grasping each component of the lateral canthal complex and lower lid excursion was reassessed.

Results/Complications: The three layers composing the lateral canthal complex, which are the LPR, SLCT, and LCT, were confirmed (Figure 1, A). The LPR loosely adherent to the SLCT and was relatively mobile. The SLCT on the other hand was immobile and rigidly fixed to the lateral orbital rim periosteum. The SLCT, also known as the lateral orbital thickening, was continuous with a stout fibrous ring that was fixed to the lateral orbital rim. This continuous fibrous structure continued superiorly as a well-defined strong septum originating from the arcus marginalis forming the inferior boundary of the retro-orbicularis oculi fat (ROOF). It continued inferiorly as the bilamellar orbicularis retaining ligament. Suture fixation of the LPR (Figure 1, B & C) and LEITP resulted in the greatest excursion of the lower lid margin. In contrast, lateral canthopexy utilizing the SLCT resulted in no movement of the lower lid (Figure 1, D & E). Excursion of the lateral canthus via the SLCT required extensive division of the broad SLCT periosteal insertion on the lateral orbital rim along. LCT plication was possible after division and reflection of the SLCT and resulted in minimal excursion of the lower lid.

Conclusion: Based on this anatomic study, the lateral canthal area can be divided into a mobile unit and a fixed unit. For a lateral canthopexy to cause tightening of the lower lid, it should target either the LPR, LEITP or the lateral orbicularis oculi muscle. In contrast, minimal lower lid excursion is observed if the SLCT or LCT are utilized – therefore, lateral canthoplasty is required with extensive release of the retaining ligaments for effective lower lid mobilization utilizing the SLCT or LCT.

Figure 1: Lateral Canthal Complex. A, The Lateral Palpebral Raphae (LPR) is in continuity with the orbicularis muscle and forms the most superficial component of the lateral canthal complex. The Superficial Lateral Canthal Tendon (SLCT) lies deep to the LPR. The SLCT has a broad stout attachment to the lateral orbital rim periosteum and is in continuity with the orbital septum and arcus marginalis. The Lateral Canthal Tendon (LCT) lies deep to the SLCT and inserts ~2mm inside the orbital rim (not shown). The inferior lid orbicularis muscle and orbital septum are reflected inferiorly and secured with suture. B & C, Canthopexy grasping the LPR results in the greatest excursion of the lower eyelid. D & E, Canthopexy grasping the SLCT does not result in lower eyelid excursion.

Goals/Purpose:

Rhinoplasty presents with a unique set of problems and challenges when performed in older adults. Moreover, the ageing nose is often defined by the following features: 1) ptotic nasal tip, 2) dorsal pseudo-hump, 3) nasal lengthening, 4) counter-rotation, and 5) acute nasolabial angle. In order to address these issues, plastic surgeons prioritize performing tip de-rotation with tip refinement, increasing tip projection and relative columellar lengthening through columella strut grafts, decreasing the overall nasal length, correcting the dorsal hump, supporting the internal nasal valves through dorsal spreader grafts, and correcting septal deviation and inferior turbinate hypertrophy, if present. This article presents a review the technical considerations in older age rhinoplasty and presents a case series of patients who underwent rhinoplasty at 55 years old or older. This case series illustrates how specific techniques were performed in order to address the aforementioned deformities and how these corrections were reflected through changes in anthropometric measurements from pre to post-operative (i.e. 12 months) timepoints.

Methods/Technique

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Demographics and operative details were analyzed. Information collected included basic demographic factors, which included ethnicity and insurance status, indications, reasons, and motivations for surgery, history of prior rhinoplasties, operative report details, which include the use of osteotomy, septoplasty, septal caudal extension grafts, L columellar strut grafts, spreader grafts, auto-spreader grafts, and tip onlay grats, anti-coagulation medications, age at the time of rhinoplasty, co-morbidities, ASA status, and tobacco status, and post-operative events, which included complications and incidence of revision rhinoplasties. Three-dimensional photographs were assessed using VECTRA (Canfield Scientific, Parsippany, N.J.) at two different time points (pre-operative and post-operative at 12 months). Standard facial anthropometric measurements, including nasal tip projection, nasolabial angle, nasal tip angle, were taken.

Results/Complications

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In our retrospective review of 27 patients, the vast majority were Caucasian (85%) and female (85%). Most underwent rhinoplasty for functional (89%) and aesthetic (70%) reasons, as opposed to traumatic (48%) events. This was similarly found in the literature, in which studies detail the utilization of septoplasty, turbinate co-ablation, spreader grafts, and spreader flaps in addressing symptoms of nasal obstruction, as well as the use of septal caudal extension grafts, L columellar strut grafts, and tip grafts to achieve tip projection and refinement. In terms of post-operative outcomes, there were no complications recorded, but five patients received revision rhinoplasties. Other post-operative surgeries included fat grafting, nasal valve reconstruction, and cartilage reconstruction.

Our case series include four patients who underwent rhinoplasty at an age greater than fifty-five years old. The first was a 72-year-old Caucasian female with internal valve collapse (inverted V), turbinate hypertrophy, and S-shape nasal deformity; she received septoplasty and turbinate ablation in order to address nasal obstructive symptoms; rib cartilage was harvested for dorsal augmentation and projection. The second patient was a 67-year-old male septal deviation, internal valve collapse (inverted V), as established by a positive Cottle maneuver, and saddle nose deformity; he underwent spreader grafts and auto-spreader grafts in order to address internal valve collapse, lateral crural articulating grafts for external valve incompetence, septoplasty and turbinate ablation for nasal obstructive symptoms, and tip onlay graft and septal caudal extension graft for tip refinement and projection. The third patient is a 69-year- old female who received spreader grafts and auto-spreader flaps for internal valve collapse, articulated alar rim grafts for external valve incompetence, osteotomies for nasal stabilization, and an infralobular graft for tip projection. The fourth patient was a 57-year-old Asian female presented septal deviation, internal valve collapse (inverted V), turbinate hypertrophy, external valve collapse, with slit like nares. Spreader grafts, turbinate ablation, and septoplasty were performed to resolve nasal obstruction; osteotomies were done to stabilize the bony vault; dorsal reduction was performed through rasping after tip complex refinement with a tip onlay graft. For these four patients, there were increases in Goode’s ratio, a measure of tip projection and in nasolabial angle after rhinoplasty.

Conclusion

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Rhinoplasty presents unique challenges and technical complexities when performed in the older adult population. This study details specific procedural approaches through a case-series, and assesses these techniques through a report of anthropometric measurements at pre- and post-operative timepoints. Our analyses found that indications for rhinoplasty and surgical techniques vary tremendously amongst patients who undergo rhinoplasty. General considerations include the restoration of tip projection and refinement, relief of nasal obstruction, correction of the dorsal hump, and stabilization of the nose and dorsum. In all, certain techniques did confer objective changes in anthropometric measurements, and also provided favorable aesthetic and functional outcomes within our cohort of 27 patients. To fully understand the long-term clinical outcomes of older age rhinoplasty, future studies could incorporate a combination of surveys to assess functional outcomes, anthropometric measurements, and specific techniques performed by plastic surgeons.

Goals/Purpose: There were almost 12 million nonsurgical cosmetic procedures performed in the United States in 2016, which represented a 12% increase from the previous year, and popularity is expected to continue rising. Furthermore, nonsurgical fat reduction and body contouring have seen a dramatic increase in popularity among both men and women. However, there has been very little work focused on the public’s perception of the ideal abdominal muscles. Thus we sought to analyze patient perspectives on ideal abdominal contours and attitudes towards methods of improving the appearance of the abdomen.

Methods/Technique: A prospective cross-sectional study of 718 random volunteers recruited through Amazon Mechanical Turk© was conducted. A survey instrument was administered to all study participants to assess the importance of ab symmetry, pec muscle definition, serratus muscle definition, and natural feel.

Results/Complications: Study participants across all ages, gender, ethnicity, and marital status indicated that a 6-pack was the ideal abdominal muscle count. They also rated the symmetry (61.06 ± 1.87) and natural feel of abs (60.72 ± 1.75) as the two most important aesthetic features in consideration of ideal abs. Study participants who reported exercising more than twice a week expressed a greater interest in nonsurgical procedures to achieve ideal abs (p = 0.007).

Conclusion: “Ideal Abs” are six in number, symmetric and feel natural. Millennials are much more willing to consider nonsurgical options to achieve ideal abs than surgery. Individuals who maintain a high level of fitness are interestingly, more likely to want ideal abs and nonsurgical methods to achieve them.

Goals/Purpose: Physical appearance of the face plays a critical role in the social life of a person. Several studies concluded that there is a direct correlation between a patient and their self-image, which can be drastically altered by the perceptions of others. This can have a negative effect on the self-esteem of a patient, resulting in anxiety, depression, and other psychological disorders, and subsequently social avoidance which may exacerbate these conditions. Recently, it has been proposed that psychosocial concerns may motivate the demand for aesthetic rhinoplasty. Although successful operations often improve the quality of life and self-esteem symptoms in patients with sound mental health, they may actually result in unsatisfactory outcomes in those patients with significant depression, anxiety, or other severe psychological disorders. As such, the purpose of this study was to assess the incidence of psychological disorders in patients seeking rhinoplasty.

Methods/Technique: A prospective cross-sectional study of 298 random volunteers was conducted, with each participant completing a survey instrument that was administered through an internet crowd-sourcing service (Amazon Mechanical Turk©). Participants were asked to complete a 10-item standardized SHNOS scale, and a 26-question PRIME-MD questionnaire in order to assess functional and aesthetic need for rhinoplasty, and the incidence of psychological disorders respectively. Participants were also asked to assess their satisfaction with the overall appearance of their nose both before and after administration of the survey in order to evaluate response bias.

Results/Complications: A total of 298 volunteers successfully completed the survey, with only 5.03% of survey participants demonstrating a response bias after completing the PRIME-MD questionnaire. With respect to gender, 38.95% of female participants reported a willingness to undergo aesthetic rhinoplasty, with a significantly lower number of men reporting the same (27.78%, p = 0.042). There was also a significantly higher percentage of young adults between the ages of 18-24 (52.92%) willing to undergo aesthetic rhinoplasty, as compared to any other age group (p < 0.01). Income further demonstrated a significant role in the willingness to undergo aesthetic rhinoplasty, with 47.37% of individuals with annual household income of $50,000-$75,000 interested in rhinoplasty, while only 32.41% of individuals with income less than $50,000 interested in rhinoplasty (p = 0.033). Of those participants that were satisfied with the overall appearance of their nose, 15.32% still reported a willingness to undergo aesthetic rhinoplasty. Furthermore, 57.84% of patients interested in surgery reported a psychological disorder as determined by the PRIME-MD questionnaire.

Conclusion: The results of this study, as a reflection of the general US population, demonstrate that a majority of individuals interested in aesthetic rhinoplasty may be suffering from a mental disorder. Those suffering from major depressive disorder, generalized anxiety disorder, or body dysmorphic disorder may seek aesthetic rhinoplasty as a solution. As such, is important that surgeons assess patient mental health prior to treatment in order to avoid unsuccessful outcomes secondary to psychosocial illness.

Goals/Purpose: Common treatment for chronic migraine headaches include injection of corticosteroid and anesthetic agents at local trigger sites. However, the effects of therapy are short-term and lifelong treatment is often necessary. In contrast, surgical decompression of migraine trigger sites accomplishes the same goal yet demonstrates successful long-term prevention of chronic migraines. In addition to cost considerations, patients and physicians must discuss quality of life implications of various treatment options. These include characteristics of treatment such as the probability of a successful outcome, adverse events associated with treatment, contraindications, duration of treatment, inpatient and outpatient visits, and overall changes in quality of life before and after treatment. Therefore, analysis is necessary to determine the complex interplay between the quality of life conferred to patients and cost of the available treatment options for chronic migraine disorders. As such, our primary objective was to perform a cost-utility analysis to determine which patients would benefit most from available treatment options in a cost-conscious model.

Methods/Technique: A cost-utility analysis was performed in consideration of costs, probabilities, and health state utility scores of the opposing interventions. Amazon Mechanical Turk© crowdsourcing was used to derive utility scores associated with surgical decompression and injection therapy. A systematic review was also performed to identify common complications of treatment and their associated probabilities. Direct costs were derived from national Medicare facility reimbursement data and outpatient care billing data for fiscal year 2017, and indirect costs were accounted for by our utility estimates.

Results/Complications: Injection therapy offered a minor incremental benefit in quality-adjusted life-years greater than surgical decompression (QALY Δ = 0.6). However, long-term injection therapy was significantly costlier to society than surgical decompression, with treatment estimated at $106,887.96 greater than the cost of surgery. The results of our cost-utility analysis thus conferred a positive ICUR of $178,163.27 in favor of surgical decompression.

Conclusion: Surgery provides a durable intervention and has been shown in this study to be extremely cost-effective despite a very minor QALY deficit in comparison to injection therapy. If patients are identified that require treatment in the form of injections for less than 8.25 years, they may fall into a group that should not be offered surgery.

Goals/Purpose: Facelift continues to be one of the most common aesthetic procedures performed in the United States. Although there exist many techniques and variations, SMAS manipulation, by way of plication, overlap or SMASectomy are common and have been shown to result in favorable cosmesis and durability. However, there is a lack of current complications data in the discussion of this technique. In this study, operative outcomes of facelift procedures performed at a private outpatient center were examined in order to determine complication rates of SMAS manipulating procedures as compared to other techniques. Additional perioperative benefits of SMAS dissection, including decreased anesthesia time and overall operative time, which may decrease patient risk factors of DVT and improve overall outcomes, were also explored.

Methods/Technique: The records of all patients who underwent a facelift procedure between December 2004 and March 2019, were reviewed for this study. All procedures were performed at an AAAASF-accredited outpatient facility in Marina Del Rey, California. This represents data on 241 total patients. Retrospective chart review was performed to include data on patient characteristics, operative technique, and complications.

Results/Complications: Average operative time of 152.68 ± 51.50 minutes and anesthesia time of 175.00 ± 54.07 minutes was observed amongst those patients that underwent SMASectomy. This was significantly lower (p < 0.000001) than those that did not undergo SMASectomy (average operative time of 265.25 ± 85.25 minutes and anesthesia time of 294.22 ± 85.31 minutes). There were no observed facial nerve injuries among patients that underwent SMASectomy, and this technique was not associated with a significant increase in overall complications (p = 0.602). Caprini scores were also calculated for 148 patients (61.41%), with a mean score of 4.28 ± 1.62, representing an average moderate risk of DVT among these patients (Figure 6). However, no DVT events were observed in this patient population.

Conclusion: In the hands of an experienced surgeon, the SMASectomy facelift technique offers the unique advantage of significantly reducing operating time and anesthesia time and can provide extremely favorable and long-lasting aesthetic results. In addition, there may be a reduced risk of thromboembolic events due to less total time in the operating room. The authors recommend that SMASectomy be the primary facelift technique offered to patients both for the reduced potential VTE risk, as well as for the exceptional aesthetic outcomes already well documented in the literature.

Goals/Purpose:

Patient-centered language is fundamental to professionalism. Unlike other surgical fields, the language used in aesthetic surgery has largely been influenced by marketing and popular culture, rather than scientific terminology. Yet, little is known regarding how patients perceive informal terminology in aesthetic surgery. Since unprofessional language may negatively affect the patient-surgeon relationship, we sought to understand how a set of commonly used aesthetic surgery terms is perceived by aesthetic surgery patients. We hypothesized that some patients would find these terms inappropriate, representing an opportunity for improved professional communication.

Methods/Technique:

After institutional review board approval, a survey instrument was iteratively revised through pre-pilot testing. The instrument was pilot tested (n=25), and internal validity was assessed by computation of Cronbach’s alpha (0.86). Between July and August 2020, we invited 898 aesthetic surgery patients to participate in the anonymous online survey. All patients over 18 years old who were scheduled to undergo a cosmetic plastic surgery procedure between January and December 2019 at Vanderbilt University Medical Center were invited by email. No invitations were returned to the sender. Two subsequent email requests were sent to non-respondents.

Results/Complications:

347 patients completed the survey (38.6%). The median age was 51 years, most were female (95.7%), and the majority identified as white (85.6%). The demographic information of respondents and non-respondents were comparable (non-respondent median age = 50 years; 92.8% female; 76.6% white).

Over a third (37.3%) of respondents perceived the phrase “mommy makeover” as inappropriate when discussing aesthetic surgery after pregnancy, and over a quarter (25.9%) disapproved of the term “nose job.” Two thirds (66.0%) felt the phrase “boob job” is inappropriate. A third (33.7%) reported that the terms “top” and “bottom” surgery are inappropriate when discussing gender-affirming surgery. Nearly half (44.7%) perceived the term “turkey neck” as inappropriate, and 29.2% disapproved of the phrase “love handles.” However, a majority (73.1%) felt the phrase “tummy tuck” is appropriate when describing aesthetic abdominal surgery. Nearly three-quarters (70.9%) preferred, or were neutral about, the exclusive use of medical terms when discussing aesthetic surgery.

Conclusion:

Many patients found the informal language of aesthetic surgery to be inappropriate. In open response comments, patients characterized common phrases as “degrading,” “patronizing,” and “a barrier to clear communication.” For these patients, informal terminology may be perceived as unprofessional and may harm the patient-surgeon relationship. Since most respondents prefer, or were neutral about, the exclusive use of medical terminology, avoiding non-medical terms is generally the most patient-centered approach to communication. Although some patients may use informal aesthetic surgery terms in conversation and may not recognize or understand the medically equivalent term, surgeons should only use informal language when it reflects the patient’s preferences. It should not be the default among all patients. When informal terms are used, we encourage the adoption of body-positive language and advocate against the use of misogynist terminology or conceptions. To maintain the highest level of professionalism, surgeons should strive to use patient-centered language, and this may require rethinking the current vernacular of aesthetic surgery.

Goals/Purpose

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We describe the one-stage surgical technique that has been used by the senior author for the past 30 years for all his primary grade 2 and 3 augmentation/mastopexies. The article provides a safe, simple and reproducible approach to a challenging procedure. The use of the inferior pedicle for the mastopexy, in a presence of a sub-musculofascial augmentation, rather than a lesser procedure as described in the literature, gives us the freedom to relocate the breast in front of the implant with a tighter skin brassiere. The major benefit of this procedure is that it provides a long-lasting result and makes any future maintenance procedures related to aging of the breast, easily manageable without running the risk of bottoming, implant extrusion, or necrosis.

Methods/Technique

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In our chart review, we identified 124 patients who underwent primary one-stage augmentation /mastopexies in the past 30 years. As we will demonstrate in our intraoperative pictures we start preoperatively by marking only the midclavicular and inframammary fold lines with the patient in the upright position.

Breast augmentation is then performed with smooth round silicone implants, using a 4 cm inframammary fold incision centered exactly under the nipple/areola complex. A sub- musculofascial augmentation is then performed as described by Dr. Bostwick. The sub-musculofascial plane is then approximated completely in two layers at the muscle layer and the subcutaneous tissue layer. With the implants in place and the patient in the upright position, we then complete the Wise pattern markings for an 8-9 cm. in width, inferior pedicle with its base centered over the closed augmentation incision.

The inferior pedicle is then de-epithelialized and sectioned in the usual fashion. Lateral, medial and superior skin excisions may include underlying tissue, if needed, for better contouring of the breast with the implants in place. Since 2006 we include a transverse plication of the pedicle as described by Dr.Mark Rubin, and thereby shortening the length of the pedicle. We choose to mark the new nipple-areolar position after the closure of the T incision.

Results/Complications

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One hundred and twenty-four patients ranging from 26-61 years old underwent one-stage augmentation mastopexy with a split inferior pedicle and approximately 40% of these were smokers. The follow up of the cases ranges from 2 months to 20 years. From 1990-1999, some of our patients were lost to follow up due to the relocation of our practice from Florida to Greece. We present only the primary correction of Grade 2 and Grade 3 ptosis with augmentation mastopexy using the Wise pattern. We do not include vertical and crescentic excision combined with augmentation or any secondary procedures related to the correction of double bubble, waterfall phenomenon, capsular contracture or corrective procedures related to the aging of the breast. Minor complications included three augmentation and one mastopexy hematomas that needed evacuation; four superficial T-point sloughing; and six marginal areolar superficial sloughs. We did not have any infections, implant extrusions or nipple loss.

We do not consider as complications secondary maintenance procedures related to aging and scar revisions.

Conclusion

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The technique described is a combination of an inframammary fold sub-musculofascial breast augmentation and an inferior pedicle mastopexy centered over the augmentation incision. Therefore, the inferior pedicle is transversely split at the inframammary fold by the augmentation incision. Even though it sounds unorthodox for the vascularity of the inferior pedicle this incision does not compromise the viability of the flap. This technique has been proven to be a workhorse in our practice.

The advantages of this procedure for a long-lasting result are derived from the use of the smooth silicone implants, the coverage of the implants at the inferior pole by the musculofascial layer and the versatility of the tightening of the skin brassiere that the inferior pedicle with the Wise pattern allows. This procedure also makes it technically easy to perform any long term revisions the patient may benefit from, in the decades to come.

Goals/Purpose

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The objective of this study was to understand which anthropometric measurements and angles determine attractiveness in young Asian eyes. The goal of this study was to discover the most important features of attractiveness in Asian eyes to help guide surgical techniques.

Methods/Technique

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Frontal facial photos of young Asian women (approximately mid-twenties) were collected from publicly available sources online from August to October 2020. Photos with excessive makeup distorting anatomy, non-neutral expressions, ptosis, a monolid crease, or a negative intercanthal tilt were excluded. The periorbital region of each eye was cropped and all left eyes were reflected across a vertical axis to gather a collection of only right eyed images. These images were evaluated by 10 people of varying ethnicities, age, and occupation on a likert scale of 1-5 determining attractiveness. Images were subsequently standardized by iris diameter and analyzed using ImageJ software. Thirty-eight measurements relating various eye anatomy were collected from each attractive and unattractive eye. Finally, peak points from the brow, upper lid crease, upper lash line, and lower lash lines were imposed on a golden spiral to determine goodness of fit for the attractive and unattractive eye cohorts.

Results/Complications

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A set of 322 young Asian eye photographs were evaluated for attractiveness. Eyes that received a majority rating of ³ 4 from 10 evaluators were designated as attractive, while those that received a majority rating £ 2 were deemed unattractive. These thresholds were set to find only the most significant differences between the attractive and unattractive cohorts. A total of 66 attractive eyes and 43 unattractive eyes were compared using 38 unique measurements.

Peak Points

The distance from the superior brow peak to the lateral canthus was significantly smaller in attractive eyes, 23.02 ± (2.7) mm compared to unattractive eyes 26.18 ± (3.09) mm, (p=<0.001). The angle of the superior brow peak was lower than that of the upper lid crease peak and upper lash line peak from the pupil center in attractive eyes 65.38 ± (7.76), compared to unattractive eyes, 72.08 ± (9.98), (p<0.001). The upper lid crease and upper lash line peaks were approximately 8-9 degrees medial to the superior brow peak in attractive eyes compared to ~6 degrees lateral in unattractive eyes, (p=0.01).

Upper Lid Show and Pretarsal Show

The upper lid show at the punctum, medial limbus, mid-pupillary line, lateral limbus, and lateral canthus were all significantly smaller in attractive eyes. The ratio of the upper lid show to pretarsal show in attractive eyes was less than in unattractive eyes at the lateral canthus (2.74 ± (1.16) vs 3.48 ± (1.82), p=0.04). and medial limbus (3.8 ± (1.9) vs 6.01 ± (4.45), p=0.01).

Palpebral Aperture to Upper Lid Show Ratios

The maximum palpebral aperture height was not significantly different across groups (10.94 ± (1.24) vs 10.8 ± (1.33), p=0.70). However, when comparing ratios of the aperture heights to upper lid show along the punctum, medial limbus, mid-pupillary line, and lateral limbus, attractive eyes had greater ratios than unattractive eyes. For example, at the mid-pupillary line the palpebral height to upper lid show ratio was ~2:1 for attractive eyes compared to ~3:2 for unattractive eyes, p=<0.001.

Miscellaneous Measurements

Intercanthal height, tilt, and medial canthal angle were not significantly different across groups. However, the angle of the lower lash line as it bends at the punctum was greater in attractive compared to unattractive eyes. This angle measures the smoothness of curvature of the lower lash line. The distance from pupil center to the lateral canthus was lower in attractive eyes, 12.75 ± (1.69) vs 13.68 ± (1.21), p=<0.001.

Conclusion

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The features determining attractiveness in Asian eyes may be different than in Caucasian eyes. While in Caucasian eyes a greater positive canthal tilt, higher ratio of upper lid show to pretarsal show, and lateralized peak points deem attractiveness, in attractive Asian eyes these relationships do not hold true.

In attractive young Asian eyes the superior brow peak position is far more important and its relation to the peak points of the upper lid and upper lash line. In fact, these peak points may be medialized in the Asian eye and still be attractive so long as the superior brow peak is more lateral. Furthermore, in Asian eyes, the ratio of palpebral heights to upper lid show seem to be more important than pretarsal show. An understanding of these proportions can help guide double-eyelid surgery, brow lifts, and filler injections. Finally, too great of a distance from the center of the pupil to the lateral canthus may lead to an unattractive eye, which has important implications for the planning of a lateral canthoplasty or canthopexy.

While the golden spiral has been purported to have significance in attractive eyelid topography in Caucasian eyes, we found that it does not have much relevance in determining attractiveness in Asian eyes.

Goals/Purpose:

The aging process of human skin is characterized by a thinning of the dermis, atrophy of the extracellular matrix, and reduced collagen synthesis. Loss of collagen in the dermis is an aesthetic concern, as it is the main structural support in the dermis. Its loss, therefore, results in skin laxity. The use of non-invasive and minimally-invasive aesthetic treatments to reduce signs of aging has gained increasing popularity. Devices utilizing several different types of energy have been developed, including laser, radiofrequency, and ultrasound. Bipolar fractional radiofrequency devices use microneedles and a controlled thermal injury to stimulate neocollagenesis and neoelastosis. The purpose of this study was to evaluate the safety and tolerability of a bipolar fractional radiofrequency device on submental tissue and its effect on skin tightening and contour change.

Methods/Technique:

This single-center, unblinded, non-randomized study enrolled 15 qualified and consenting subjects between the ages of 21 and 70 years old. Exclusionary criteria included, but was not limited to immunosuppression; use of anticoagulants; history of photosensitivity; pregnancy or nursing; excessive skin laxity; scarring, tattoos, metal implants, or open wounds in the treatment area; use of oral retinoids or corticosteroids within the past 6 months; arrhythmias or other significant cardiac history, including pacemaker implantation; radiation therapy in the treatment area; or any skin pathology that could interfere with treatment or evaluation. After receiving a local anesthetic of 1% lidocaine with epinephrine 1:200,000, each subject received one bipolar fractional radiofrequency microneedling treatment (Candela Medical Ltd., Wayland, Massachussetts) to the submentum. Subjects followed up three- and six-months post-treatment. At every visit, standard and 3D photography were performed. Non-invasive measurements, including transepidermal water loss (TEWL), high-resolution ultrasonography, optical coherence tomography (OCT), and BTC-2000 were also taken. Finally, microbiopsies, 0.33mm in diameter, were collected in the midline of the submentum at the treatment and two follow-up visits. During the treatment, subjects were asked to assess their level of pain on an 11-point scale. Blinded photo evaluations were performed by three physicians, who were subsequently unblinded to assess any observed changes using the Global Assessment Improvement Scale (CGAIS).

Results/Complications:

All subjects experienced pinpoint bleeding at the microneedle insertion sites during the treatment, but it was ensured that any bleeding had ceased before subjects left clinic that day. Erythema, edema, and bruising was noted in all subjects post-treatment, with average scores of 2.63, 2.00, and 1.88, respectively, on a scale of 0 (None) to 4 (Extreme). However, all of these reactions are anticipated and subjects reported that they resolved within days or up to 2 weeks post-treatment. No burns, crusting, hypo- or hyperpigmentation, or any unanticipated adverse events were noted in any subjects either during treatment or in the follow-up phase. Patient comfort during treatment was also high, as the average pain score reported with use the of local anesthetic was 2.0 out of 10.

Using the Markerless Tracking feature on the H2 3D Imaging System (Canfield Scientific, Parsippany, New Jersey), skin surface changes and volume difference of the submentum were calculated, demonstrating a statistically significant contour change after the single treatment. The three evaluators noted a clear improvement in the appearance of the submentum, both based on blinded photo evaluations and CGAIS scoring. Additionally, the microbiopsy samples were used to correlate changes seen in the non-invasive skin measurements with histology and gene expression. The levels of extracellular matrix proteins, such as collagen, elastin, and hyaluronic acid, were measured and compared between baseline and the follow-up visits, as well as the relative expression of inflammatory markers.

Conclusion:

The results from this study illustrate the safety and tolerability of a single treatment using a bipolar radiofrequency microneedling device to tighten submental tissue. Both non-invasive skin measurements and microbiopsy data demonstrated objective changes in skin architecture after treatment. The treatment was well-tolerated among all subjects, with only minimal discomfort reported after injection of a local anesthetic. Though subjects experienced mild to moderate erythema, edema, and bruising as a result of treatment, these side effects were anticipated and resolved within 2 weeks of treatment. There were no adverse events related to either the device or the treatment throughout the course of the study. Additionally, 3D imaging demonstrated a significant lift and contour change within the treatment area. Further studies may evaluate a larger sample size or the feasibility and tolerability of this treatment on other regions of the body.

Goals/Purpose

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With advancements in device technology and availability, there is a demand among some patients for non-surgical and minimally invasive options for facial rejuvenation. Although Botox remains the most common aesthetic procedure performed by plastic surgeons, there are many other neurotoxins and fillers currently available for the treatment of wrinkles. Radiesse (calcium hydroxylapatite) and Sculptra (poly-L-Lactic acid), for example, are dermal fillers FDA-approved to smoothen moderate to severe facial wrinkles and folds. There are also non-surgical and minimally invasive options for the treatment of skin laxity. Tissue heating with microfocused ultrasound targets the deep dermis and subcutaneous tissue, where focused damage is thought to cause collagen remodeling and resultant skin tightening. Microneedling with bipolar fractional radiofrequency induces both mechanical and thermal damage. The microneedling treatment inflicts injury on the skin, resulting in the wound healing process and resultant collagen production. Additionally, the heat generated by radiofrequency is thought to lead to collagen denaturation and remodeling, as well as a reduction in adipose tissue.

While these procedures are routinely performed in many clinics, limited investigation has been undertaken to examine their effects on subcutaneous tissue. In particular, the degree of inflammation beneath the skin associated with these dermal treatments has not been evaluated in either human or animal models. The objective of this study, therefore, is to investigate the long-term subcutaneous effects of these four minimally invasive aesthetic treatments.

Methods/Technique

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After receiving approval from the university Institutional Animal Care and Use Committee (IACUC), four aesthetic procedures were performed, each at two abdominal sites, on the abdomen of a pig (eight treatment sites total). These treatments included two injectables, 1cc of calcium hydroxylapatite (Radiesse; Merz North America, Inc., Raleigh, North Carolina) and 5cc of poly-L-lactic acid (Sculptra Aesthetic; Galderma Laboratories, L.P., Fort Worth, TX), as well as a bipolar fractional radiofrequency microneedling treatment (Profound System; Candela Medical, Wayland, Massachussetss) and a microfocused ultrasound treatment (Ulthera; Merz Aesthetics, Raleigh, North Carolina), both over a 2 in. x 2 in. area. All four aesthetic treatments were conducted in the same session under general anesthesia using 0.04 mg/kg atropine. The areas that received treatment were tattooed to identify the location and type of treatment performed. An untreated area was also marked to serve as a control. 90 days post-treatment, the treated skin and underlying subcutaneous tissue, as well as the control area, were excised to examine any histological changes resulting from the treatment. Additionally, gene expression assays of the treated skin and subcutaneous tissue were performed to assess for inflammatory markers.

Results/Complications

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All four aesthetic procedures were successfully performed without complication. In the four areas treated with calcium hydroxylapatite and poly-L-Lactic acid, mild pinpoint bleeding and edema was noted immediately post-injection, which subsided within minutes. Following bipolar fractional radiofrequency microneedling treatment, transient pinpoint bleeding was also observed, as well as mild bruising and moderate edema and erythema, all of which are anticipated reactions. The bruising, edema, and erythema resolved within 2 weeks of treatment. Microfocused ultrasound is a non-invasive treatment, and only mild, transient erythema was noted immediately following treatment. No aesthetic complications or unanticipated adverse events occurred as a result of the procedures.

Biopsies from the eight abdominal sites, as well as the untreated area, were successfully extracted for histology and gene expression analysis. Histologic staining allowed for visualization of the skin architecture, including the epidermis, dermal-epidermal junction, and subcutaneous layer. No significant changes were noted in the subcutaneous tissue following injection with either filler. After treatment with both energy-based devices, changes in the expression levels of extracellular matrix genes, as well growth factors and inflammatory genes, could be measured in the excised samples, even 90 days post-treatment.

Conclusion

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The results of this exploratory study highlight the impact several dermal aesthetic treatments have on deeper subcutaneous tissues and immune activity within the skin. While subcutaneous effects are anticipated with microfocused ultrasound, which is known to target the deep dermis and subcutaneous tissue, bipolar fractional radiofrequency microneedling technology is often advertised as producing a controlled thermal injury specifically to the dermis. Gene expression analysis, however, showed evidence of inflammatory processes in the subcutaneous tissue, deeper than what is originally anticipated. These results may be used to educate both future patients and clinicians on previously unknown risks to underlying tissues beneath the intended dermal treatment area.

Goals/Purpose

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Acne vulgaris is a common, chronic inflammatory condition that can result in permanent scarring. Although there is no gold standard treatment for this condition, there are a number of options currently in use or under investigation. Microneedling, which has been assessed over the past two decades, has been shown to improve the appearance of atrophic acne scars based on blinded photo evaluations. Additionally, histologic analyses have demonstrated increases in collagen types I, III, VIII, as well as total elastin levels. Other modalities under investigation include laser resurfacing, particularly with carbon dioxide (CO₂) and Erbium:YAG lasers, and chemical peels. Finally, dermal fillers can be used to increase volume and fill in depressed scars, leading to a smoother appearance in skin texture. Injectable solutions that have been evaluated include hyaluronic acid, poly-L-lactic acid, calcium hydroxylapatite, human collagen derivatives, or autologous fat. Autologous fat offers the benefit that there is no risk of allergic reaction, as the filler is derived directly from the patient. Several studies have been conducted to assess the effects of this treatment, but have been limited to subjective measures of evaluation, such as blinded photo reviews and patient satisfaction surveys.

The purpose of this study was to assess the efficacy and tolerability of autologous fat grafting in men and woman with facial acne scars.

Methods/Technique

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This single-center, non-randomized, pilot study enrolled up to 15 subjects between the ages of 21 and 50. Each subject presented for a single autologous fat grafting treatment to their facial acne scars. Harvest sites included the abdomen, hips, or inner thighs, depending on the subjects’ body fat distribution, and were anesthetized with a local injection of 1/4% lidocaine with epinephrine 1:200,000 prior to harvest. After centrifuging the fat and anesthetizing the subject’s face with a local injection of 1% lidocaine with epinephrine 1:200,000, the aspirate, containing 90% fat and 10% oil, was injected into the regions of the face where acne scars were present. Subjects returned for follow-up visits three months and six months post-treatment.

At each visit, standard and close-up photographs were taken. Antera 3D imaging (Miravex Limited, Dublin, Ireland) was also performed to measure changes in skin texture and volume. The VISIA Complexion Analysis System (Canfield Scientific, Parsippany, NJ) obtained standard, cross-polarized, and UV photographs to analyze skin tone, texture, wrinkles, pore size, actinic sun damage, and porphyrins. Non-invasive measurements, including transepidermal water loss (TEWL), high-resolution ultrasonography, optical coherence tomography (OCT), and BTC-2000 were performed at the treatment and two follow-up visits. Microbiopsies, 0.33mm in diameter, were collected from a deep-pitting acne scar on the cheek, of which the exact location depended upon the subject’s clinical presentation. Finally, blinded photo evaluations were performed, and the Global Assessment Improvement Scale (GAIS) was completed by clinicians and subjects at the two follow-up visits.

Results/Complications

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All subjects experienced mild bleeding at the harvest and injection sites. The harvest sites were closed with absorbable sutures, and any bleeding at the injection sites ceased within minutes of completing the procedure. Mild edema, bruising, and erythema was also noted in all subjects post-treatment, but this is an anticipated reaction and resolved within 72 hours of treatment. Subjects reported that with local anesthesia, any discomfort associated with the procedure was minimal. No infections or any unanticipated adverse events were reported throughout the course of the study.

Antera 3D Imaging, VISIA Complexion Analysis, and OCT measurements showed a statistically significant improvement in skin roughness and texture. Additionally, microbiopsy analysis was used to correlate changes seen with the non-invasive skin measurements. At the follow-up visits, the relative intensities of several extracellular matrix genes were increased, and skin architecture was visualized using both Trichrome and hematoxylin and eosin (H&E) staining. The two clinician reviewers noted a clear improvement in subjects’ facial acne scars, both based on blinded photo evaluations and CGAIS scoring. Additionally, subjects reported that the appearance of their skin was much improved from the initial condition.

Conclusion

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The results of this study demonstrate the safety and tolerability of autologous fat grafting as a minimally invasive treatment of facial acne scars. The treatment was well-tolerated among subjects, with minimal discomfort reported after injection of local anesthesia. Subjects experienced bruising, edema, and erythema following treatment, all of which were mild and transient. Objectively, 3D imaging and non-invasive measurements showed a statistically significant improvement in measured skin roughness and texture. Additionally, microbiopsies were successfully extracted for histology and gene expression analyses. Subject satisfaction was high, and clinician photo evaluations demonstrated a perceived improvement in the appearance of the subjects’ acne scars. Further studies may recruit a larger sample size or evaluate the long-term efficacy of this treatment past six months.

Goals/Purpose:

Along with the face, neck and chest, hands are to visible signs of aging. As in other parts of the body, human aging on the dorsal hand is characterized by thinning of the dermis and reduced collagen synthesis. Loss of dermal collagen results in skin laxity and the appearance of crepiness and wrinkles. Additionally, photo-damage, mostly due to ultraviolet radiation, causes degradation of elastic fibers and the appearance of dark spots. Finally, soft tissue atrophy and resultant volume loss expose underlying structures, such as veins, tendons, and joints, and bony prominences. Hand rejuvenation procedures, including sclerotherapy, fillers, microneedling, laser resurfacing, and intense pulsed light therapy, are commonly used by plastic surgeons to combat the processes that cause aging of dorsal hand skin. Objective tools to evaluate the efficacy of these cosmetic treatments are therefore needed.

To date, the Merz Hand Grading Scale is the only hand grading scale that has been validated for the assessment of dorsal hand aging. This scale, however, is limited, in that it only evaluates volume loss. As other factors also contribute to the appearance of aged hands, more scales that take these additional components into account must be created.

The objective of this study was to develop three validated scales for the assessment of signs of dorsal hand aging. The goal was to determine whether photographic classification systems of wrinkles and spots, both intensity and density, can be used consistently to objectively characterize the dorsal hand.

Methods/Technique:

Three numerical scales were created in this study. The Dorsal Hand Wrinkle Scale ranges from Grade 0 (no wrinkles) to Grade 4 (deep wrinkles with defined edges), while the Dorsal Hand Pigmentation Density and Intensity Grading Scales are four-point scales ranging from Grade 0 (no dark spots) to Grade 3 (severe dark spots). One dorsal hand was photographed and edited in Adobe Photoshop (Adobe Systems, San Jose, CA) to create a visual representation of all three scales. Additionally, sample subject photos were chosen for each grade as further reference.

Up to 50 healthy volunteer subjects with Fitzpatrick skin types I-IV were recruited for this study. Exclusionary criteria included any unique features on the dorsal hands that could result in subject identification and any excess hair or skin conditions that might interfere with classification. Images of the left and right dorsal hand were taken using a Nikon D7100 in the Department of Plastic Surgery professional photography studio. Using up to 25 randomized photos, five reviewers were trained on the three scales. Additionally, evaluators were asked to provide a score for the validated Merz Hand Grading Scale. After a discussion of grading decisions, the reviewers viewed the 75 remaining photographs and assigned a grade to each photograph for the three investigational scales and the Merz Hand Grading Scale. The rate of interobserver agreement was calculated for the three scales under investigation and the Merz Hand Grading Scale.

Results/Complications:

Although no demographic data information was collected from subjects, a wide variety of dorsal hands were photographed, ranging from no visible signs of aging, to severe wrinkling, laxity, and dyschromia. It was ensured that multiple photographs were obtained for every score on all of the grading scales.

The three scales under investigation were reliably and consistently used to characterize wrinkles and dark spots on the dorsal hand. After training the five reviewers on these three scales, interobserver variability was low. Furthermore, the interrater agreement for each of the three scales was similar to the results of the Merz Hand Grading Scale assessment.

Conclusion:

The results of this study demonstrate the reliability and validity of three new scales that characterize the appearance of wrinkles and dark spots on the dorsal hand. After analyzing the results of all three scales, interobserver variability was low and of a similar degree to that seen with the Merz Hand Grading Scale assessment. These scales provide a simple tool to objectively measure the changes associated with aesthetic treatments specifically targeting the dorsal hand, and clinical evaluations of the aging hand no longer have to be limited to volume loss.

Goals/Purpose: Patient photographs are a valuable planning and communication tool in plastic surgery. However, photographic images can clash markedly with patients’ self-perception. These static, 2-dimensional images lack dynamism, capturing only a single moment, expression, light, and angle. More importantly, they are the reverse of the more familiar image an individual sees in a mirror. Consequently, facial asymmetries appear “flipped” in photographs, making them appear exaggerated to the individual. A non-reversing mirror (NRM) allows patients to see their dynamic, non-reversed image and familiarize themselves with how they appear in photographs and to others. Thus, the aim of this study was to explore the effect that a NRM has on facial self-perception, and whether or not it changes an individual’s goals when considering facial cosmetic procedures.

Methods/Technique: Individuals interested in obtaining facial aesthetic surgery or non-invasive cosmetic procedures (n=30) were asked to inspect their reflections in both a NRM and a standard mirror for thirty seconds each. The order in which these two mirrors were used was randomly assigned using a random number generator. Following each thirty second period, subjects completed sections of the FACE-Q™. Following the completion of these questionnaires twice, subjects were asked a brief series of open-ended, qualitative questions comparing the two mirrors. Descriptive data such as age, gender, race, and history of prior facial aesthetic procedures were collected. Wilcoxon signed-rank, Mann Whitney U, and Pearson’s Chi-squared tests were performed for analysis.

Results/Complications: Median subject age was 31.5 years; 60% were female. Participants scored significantly worse on the FACE-Q™ Age Appraisal and Appearance-Related Psychosocial Distress when using the NRM vs. standard mirror (p=0.007 and 0.001, respectively). However, there was no significant difference in Age Visual Analogue Score. The order in which the mirrors were used did not have a significant effect on any of the questionnaire scores (p>0.05). Similarly, there was no significant difference in scores between subjects with a history of aesthetic facial procedures and those without (p>0.05). Chi-squared analysis initially demonstrated that females were significantly more likely to notice a difference in the NRM (p=0.046); subjectively, female subjects exhibited much stronger emotional reactions to their reflections. However, upon post-hoc testing, this difference was no longer statistically significant. In response to the supplementary questions, 83.3% of participants reported a qualitative difference in their appearance when looking into the NRM. When asked to elaborate on what they noticed, asymmetry or exaggeration of a perceived flaw was the most common complaint. Most subjects reported that their faces seemed less symmetric and less balanced (73% and 53%, respectively) in the NRM. Thirty percent endorsed that looking in the NRM had changed their facial aesthetic surgical goals.

Conclusion: A NRM can serve as a bridge between the familiarity of the patient’s reversed reflection and their less-familiar, non-reversed photographs. It may serve as a useful physician-patient communication tool when discussing goals and expectations for facial aesthetic procedures.

Goals/Purpose: Plastic surgeons increasingly use social media as a mainstay of patient engagement, research distribution, and trainee education. Various networking platforms provide far-reaching, valuable opportunities for information dissemination; however, disparities in patient representation within social media content exist. As the use of social media by plastic surgeons continues to expand, it is critical to evaluate and advance the representation and diversity of patients on these platforms. Appropriate patient diversity is integral to promote interaction with all patients and ensure the adequate training of plastic surgeons to work with diverse populations. This study aimed to assess patient representation, particularly of racial and ethnic groups, among plastic surgery Instagram accounts.

Methods/Technique: The Instagram accounts from 9 plastic surgery professional organizations and journal accounts were analyzed for posts containing patient images between April 2015 and June 2020. Each unique patient image and its corresponding caption was analyzed for demographic factors, including skin tone, biological sex, age, and transgender identity representation. Skin tone was assessed as a proxy for racial identity, using the Fitzpatrick Scale to categorize as white (1-3) or non-white (4-6). Univariate analysis was performed to determine differences in representation among posts and to compare patient representation on Instagram with the United States (US) Census Bureau data on race and ethnicity and the American Society of Plastic Surgeons (ASPS) Annual Report data on race and ethnicity of plastic surgery patients.

Results/Complications: A total of 6719 posts from 5 journals and 4 professional organization accounts were found to contain 2547 unique patient images. 88.14% of patient images depicted white skin tone, while only 11.86% displayed non-white skin tone. Only 0.31% of images represented transgender patients, all of whom were transfemale individuals. Cosmetic plastic surgery patient images had a higher frequency of white skin tone as compared to reconstruction surgery images (89.93% vs. 81.98%, p<0.001). From 2016 to 2020, non-white skin tone representation improved from 10.34% to 18.60% of posts (p=0.003). However, when compared to the US Census data and the ASPS Annual Report data on race of patients undergoing plastic surgery, our data revealed substantial underrepresentation of patients of color on social media (p<0.001).

Conclusion: Our study highlights the underrepresentation of patient populations, notably racially and ethnically diverse patients, within plastic surgery social media imagery. Though people of color comprise 30% of patients undergoing plastic surgery procedures, only 12% of patient images on Instagram represent this population. Active efforts to ensure equitable representation of patients on widely accessible social media platforms is essential to decrease patient barriers to healthcare and improve physician training to engage with diverse patient populations.

Goals/Purpose

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Many breast lift and breast reduction techniques are limited by their design. There is a tendency for the lower pole of the breast to stretch over time (bottoming out) and for the upper pole of the breast to lose volume. The structural technique is inspired by the work of Dr. Ermette De Longis, who devised a method of mastopexy that moves the central inferior breast tissue into the upper pole of the breast and anchors this in place with a dermoglandular flap that passes through the pectoralis major muscle (Figure1). The inferior aspect of the vertical scar sweeps laterally in a gentle curve, which tightens the base of the breast and eliminates the redundancy that occurs at the base of many vertical mastopexies. The net effect is a dramatic recompaction of the breast tissue and a significant restoration of upper pole fullness. The technique can be applied to mastopexy, reduction, augmentation-mastopexy, and breast revision. In this presentation the fundamentals of the technique will be described along with clinical examples of its applications.

Often patients desire breast lift surgery but prefer to avoid breast implants. With many breast lift techniques there is a lack of long-term fullness in the upper portion of the breasts. As a result, plastic surgeons frequently resort to routine use of implants in the mastopexy operation. This may lead to a result that is larger than the patient desires. For many patients the structural technique allows for a lift without implants, as natural breast tissue is transposed to provide upper pole volume.

Methods/Technique

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The patient is marked with her arms by her sides. The midline of the body and the midaxis of each breast are marked, as well as the existing inframammary fold level (Figure 2). The new position of the superior areolar border is marked on the midaxis, typically 2 cm above the transposed position of the inframammary fold (Point C). The skin is pinched to determine the extent of periareolar resection (Points A and B). The breast is displaced medially and laterally and the point where the displaced breast overlies the midaxis is marked medially and laterally (Points D and E). Curves are constructed that pass through these points and intersect superiorly with points A and B. Beneath Points C and D the curves incline toward a point at the inferolateral breast above the existing inframammary fold (Figure 3).

The new areolar border is marked and deepithelizliation is carried out. A superiorly-based dermoglandular flap is elevated off the lower central breast tissue (Figure 4). The underlying central breast segment is released medially, laterally, and inferiorly and is elevated off the subglandular plane (Figure 5). Mobilization continues beneath the breast, which creates a space into which the tissue can be transposed. With the breast tissue flap now in the upper pole, the dermoglandular flap is passed through an opening in the pectoralis muscle and anchored in place. The medial and lateral pillars are sutured together until the new inframammary fold level is reached, then the closure inclines laterally. This, along with vigorous liposuction, sets the new base of the breast (Figure 6). The incisions are closed in the usual way.

Results/Complications

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A total of 180 patients have been treated with this technique. One patient early in the series required a second operation to further lift one breast. Two hematomas were treated by aspiration. Four patients required minor revision of the surgical scars under local anesthesia. There were no infections or serious complications requiring hospitalization.

The technique provides balanced volume to the upper pole of the breast (Figure 7) and can be combined nicely with implant down-sizing (Figure 8). It is also useful for patients who desire implant removal and lift, if there is sufficient tissue in the lower portion of the breast.

The structural technique provides surgeon and patient with three advantages: multilevel anchoring of tissue to maintain breast shape, the creation of a natural fullness in the upper portion of the breast, and the avoidance of a surgical scar at the medial aspect of the breast.

Conclusion

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The structural technique is an effective surgical method to restore the breast to a proper position and compact structure. The technique provides significant restoration of upper pole fullness without the need for implants. Complications are minor and infrequent.

Goals/Purpose

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Hyaluronic acid (HA) filler injection is generally regarded a safe procedure. However immediate major complications do exist, notably blindness and skin ischemia/necrosis. Hyaluronidase (HAse) is an enzymatic reversal agent for immediate ischemic complications of HA fillers. Unfortunately, many barriers exist for injector sites to stock HAse, including price, short shelf-life, and complacency given the rare incidence of ischemic complications. As a result, emergency rooms (ERs) are often expected to be a safety net in cases when injectors encounter an ischemic complication but have inadequate (or absent) supplies of HAse to address complications. Currently little is known on the availability of hyaluronidase in ERs. The authors sought to: 1) determine the immediate availability of HAse in ERs across the state of California; 2) determine the institutional and geographical predictors of HAse availability; and 3) provide injectors with recommendations to obtain HAse when personal/practice supplies are inadequate.

Methods/Technique

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Authors conducted a scripted telephone survey of all Californian ERs, inquiring about hyaluronidase availability. Proportions of HAse availability were compared among different geographical regions, various trauma center level designations, and children's hospital status, using χ2 tests. A Mann-Whitney U test was used to compare median bed counts between hospitals that had HAse available and those that did not.

Results/Complications

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The present study included 330 Californian ERs and achieved an 89.7% response rate (n=296). Overall, 45.6% of ERs were found to not have HAse in their pharmacy inventory. HAse availability was positively associated with level I-III adult trauma center status, pediatric trauma center status, children’s hospital status, hospitals with higher median bed counts, and regional geography (p<0.05, all).

Conclusion

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HAse availability in ERs is unreliable across the state of California, posing a risk to patient safety as ERs are often expected to function as a safety net for HA filler ischemic complications. In emergent situations for which injectors have inadequate/absent supplies of HAse, the authors recommend calling hospitals/ERs in advance to verify HAse availability. Injectors should be methodical about their calls, and prioritize according to not only proximity, but also by hospital size, trauma center designation, and availability of pediatric services.

Goals/Purpose: Augmentation of the nasal cartilages with cartilage grafts for cosmetic and reconstructive procedures is performed usually by grafting autologous cartilage. Although, it has complications. For this reason, costal cartilage allograft by the Musculoskeletal Transplant Foundation (MTF) provides an alternative in rhinoplasties. Our goal is to compare MTF’s allograft costal cartilage with autograft costal cartilage with respect to clinical utility, complications, and patient satisfaction in reconstructive and cosmetic rhinoplasty.

Methods/Technique: This is a single-center, non-blinded, clinical trial, conducted in healthy adult subjects undergoing a reconstructive or cosmetic rhinoplasty involving the use of cartilaginous graft. This study will evaluate the outcomes and utility of MTF allograft compared to autologous harvest of costal cartilage. 30 subjects will be recruited. Eligible, consenting patients will be grouped into their respective cohort. They will choose to receive either the autologous or cadaveric graft. Prior to surgery, the patients fill out the pre-operative sections of a Face-Q checklist and will have pictures taken for documentation purposes. Subjects will have 1 week, 6 weeks, 12 weeks, 6 months, and 1-year clinical follow-up, which will include, patients completing the corresponding sections of the Face-Q, standardized 2D and 3D photographs. data on adverse effects and discomfort will also be collected throughout the study period. Observers and radiologists involved in outcome assessments will be blinded to study treatments throughout the duration of each patient’s evaluation period.

Results/Complications: 30 patients have been recruited so far and are involved in different stages of follow up, divide into two groups (MTF and Autologous), both groups show no difference in the pre-operative Face-Q checklist (p-value >0.05). On 1 week, 6 weeks and 12 weeks follow up both groups show no significant difference. On 6 month and 1 year follow up there is still not enough data to project any results yet. Patients' 2D and 3D photos reveal that there is no warping or resorption in our cadaveric cartilage group so far compared with the rib cartilage group. Longer follow up will be collected.

Conclusion: It is expected to prove not a significant difference between MTF and autologous cartilage when it comes to 1-year outcomes in satisfaction, recovery, and complications, leaving the door open for further studies to explore additional benefits of MTF use.

Goals/Purpose

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Implicit bias may impact health outcomes for patients of racial and ethnic minorities. While most images in plastic surgery literature reflect white skin types, the content of online resources has not been studied (Massie et al, 2019). Especially in aesthetic surgery, where the internet is a commonly used resource for patient decision making, it is paramount to understand the extent of diversity in images available to patients online (Parmeshwar et al, 2018). The objective of this study was to determine if online before/after images of breast augmentation represent the racial and ethnic patient population in the US.

Methods/Technique

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A Google search for “boob job [city name]” was conducted for 7 US cities. The first 20 websites were analyzed for inclusion of before/after patient photos, and each case was categorized as a Fitzpatrick skin type I-VI by three reviewers. The top 10 pages of “breast augmentation before/after” images on the patient blog Realself were also analyzed to understand what patients themselves are posting. Previous studies have classified skin types I-III as white and IV-VI as non-white, however conflating race with Fitzpatrick types can be problematic and inaccurate (Massie et al, 2019; Ware et al, 2020). We analyzed images by groupings of skin types (I-II, III-IV, and V-VI), as the greatest inter-rater variability existed between the grouped categories. Additionally, since it is difficult for skilled researchers to distinguish types within the groupings while using reference pictures/definitions, we believe these categories are consistent with how patients would view similarities and differences in skin types presented.

Demographic data for each city and nationwide ASPS surgical data were also collected to compare patient representation in online images to the composition of the general population and women undergoing breast augmentation. We used descriptive data to describe percentages of skin type and their distribution. Statistical analysis was conducted using Microsoft Excel and STATA.

Results/Complications

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In total, 109 websites and 3549 images were analyzed. The most common Fitzpatrick skin types were I-II, ranging from 80.41% in Miami and 90.70% in LA. Types III-IV were second most common, ranging from 8.68% in LA to 18.43% in Miami. Atlanta had the most V-VI skin types, at only 1.65%. Of 299 Realself images analyzed, 91.64% were skin types I-II. Table 1 shows complete data.

We do not believe that Fitzpatrick types can be conflated with racial or ethnic categories, and we recognize that vast diversity exists between skin types IV-VI. However, to underscore the sparse representation of higher number skin types, and to best compare our data to existing literature and census data, we have included Table 2, grouping our data against 2019 US census data as “white” (I-III) and (“non-white”) VI-VI. Notably, census data show that most residents of the cities self-designate as a race origin other than white, ranging from 62.90% in Atlanta to 90.20% in Miami.

Table 1: Percentages of Fitzpatrick skin type by city

City	I-II	III-IV	V-VI
Baltimore	85.85	13.78	0.37
Dallas	88.38	12.01	0.83
Chicago	88.38	10.52	1.10
Miami	80.41	18.43	1.15
New York	88.75	10.84	0.41
Los Angeles	90.70	8.68	0.62
Atlanta	83.71	14.64	1.65
Realself	91.64	7.69	0.67

Table 2: Percentages of Fitzpatrick skin type vs. US Census data as “white” or “non-white” by city

City	I-III (“White”)	IV-VI (“Non-White”)	Census data: White, not Hispanic or Latino	Census data: Non-white
Baltimore	93.67	6.33	27.50	73.90
Dallas	96.89	3.11	29.00	72.20
Chicago	95.92	4.08	32.80	68.50
Miami	93.09	6.91	10.70	90.20
New York	95.09	4.91	32.10	71.30
Los Angeles	97.52	2.48	28.50	73.60
Atlanta	91.96	8.04	37.60	62.90

(Note: can select multiple races on census)

Conclusion

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Our study showed that online images that serve as patient education material consistently represented lower number Fitzpatrick skin types across cities in all quadrants of the US. However, census data clearly depict significant diversity in the cities studied. This leads us to believe that online images do not accurately reflect the skin type diversity of our cities nor do they represent our breast augmentation patients. These findings illuminate possible implicit bias in our image selection as healthcare providers. To work towards equitable care, it is imperative that considerable thought and effort be put into designing plastic surgery online resources so that they are inclusive and representative of skin type diversity.

Citations:

Massie JP, Cho DY, Kneib CJ, Burns JR, Crowe CS, Lane M, Shakir A, Sobol DL, Sabin J, Sousa JD, Rodriguez ED, Satterwhite T, Morrison SD. Patient Representation in Medical Literature: Are We Appropriately Depicting Diversity? Plast Reconstr Surg Glob Open. 2019 Dec 26;7(12):e2563. doi: 10.1097/GOX.0000000000002563. PMID: 32042543; PMCID: PMC6964926.

Parmeshwar N, Reid CM, Park AJ, Brandel MG, Dobke MK, Gosman AA. Evaluation of Information Sources in Plastic Surgery Decision-making. Cureus. 2018 Jun 9;10(6):e2773. doi: 10.7759/cureus.2773. PMID: 30109166; PMCID: PMC6084688.

Ware OR, Dawson JE, Shinohara MM, Taylor SC. Racial limitations of fitzpatrick skin type. Cutis. 2020 Feb;105(2):77-80. PMID: 32186531.

Goals/Purpose:

The concurrent approach of breast conservation therapy (BCT) and breast reduction, otherwise known as oncoplastic reduction, has become a popular treatment option for women with breast cancer who want to avoid total mastectomies. The goal of oncoplastic breast surgery, of which oncoplastic reduction is one technique, is to achieve tumor free margins and minimize breast deformity to attain the best aesthetic and functional outcomes. Oncoplastic reduction can be performed using local breast parenchymal flaps for tissue rearrangement.

Appropriately designed pedicles help to maintain tissue vascularity and native sensations. The choice of pedicle design is highly dependent on tumor location. For example, tumors in the upper quadrants typically receive an inferior pedicle approach, while tumors in the lower quadrants are best managed with a superior pedicle design. Since most breast cancers arise in the upper outer quadrant, the inferior pedicle design is most frequently used. The inferior pedicle approach may be a suitable aesthetic choice for large, ptotic breasts due to its ability to effectively remove excess breast tissue. On the other hand, the inferior pedicle design may cause unnecessary fullness to the inferior breast and loss of conical projection, in turn producing poorer aesthetics compared to other pedicle designs.

To our knowledge, there has been no study that has looked at the influence of pedicle technique on aesthetic and quality-of-life outcomes following oncoplastic reduction. The purpose of this study is to analyze the influence of pedicle technique, as well as certain patient factors, on aesthetic and quality-of-life outcomes after oncoplastic reduction.

Methods/Technique:

A retrospective chart review was performed for all patients who underwent oncoplastic reduction between 2011 to 2018 at a single tertiary care institution. Data was collected on patient demographics, preoperative breast size, previous surgeries, oncological history, and pedicle design for oncoplastic reduction. Aesthetic evaluation of each breast was performed using a validated aesthetic grading scale. Photos were graded by four independent members of our research team (blinded to treatment group) – grading symmetry, shape, and overall appearance of each breast on a scale of 1-5. Patient satisfaction was determined through postoperative Breast-Q surveys (breast conserving therapy modules). Analysis of variance (ANOVA) was used to compared aesthetic and Breast-Q scores among the different pedicle groups. Multiple regression analyses were performed for aesthetic and Breast-Q scores with various patient factors. A p-value ≤0.05 was considered statistically significant.

Results/Complications:

A total of 225 patients (240 breasts) were evaluated. Among them, 223 (98.66%) had available information on pedicle technique used during oncoplastic reduction. Average age was 58 ± 9.2 years, BMI 32.7 ± 6.8 kg/m², and breast specimen weight 133.2 ± 129 g. The inferior pedicle approach was the most frequently utilized method in 174 (78.02%) patients. A superomedial pedicle approach was used in 20 (8.97%) patients, superior in 17 (7.62%) patients, inferomedial in 5 (2.24%) patients, superolateral in 1 (0.45%) patient, inferolateral in 1 (0.45%) patient, and “other” pedicle approaches in 5 (2.24%) patients. Ninety-two (40.88%) patients were aesthetically evaluated based on postoperative photos, and 40 (17.77%) had completed postoperative Breast-Q surveys.

There were no significant differences in BMI, preoperative ptosis grade, preoperative cup size, and breast specimen weight among patients who received different pedicle approaches. With one exception, there were no significant differences in aesthetic and Breast-Q scores among patients who received different pedicle approaches. The one exception is that the inferior pedicle approach was associated with a higher “satisfaction with breast” Breast-Q score (p=0.0174). Multiple regression analyses of aesthetic and Breast-Q scores showed no significant correlation with BMI, preoperative ptosis grade, preoperative cup size, and breast specimen weight. However, BMI was found to be negatively correlated with the “overall appearance” score on the aesthetic grading scale (p=0.0385).

Conclusion:

The choice of pedicle design in oncoplastic reduction has no significant influence on postoperative aesthetic outcomes in terms of breast symmetry, nipple-areolar complex symmetry, and overall appearance. The inferior pedicle approach may be associated with higher patient satisfaction with breast after oncoplastic reduction. BMI, preoperative ptosis grade, preoperative cup size, and breast specimen weight have no significant impact on patient satisfaction with breast and self-reported wellbeing measures after oncoplastic reduction. However, increasing BMI may have a negative influence on overall aesthetic outcomes.

Goals/Purpose:

Within aesthetic surgery, there exists a spectrum of safety profiles of various procedures. With continuous innovation in Plastic Surgery, new procedures are constantly introduced. A number of these procedures are generally safe, but have potential for very rare yet serious complications. Many surgeons stray away from these procedures due to safety concerns while continuing to regularly perform more common, well-established operations that arguably pose greater risk for serious complications. The purpose of this study is to survey the Aesthetic Society membership to elicit perception of risk of several novel or less mainstream procedures, and to compare against perceived risks of more common procedures.

Methods/Technique:

With the approval of the Aesthetic Society Executive Committee, a 24 item survey was sent out to all members of the Aesthetic Society. The data was analyzed using univariate and descriptive statistics. This study was deemed exempt status by the University of Michigan Institutional Review Board.

Results/Complications:

A total of 198 surveys were returned, 163 of which were completed. 91% of respondents were board certified by the American Board of Plastic Surgery. 78% of respondents were male, and the average age reported was 59 (range: 36-77). 93% of respondents have been in practice for over ten years. When asked to select the top three procedures performed in their practices, the most common responses were breast augmentation (n=101), abdominoplasty (n=87), and facelift (n=51).

With regard to novel and less mainstream procedures, 51% of surgeons said they do not perform filler rhinoplasty in their practice, with danger to patient being cited as the most common reason for avoiding the procedure. 46% of surgeons reported that they perceived the overall complication rate of filler rhinoplasty to be 5% or higher, with 24% believing skin necrosis to be the most common complication. 33% believe the risk of blindness with this procedure to be 0.1% or higher.

51% of respondents perform gluteal augmentation with fat grafting (“Brazilian Butt Lift”) in their practice. Of those who do not, 61% cited danger to patient as their reason. 70% of surgeons believe the complication rate of BBL to be 5% or higher. 46% of respondents believe the risk of fat embolism to be 1% or higher.

91% of surgeons do not perform submandibular gland excision with facelift, with nearly half of them reporting danger to the patient as their concern. 73% of surgeons believe the risk of expanding hematoma with airway compromise to be greater than or equal to 0.1% in this surgery.

Overall, 44%, 61%, and 80% of surgeons believe the risks of filler rhinoplasty, BBL, and resection of submandibular glands, respectively, to be “borderline”, “mostly unacceptable”, or “unacceptable”. This was compared to abdominoplasty where 96% reported the risks to be “minimal” or “acceptable.”

Of note, for all three procedures (filler rhinoplasty, BBL, and resection of submandibular glands), surgeons overwhelmingly reported learning how to perform them at a conference, from a colleague, or from self-study, with virtually none reporting learning in residency or fellowship.

Conclusion:

Overall, Plastic Surgeons perceive risks of certain procedures to be higher and more severe than available data suggests. The true complication rate of filler rhinoplasty hovers at around 1.6%, with no skin necrosis or blindness recorded in any large cohort studies, far below the perceived rates of these complications.¹ A recent meta-analysis reports that gluteal augmentation with fat grafting has a 7% complication rate, which is consistent with the study population’s perceptions. The risk of fat embolism, however, is approximately 0.1%, a number significantly overestimated by 46% of respondents.² There has only been one paper describing a single episode of expanding hematoma causing airway compromise in the setting of submandibular gland excision, giving it a 0.8% incidence in that particular study.³ Given the lack of other data on the topic, it is likely that it is even less common. All in all, Plastic Surgeons over-estimate the risks of these procedures, particularly filler rhinoplasty, which the data suggests is quite safe. Interestingly, large numbers of respondents rated these three procedures as having significantly more unacceptable risk profiles when compared to procedures such as abdominoplasty, which has a 0.3-1.1% risk of thromboembolism (a potentially devastating complication), or augmentation-mastopexy, which has a 23% complication rate. It appears that Plastic Surgeons overestimate the risk of procedures with which they are less familiar in comparison to more commonly performed operations.

Citations:

1. Williams LC, et al. Nonsurgical Rhinoplasty: A Systematic Review of Technique, Outcomes, and Complications. Plast Reconstr Surg. 2020 Jul;146(1):41-51.
2. Condé-Green A. et al. Fat Grafting for Gluteal Augmentation: A Systematic Review of the Literature and Meta-Analysis. Plast Reconstr Surg. 2016 Sep;138(3):437e-46e.
3. Mendelson BC, Tutino R. Submandibular Gland Reduction in Aesthetic Surgery of the Neck: Review of 112 Consecutive Cases. Plast Reconstr Surg. 2015 Sep;136(3):463-471

Goals/Purpose

:

Surgical chin implantation is performed to improve overall facial harmony. Over time, implant complications, significant bony erosion, or worsening aesthetic appearance may necessitate re-operation, classically with re-implantation. Here, we examine the morphologic outcomes of patients receiving implant removal and sliding osseous genioplasty instead of re-implantation.

Methods/Technique

:

Pre- and post-operative CT scans from patients receiving implant removal and sliding osseous genioplasty from two surgical centers were assessed using Mimics 3D software. Volumetric analyses were performed to estimate the size of the chin implant and the amount of bony erosion. Cephalometric measurements of chin morphology were utilized to assess bony and soft tissue chin movement and projection following surgery. Anatomic ratios were calculated and compared to age-matched controls.

Results/Complications

:

8 preoperative and 4 postoperative CT scans were analyzed from 9 patients receiving implant removal and sliding osseous genioplasty. Significant bony erosion was seen beneath the implant in all preoperative images, with as much as 75% of the implant volume eroding through bone in some cases. Following implant removal and genioplasty, patients had increased tissue chin projection as evidenced by both soft tissue and bony linear and angular measurements: increased gonion-pogonion length bilaterally (p<0.05), increased condylion-pogonion length bilaterally (p<0.05), increased nasion-sella-gnathion angle (p=0.01), and increased sella-nasion-pogonion angle (p<0.001). Post-operative chin anatomic ratios more closely approximated that of normal age-matched controls.

Conclusion

:

Chin implants were associated with significant bony erosion and abnormal morphologic characteristics in our study patients. Implant removal with subsequent osseous genioplasty improved chin projection and facilitated a more normal chin appearance.

Goals/Purpose:

The Interi System is a new internal wound control system specifically designed to deliver continuous, consistent negative pressure (125 mmHg) to closed internal wound spaces in order to approximate surgically-created tissue planes. Seroma formation and subsequent poor wound healing are the most common complications following surgery and are costly to the healthcare system. Currently used single-channel drains for fluid evacuation provide limited and inconsistent levels of negative pressure, and by design are not able to achieve broad access to internal wound sites. As effective tissue approximation and fluid evacuation is critical to wound healing, there is thus a need for alternate strategies.

Negative pressure delivery to deep tissue planes is accomplished through the Interi System’s multi-branched Manifold that can be peeled, as needed, to create a total of 4 branches. The Manifold, placed intraoperatively, is arranged within the surgical site for maximum coverage. The Manifold exits through a single exit site and is attached to a Therapy Unit via a one-way connector. The Therapy Unit is a single-use, portable device that simultaneously delivers continuous, consistent negative pressure and evacuates fluid. The system was designed for patient ease and to minimize hassle when removing and replacing the Therapy Unit when full.

In advance of broad commercialization of the Interi System, this survey-based study was undertaken to assess surgeons' early experience with the use of the Interi System in patients undergoing abdominoplasty.

Methods/Technique:

This survey-based study was conducted with surgeons who had performed abdominoplasty and used the Interi System between July and October 2020. Surgeons were surveyed on the day of surgery and at the end of therapy for each patient. The survey included questions on ease of use of Interi intraoperatively, ease of training the patient in using the Therapy Unit at home, acceptable functioning of the Interi System as perceived by the patient and the surgeon, and ease of removal of the Manifold by the surgeon. Surgeons were asked to rate their responses on a 5 points agree/disagree scale (where 5 = Strongly Agree and 1 = Strongly Disagree). The duration of therapy and volume of fluid collected were also captured in the survey.

Results/Complications:

A total of 13 surgeons participated in the survey reporting initial use of Interi in 33 patients. Results from 12 surgeons and 29 patients who completed therapy with Interi and submitted the final survey are reported here. 72% of the patients (n=21) underwent concurrent abdominoplasty and liposuction. Surgeons trimmed Manifold branches in 21% of patients (n=6). All, but 3 patients, were discharged on the same day following surgery. The surgeons reported that the Manifold was easy to place intraoperatively with average score of 4.9 on 5-point scale where 5 = Strongly Agree. All surgeons strongly agreed that the connector was easy to attach with 100% scoring 5.0; training the patient to use the therapy unit at home was simple and straightforward, with an average score of 4.8.

The Manifold was left in place for an average of 8.4 days (range: 6-14 days). An average of 643 mL (range: 260-1605 mL) of fluid were collected during the therapy period. High-resolution ultrasound was performed in 12 patients during the therapy period, with no fluid detected in the subcutaneous spaces in any patients. Surgeons reported that the Interi System functioned acceptably during the duration of therapy with an average score of 4.8 and that the Manifold was "easy to remove, considering force required and patient tolerance compared to standard surgical drains" with an average score of 4.8. Similarly, surgeons reported that the majority of patients strongly agreed that the Interi System functioned acceptably during the therapy period, average score of 4.6.

Open-ended survey responses commented on patient and operating room staff ease of use, ease of manifold removal as well as not negative comments on the size or weight of the Therapy Unit. There were also general comments regarding observations of little edema and soft overlying tissue. Two surgeons noted a slightly larger exit site hole after Manifold removal compared with standard drains.

Conclusion:

Early experience with the use of the Interi System in abdominoplasty suggests that the system is easy to use, is well tolerated, and functions acceptably as conceived. Future controlled studies to evaluate the safety and efficiency of the Interi System are planned.

Goals/Purpose:

Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) is a newly defined, locally aggressive T-cell lymphoma that can develop following breast implantation. In 2019, the National Comprehensive Cancer Network (NCCN) guideline recommended definitive treatment to be total capsulectomy with removal of the implant and to consider prophylactic contralateral removal. However, as a lymphoma, it is pathologically distinct from breast cancer, and thus requires its own policy from insurance companies. The authors evaluated the insurance coverage for the management of BIA-ALCL and compared it to the recommendation by the NCCN guidelines.

Methods/Technique:

The authors conducted a cross-sectional analysis of US insurance policies for coverage of breast implant removal in the setting of BIA-ALCL. Insurance companies were selected based on their market share and state enrolment. Web-based searches and telephone interviews were conducted to identify the policy. Medical necessity criteria were abstracted from the publicly available policies.

Results/Complications:

Of the 101 companies assessed, only 29 had a policy for the surgical management of BIA-ALCL. 100% of these policies provided coverage of the implant removal of the breast diagnosed with BIA-ALCL. Without a diagnosis, 14 (48%) policies allowed for the prophylactic removal of a texture implant, with 7 (24%) specifying the Allergan BIOCELL and tissue expanders. Furthermore, 7% of policies (n=2) covered removal of a breast implant for BIA-ALCL-associated symptoms alone. The most common coverage requirement was documentation of the original implant indication (n=7, 24%) whereas one in ten policies (10%) required a specific pathology or cytology diagnosis of the BIA-ALCL. For the contralateral breast, 18 policies covered their prophylactic removal. However, insurers were less likely to cover prophylactic contralateral breast implant removal if the original reason for the implant was cosmetic rather than medically necessary (41% vs 62%, p=0.0099). After removal of either implant, 22 policies covered an implant reinsertion, but again, fewer would do so if the implant was cosmetic rather than medically necessary (55% vs 76%, p=0.0040).

Conclusion:

Though a relatively novel diagnosis, the comprehensive guidelines by NCCN provides little excuse for the marked scarcity of insurance coverage for the treatment of BIA-ALCL. Furthermore, there is notable intercompany variation based on whether the original reason for the breast implant was cosmetic or medically necessary. This variability may significantly reduce access to definitive treatment in patients with a cancer diagnosis.

Goals/Purpose

:

Patients access online cosmetic health information to help with decision making. This information is unregulated, variable in quality, and may be biased. The purpose of this study was to compare the most popular cosmetic injectables websites and to assess their readability, quality, and technical performance.

Methods/Technique

:

A Google search for “Botox” and “Fillers” was performed in July 2020, identifying the most popular health information websites. Sites were analyzed for their readability using eight established tests used commonly by school teachers to determine reading difficulty. Health information quality was assessed using the validated DISCERN criteria and the Health on the Net principles (HONCode). Technical qualities were evaluated using two website evaluation algorithms, WooRank and WebsiteGrader which assessed a site’s performance, security, search engine optimization (SEO), social media integration, mobile friendliness, and ease of use.

Results/Complications

:

Eighty-five websites were analyzed (13 academic/hospital websites (AHW), seven commercial websites (CW), 25 private practice board-certified websites (PPBCW), seven private practice not board-certified websites (PPNBCW), 16 online health reference websites (OHRW), and 17 other websites (OW). The mean readability consensus score was 11 (eleventh-grade reading level). The mean DISCERN quality scores were higher for OHRW (58.4) compared to AHW (49.8, p=0.045), CW (42.1,p=0.045), PPBCW (36.8, p<0.001), and PPNBCW (34.1, p=0.002). No correlation between a website’s rank and its DISCERN score was found, r= -0.07 (p=0.49). WooRank and WebsiteGrader scores were lower for CW (63.3, 60.1) compared to OHRW (77.8, 73.3, p=0.03).

Conclusion

:

Cosmetic injectable websites are too difficult to read by the 6^th grade standard recommended by the National Institutes of Health (NIH) and the American Medical Association (AMA).This has implications for the ability of many patients to be fully informed consumers. When compared across categories there was no difference in readability among websites, suggesting that all website author contributor groups need to simplify language, use fewer complex words, eliminate technical jargon, and shorten sentences to deliver more readable information.

OHRW sites are superior in quality compared to all other groups, including physicians regardless of board-certification status. Physician based websites should look to OHRW as a resource when designing the content of a site. Furthermore they should include aspects related to treatment side effects, alternative treatment options, and the effect of a treatment on a patient’s quality of life while citing references to evidence these claims.

Physicians may benefit from the use of online technical software to evaluate and improve their websites. These technical software programs generate reports highlighting strengths and weaknesses of a website. They may suggest adding key words, social media integration, or image use for better SEO. Furthermore they may provide insight into a website’s security, mobile friendliness, ease of access, and navigation. Enhancing these technical aspects may lead to more accessible information, allowing patients to become more informed.

Since patients heavily rely on online health information to guide their medical decisions, increasing the readability, quality, and technical aspects of a website may lead to more productive in-office conversations and greater satisfaction with treatment results. Online information has the ability to set expectations, inform patients, help guide patients to correct treatment options, and keep them safe. These intended effects can only be realized with readable, high quality, and technically accessible health content.

Goals/Purpose

:

To evaluate safety and effectiveness of a biostimulatory poly-L-lactic acid (PLLA) injectable implant for correction of nasolabial folds after changes in reconstitution and injection procedures compared to US label.

Methods/Technique

:

In this 48-week, randomized, evaluator-blinded, multi-center study (NCT03780244), subjects were treated to optimal correction of nasolabial folds at a single treatment regimen consisting of 4 injection sessions with 4-week intervals, with PLLA reconstituted with 8 mL or 5 mL sterile water for injection. The 8 mL product included an additional 1 mL 2%-lidocaine, and was injected immediately after reconstitution without standing time. Primary endpoint for effectiveness was blinded evaluation of change from baseline of both nasolabial folds at Week 48 using a validated wrinkle assessment scale (WAS)¹. Aesthetic improvement and adverse events were assessed.

Results/Complications

:

A total of 59 subjects were included in the 8 mL group and 21 subjects in the 5 mL group. Most subjects were female (95%), mean age was 51.5 years. Both groups demonstrated high WAS responder rates (at least 1-grade improvement from baseline) at Week 24 (≥75%) and Week 48 (≥67%; hence primary effectiveness endpoint metAesthetic improvement was high (≥86%) throughout the study. Adverse events related to study product or injection procedure were reported by 33% of subjects in the 5 mL group and by 12% in the 8 mL group, most events being mild and transient.

Conclusion

:

PLLA was effective for treatment of nasolabial folds, and safety was not compromised using a higher reconstitution volume including lidocaine, administered immediately after reconstitution.

References

1. Lemperle G, Holmes RE, Cohen SR, Lemperle SM. A Classification of Facial Wrinkles. Plast Reconstr Surg. 2001;108(6):1735-50.

Goals/Purpose

:

Botulinum Toxin Type A (Botox), soft-tissue fillers, and chemical peels were the most popular and fastest growing cosmetic minimally invasive procedures in 2019. Although office-based procedures such as Botox, soft-tissue fillers, and chemical peels are reliable and effective, complications can arise that must be addressed. With Botox and soft-tissue filler injections, the most common complications are bruising, erythema, and pain. However, more severe associated complications can occur, such as muscle paralysis, lagophthalmos, orbicularis oris muscle incompetence, anaphylactic reactions, and dysphagia from Botox toxin spread and granuloma formation, blindness, and vascular occlusion from soft-tissue fillers. Chemical peels can lead to erythema, irritation, burning, as well as more serious scarring. These complications can emerge even with the most precise technique and therefore must be mentioned to patients during the informed consent process. Since many patients use the internet to learn more about procedures, it may be beneficial to mention these complications on cosmetic injectable websites.

The objective of this study is to evaluate what complications are described for Botox, soft-tissue fillers, and chemical peel procedures online and to make comparisons on the level of reporting from various sources to understand how to fill some of the existing gaps.

Methods/Technique

:

The top 50 google search results for “Botox,” “Fillers,” and “Chemical Peel” were analyzed on their reporting of relevant complications. Websites were categorized based on their origin, “academic/hospital,” “commercial,” “private practice board-certified,” “private practice not-board-certified,” “online heath reference,” and “other” websites. The “other” category consisted of government, reference, news, social-media or online magazine sites. A check list of the most common and serious side effects were gathered for each procedure using the FDA’s guidelines as well as from the literature. This checklist was used to assess each website and their reporting of specific complications. Furthermore, an overall complication, prevention, management, prevalence, and disclaimer score were assigned to each site. The complication score (out of 5 points) assessed how well a website informed patients about potential side effects specific to that treatment. The prevention score (0 or 1) assessed if the site mentioned anything about ways to prevent possible complications. The management score (0 or 1) assessed if the site described ways to treat complications once they arose (e.g. applying ice to reduce swelling). The prevalence score (0 or 1) assessed if the site gave any estimation to the likelihood of a side effect. Finally, the disclaimer score (0 or 1) assessed if the site offered any sort of disclaimer suggesting that there may be other or more side effects not listed on the site.

Results/Complications

:

A total of 136 websites were analyzed, including 42 for “Botox,” 44 for “filler,” and 50 for “chemical peel.” Fifteen websites were excluded as irrelevant, duplicate, or video-based. From the selected sites, 46 (34.1 percent) were private practice board-certified physician-based. Twenty-three (17.0 percent) were developed from online health reference sites. Twenty-three (17.0 percent) were categorized as “other” sites, that included online magazine articles, government based sites, and general reference sites. Twenty-one sites (15.6 percent) were developed by either an academic board or a hospital. Twelve sites (8.9 percent) were categorized as commercial. Ten sites (7.4 percent) were from private practice not-board certified physicians.

Thirty-one (22.7%) of websites did not mention any complications or risks associated with a treatment. The most commonly reported complications were bruising (67.0%) for Botox, swelling (79.0%) for fillers, and redness (58%) for chemical peels. The least reported serious complications were toxin spread effects (31.0 percent) for Botox, vision loss (23.0%) for fillers, and allergic reaction for chemical peel (18.0%). Serious and rare side effects were reported significantly lower than common side effects, Botox (P=.001), fillers (P=.004), and chemical peels (P<.001). The overall mean (SD) complication score across all websites was 2.81/5 (1.31). Approximately half (49.6 percent) of all sites mentioned ways to prevent complications before treatment. Even less (43.7 percent), mentioned strategies on how to manage complications after they occur. Online health reference and academic/hospital sites disclosed complications better than most other categories (P<.001).

Conclusion

:

The increasing popularity of Botox, fillers, and chemical peels warrants high quality online information where patients are not only educated on all possible benefits and alternative treatments, but also on all aspects of risks and complications. The disclosure of complications for Botox, fillers, and chemical peels online are highly variable, biased towards common over serious side-effects, and different among website categories. Online health reference and academic/hospital websites are more comprehensive and should serve as a patient’s primary online source of education for risks and complications. Improvement of cosmetic websites and higher standards of complication disclosure are needed.

Goals/Purpose

:

Minimally invasive office-based aesthetic procedures such as neuromodulators and soft-tissue fillers have become increasingly popular in recent years due to their minimal downtime, affordable service, and fewer complications. In 2019, there were 7.7 million Botulinum Toxin Type A injections and 2.7 million soft-tissue fillers. With this growing demand of injectables, patients are utilizing social media and YouTube as one of their main sources of education on the topic. YouTube is used by more than 70% of adults and 81% of 15 to 25 year-olds. The information quality of videos related to the two most performed aesthetic procedures, Botox® and soft-tissue filler injections has not been assessed. The goal of our study was to determine the quality of information on YouTube injectable videos while also assessing which groups of contributors produce better videos. In addition, we sought to compare the quality of YouTube videos to websites identified by Google, using four of the most widely used methods of quality evaluation.

Methods/Technique

:

A YouTube search for “Botox” and “Fillers” was performed in July 2020, identifying the most popular health information videos. The link, rank (video number), title, author, video category, video duration in minutes, date of initial upload, view count, number of likes, number of dislikes, and number of comments were recorded. Quality was assessed using the validated Journal of American Medical Association (JAMA), Health on the Net principles (HON), and the DISCERN criteria as well as a procedure-specific content score. The content score was designed to evaluate only the most pertinent aspects of injectables that could be displayed on video. This scoring system is less comprehensive than traditional quality scoring instruments, but allows for a more just assessment of videos. Three of the authors (AP, LM, AJ) independently scored each video and averages were used during data analysis. Quality scores were compared among different groups of video contributors to determine which authors produced higher quality videos. Furthermore, video quality metrics were compared directly against injectable websites using the same search terms on Google.

Results/Complications

:

A total of 720 measurements of quality were performed across 95 YouTube videos and 85 websites. The mean (SD) quality scores were JAMA- 1.74/4 (0.718), HON- 6.66/16 (2.07), DISCERN- 40.0/80 (9.25), and content- 39.1/100 (11.9). Physician, non-physician health professionals, and other (news, magazine channels, and influencers) were all of higher quality than patient-based videos (p<.001). Video duration had no association with video quality. Video Power Index (VPI), a measure of popularity that takes into account number of views and likes, was found to have no significant difference across groups p=0.728. The mean (SD) DISCERN percentage score for videos was 50.04/100 (11.57) and significantly less than that of websites, 55.46/100 (15.74), p=.010. The mean (SD) content scores showed a similar result, 39.06/100 (11.92) vs 60.76/100 (17.65), p<.001, respectively.

When assessing the popularity of these sources, YouTube videos (16,377 (44,431.7)) were viewed more on a monthly basis than websites from Google search results (3,886.9 (11,544.9)) for aesthetic injectables, p=.009.

Conclusion

:

The increasing influence of social media and YouTube videos on patients interested in aesthetic procedures necessitates high quality online health information. The current quality of information on YouTube videos is poor overall. Much improvement is needed and plastic surgeons, who are the most frequent video contributors, are most qualified to provide this change.

We recommend that plastic surgeons who post informational videos familiarize themselves with the six major components of quality: currency, relevance, clarity, evidence, balance, and bias. By addressing these aspects, contributors would not only improve the quality of their own content, but also help guide patients to other resources. Patients should be directed towards physician-based videos rather than patient-experience videos as they may be inaccurate and of low quality. Videos that are concise with visual aids tend to help viewers stay engaged.

As a platform, YouTube videos were found to be of lower quality than websites and are likely viewed more than websites. Therefore, physicians should focus their online presence to video-based platforms, where the viewership may be larger, and seek to increase the quality of their content by utilizing the criteria set forth by various health information quality instruments. Through YouTube there exists a unique and powerful opportunity for plastic surgeons to educate, communicate, and engage with patients in a meaningful way. The quality of this interaction, however, is only as good as the quality of information that is displayed.

Goals/Purpose

:

To evaluate safety and effectiveness of HA_RC for cheek augmentation and correction of midface contour deficiencies.

Methods/Technique

:

In this randomized, evaluator-blinded, comparator-controlled study, subjects with loss of fullness in the midface area were randomized 2:1 to treatment (≤6 mL) with HA_RC or comparator (HA_JVOL). Optional touch-up (≤6 mL) was allowed after 4 weeks. The primary objective was to demonstrate non-inferiority of HA_RC relative to comparator in change from baseline on a 4‑grade midface volume scale¹ (MMVS), 12 weeks after last injection. Secondary objectives included aesthetic improvement, improvement in cheek augmentation (independent photographic reviewer), subject satisfaction, and safety.

Results/Complications

:

Subjects were randomized to treatment with HA_RC (n=142) or comparator (n=68). Most subjects were female (89%) and overall mean age was 53 years (range 24-80). Total mean volume injected was statistically less for HA_RC than comparator (4.3 mL and 4.9 mL, respectively, p=0.0134). The primary objective was met as HA_RC was non-inferior to comparator in midface fullness at 12 weeks after last injection (mean change from baseline in MMVS score: -1.4 [HA_RC], -1.3 [comparator]). HA_RC effectiveness was supported by a high degree of aesthetic improvement (≥77%) and subject satisfaction throughout the study. Cheek augmentation was assessed as improved for ≥65% of HA_RC subjects at week 48. Treatments were well tolerated; related adverse events were generally mild and transient.

Conclusion

:

HA_RC was effective, well-tolerated, and non-inferior to comparator for cheek augmentation and correction of midface contour deficiencies. Subjects treated with HA_RC required less total volume injected to achieve optimal aesthetic results.

Reference

1. Lorenc ZP, Bank D, Kane M, Lin X, Smith S. Validation of a four-point photographic scale for the assessment of midface volume loss and/or contour deficiency. Plastic and reconstructive surgery. 2012;130(6):1330-1336.

Goals/Purpose

:

Plastic surgery faculty, residencies, and institutions are frequently judged on the quantity and quality of their research output. Some of the most impressive individuals in the specialty receive financial support in the form of grants and payments to help with research ideas. We wanted to discern if funding directly correlates to greater impact in the top plastic surgery journals as measured by citations.

Methods/Technique

:

Using the Web of Science database, we identified the 50 most cited articles in each of the top plastic surgery journals from January 1975 to August 2020. We then scanned these articles for funding sources and delineated between industry, federal, foundational, and institutional while stratifying by decade.

Results/Complications

:

Between 16 journals, 13.3% of the most cited articles received funding, 2.6% of that coming from industry, 5.4% from government, 4.4% from foundations and 0.86% from institutions. The percentage of most cited articles and proportion that received funding were both correlated with decade (p=0.0017 and p=0.043, respectively). However, only the percentage of articles was found to have a significant increase over time (p=0.0068).

Conclusion

:

Although funding leads to meaningful publications, our study showed that financial support is not required to have an influence in plastic surgery research.

Goals/Purpose:

High Resolution Ultrasound (HRUS) is rapidly becoming an extension of our physical exam and finally emerging into the forefront of plastic surgery in the evaluation and follow-up of patients with breast implants. Improving breast implant technology with stronger more uniform shells, higher fill volumes and increased gel cohesivity is merging with continued improvements in HRUS coming together resulting in much more accurate way to evaluate implants. The FDA has reversed it’s prior decision for MRI screening and just released new recommendations (October 2019) for HRUS screening for silent rupture of breast implants beginning 5 years following implantation and every 2-3 years thereafter. The goal of this presentation is to report Level II outcomes of an exploratory cohort in our first 680 confirmed surgical patients undergoing HRUS, review the state of the art of this technology and to present pearls and benefits of incorporating this new technology into our practices.

Methods/Technique:

Over the past 15 years, more than 2500 breast implant patients have undergone HRUS imaging in our practice. We performed 680 surgical revisions in sequential patients during this time who also had preoperative HRUS performed with their implant diagnosis confirmed at surgery. The first 100 patients were examined with HRUS performed both by me and a board-certified radiologist independently. Determination of whether the implant was intact or not was documented and also if any fluid was present around the implant. True positive, false positives and predictive values were then determined. A Terason Ultrasound system was used to obtain images in these patients with a variable 12-15 MHz transducer. A specific imaging pattern was developed, and images recorded.

Ultrasound now has become an extension of my physical exam and I am ultrasounding, on average 12 patients a day, 20-30 patient a week as part of their routine breast implant follow-up. HRUS is easily incorporated into a plastic surgery practice, and patients are excited and assured knowing the status of their implants. Shell surfaces differences, smooth verse textured and detectable fluid around an implant is definable and increasingly important to follow in breast implant patients. HRUS has also transformed seroma management in the breast and body and is easily learned and transferable to other surgeons.

Results/Complications:

Over 2500 breast implant patients have been scanned with HRUS over the past 15 years at our center with 680 sequential breast revision patients having their preoperative ultrasound findings confirmed at surgery. We had 5 false positives in our first 300 patients with a Sensitivity rate of 97% (True Positive/Condition Positive), and Zero false negatives 100% Specificity (Fig 1-2). When an implant was identified as intact, it was indeed found intact in surgery (Fig.3-6). Although not specifically the focus of this study, fluid collections throughout the body are easily identified and treated under ultrasound guidance with differences between true fluid and tissue edema easily differentiated. his technology takes an average 7 minutes to complete per patient and is easily incorporated into a surgeons practice during their patient follow-up and we are showing it is teachable and transferrable to other surgeons and providers.

Conclusion:

Everyone needs a better imaging and screening tool for breast implant evaluation. The FDA, implant companies, plastic surgeons and particularly our patients all require a safe, fast, portable, reliable and accurate new diagnostic tool. The FDA has just released (October, 2019) their recommendation for HRUS to be used as a screening tool beginning 5 years following implantation and every 2-3 years following. Historically, ultrasound has been utilized to evaluate breast implants particularly in the 1990’s but has given way to MRI. Our study shows that one center dedicated to the implementation of HRUS can be extremely accurate in the diagnosis of shell failure with a 97% Sensitivity and Positive Predictive value and a 100% Specificity recognizing when implants are intact. Similar outcomes of growing plastic surgeon experiences (Adams, Salzman, Jewell, Edwards...) are reporting similar highly accurate results in identifying shell failure. We recommend early users refer questionable HRUS scans for additional screening with HRUS or MRI. However, most patients have multiple factors for implant exchange. We have also shown this technology is easy to learn and is transferrable to other board- certified plastic surgeons. We are developing a broad network of plastic surgeons and introducing ultrasound and helping them integrate HRUS into their practices. In addition, we are initiating additional multicenter studies and working with our societies to develop HRUS educational platforms and eventually credentialing courses.

Goals/Purpose

:

Abdominal body contouring procedures are associated with the highest rates of complications among all aesthetic procedures. Patient selection and optimization of surgical variables are crucial in reducing morbidity and complications. The purpose of this single institution study is to assess complication rates, and to evaluate Body Mass Index (BMI), operative time, and history of bariatric surgery as individual risk factors in abdominal body contouring surgery.

Methods/Technique

:

A retrospective chart review was performed of all patients who underwent abdominoplasty, circumferential body lift, fleur-de-lis panniculectomy (FDL) and circumferential FDL from August 2014 to February 2020. Endpoints were the incidence of venous thromboembolism, bleeding events, seroma, infection, wound complications, and reoperations. Univariate statistical analysis and multivariate logistic regressions were performed. Covariates in the multivariate logistic regression were BMI, procedure time, and history of bariatric surgery.

Results/Complications

:

A total of 632 patients were included in the study. Univariate analysis revealed that longer procedure time was associated with infection (p=0.0008), seroma (p=0.002), necrosis/dehiscence (p=0.016), and reoperation (p=0.002). History of bariatric surgery was associated with minor reoperation (p=0.021). These associations persisted following multivariate analyses. No significant increase in the incidence of major reoperation was found in association with overweight or obese patient habitus, history of bariatric surgery, or prolonged procedure time. BMI was not found to be an individual risk factor for morbidity in this patient population.

Conclusion

:

In abdominal body contouring surgery, length of surgery longer six hours is associated with higher incidence of seroma and infectious complications, as well as higher rates of minor reoperation. Increased risk of minor re-operation is also associated with history of bariatric surgery.

Introduction

Many authorities and medical professionals worldwide keep expressing concerns regarding the safety profile of breast implant texturization and its relation to the development of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL). Currently in global databases there has not been a confirmed case of smooth device only. Due to the recognition that texturization increases malignancy risk, the use of textured devices have been diminishing and are expected to continue to decline. In Europe texture devices still seem to be more popular in comparison with the United States and Canada. Nevertheless, the crisis with texture implants worldwide raises the need for recall and further clarification on how smooth round silicone gel implants to be properly used in retropectoral breast augmentation when given outcome is aimed.

Goals/Purpose:

The purpose of the present study is to demonstrate how do the smooth round silicone gel breast implants change their shape and how a plastic surgeon could properly handle the implants’ characteristics - projection, degree of filling and softness of silicone gel, in order to obtain any desired surgical outcome by using those devices in retropectoral placement in accordance with the patient anatomy.

Methods/Technique:

The study was designed in two parts. In the first one, an experimental model was invented in order to investigate how the shape of the round silicone devices changed when put vertically in regards of the implant projection and degree of gel filling. The devices were fixed on a specially created holder which permitted to observe the shape changes that occurred. From practical point of view it was interesting to compare how the experimental findings corresponded to the clinical results of augmented patients. That’s why in the second part of the study a retrospective analysis was conducted recruiting patients with primary subpectoral breast augmentation with smooth round silicone gel implants. Photodocumentation and clinical records of those cases were meticulously analyzed. Breast features were evaluated pre- and postoperatively and a minimal follow-up of 12 months was established. Special attention was paid to the control of the upper pole fullness. The changes of the breast contour over time were meticulously investigated.

Results/Complications:

The experimental model clearly demonstrated the shape changes of smooth round silicone gel implants that happened when switched from horizontal to vertical position. When put vertically, due to the gravity an underfilled implant tended to form a more anatomical shape with less pronounced upper pole convexity in comparison with a fully filled one which still maintained its upper pole fullness regardless of the gel cohesiveness. That observation was also registered in high-projecting devices where the anatomic conformation was even more visible. A remarkable finding was registered regarding the orientation of the implant surface wrinkles as they indicated the cohesive gel distribution inside the shell: the wrinkles were orientated more vertically in the underfilled devices. That observation could help to predict a rippling effect depending on the degree of filling.

The outcomes of 21 augmented patients (42 breasts) was identified and explored. The clinical results corresponded with the experimental observations and the full scope of aesthetic outcomes that could be obtained by using smooth round devices was revealed. Desired anatomic correction and natural appearance of the breast was achieved even in thin patients and in women with tuberous breast deformity. The upper pole contour and fullness showed to be predictable with reliable and stable control over time in all the patients when proper implant selection had been made.

In retropectoral placing in vivo compression forces of the pectoralis major muscle and overlying soft tissue further impacted the implant shape, affecting its upper half especially when the dual-plane technique with underfilled implant was applied. Those forces in combination with gravity made round silicone implants become more or less anatomical when put in the patient body. The shape change was particularly noticeable when a moderate-projecting or low-projecting underfilled device was used depending also on the gel firmness and plasticity. In fact, what one appreciates on a clinical setting is the final cumulative outcome of the above-mentioned forces, implant properties, and patient anatomy. The skillful handling all those variables is the main reason why results obtained by using round and anatomical implants can be practically indistinguishable even for experienced plastic surgeons as stated in some previous studies.

Conclusion:

It has been demonstrated both experimentally and clinically how smooth round silicone gel breast implants to be accurately used in breast enhancement surgery. By properly selected device and good surgical technique any outcome of a retropectoral breast augmentation could be obtained in daily practice: from well-shaped breast with aesthetically appealing linear upper pole and tight, convex lower one to excessive fullness and augmented appearance. Any of those results is fully achievable with no concerns regarding the potential risk of BIA-ALCL as a main issue of implant texturization.

Goals/Purpose

:

Rhinoplasty has a powerful impact on the facial profile. Classic rhinoplasty, however, often underemphasizes the chin and facial support. The purpose of this study was to review the facial profiles of rhinoplasty patients at our institution in order to describe common facial and nasal profile patterns, and to develop a diagnostic algorithm for a more holistic “profileplasty” correction.

Methods/Technique

:

All rhinoplasty patients treated by the senior author from 2011-2018 were reviewed.

Patients were categorized into two primary and six secondary subgroups according to the type of facial imbalance observed. Treatment plans and outcomes were reviewed across patient subgroups in order to enumerate recommended treatments for each patient type.

Results/Complications

:

A total of 715 rhinoplasty cases were reviewed. There were two general categories of patient profiles identified among patients: Group 1 (those with good overall facial profile but poor nasal profile) and Group 2 (those with poor overall facial profile and poor nasal profile). Analysis of Group 1 patients resulted in 2 subtypes: 1a) those with a prominent or 1b) flat nasal dorsum. Treatment in both of these subtypes focused on balancing the dorsal height and nasofrontal angle. Analysis of Group 2 patients resulted in 3 subtypes: 2a) those with a convex profile (nasal prominence with microgenia), 2b) those with a concave profile (prominent chin), and 2c) those with a “pseudo-dorsum” occurring secondary to retroposition of the lower third of the nose. Treatment plans in Group 2 centered around reducing the nasal dorsum and repositioning of the maxilla and/or chin.

Conclusion

:

Characterizing and correcting the facial and nasal profile can be complex. We describe a series of common facial and nasal profile patterns and an algorithm that allows for systematic identification of the deformity found and its appropriate treatment. Case examples are reviewed to highlight outcomes of the proposed “profileplasty” algorithm.

Goals/Purpose

:

Facial fat grafting has become increasingly popular. In 1998, Coleman standardized the technique. In 2001, stem and regenerative cells were identified in fat. In 2007, Rohrich and Pessa pointed out the different anatomical fat compartments above and below the muscles and Lambros has helped us understand facial aging as both a gradual loss of facial volume from fat atrophy, bone resorption and gravitational shifts. With the new understanding of the regenerative effects of fat along with our improved understanding of the anatomical changes that occur with aging, a new standardized facial fat grafting protocol was developed that incorporated anatomical replacement of fat with skin and tissue regeneration (ITR²).

Methods/Technique

:

We previously published our results in patients ITR² in combination with deep plane facelift and showed for the first time, progressive improvement in facial volume 18-24 months after the procedure. The technique consists of injecting 3 types of fat grafts- a more structural fat graft is placed in the deep fat compartments and in areas of bone loss; a microscopic fat is grafted into superficial compartments and a cell optimized nanofat is grafted by cannula, injected intradermally, microneedled intradermally and compounded with a liposomal transport agent and used as a biocream 2 times a day for 3 days after the procedure. To objectively evaluate the dynamic changes that occur in facial volume after ITR² fat grafting without a facelift, the same midfacial zones in 29 patients age 38 to 70 years, (average=52.9 years) were prospectively evaluated using 3D Photometric Imaging (Canfield Scientific Inc., Parsippany, NJ).

Results/Complications

:

In the 29 patients, 3D analysis of facial volume improvement over pre-operative measurements averaged 56.6% at the 1–3-month range. By 4–7 months, improvement in midfacial volume dropped to an average of 32.1%, and thereafter steadily increased to 46.6% by the 8 – 13-month period, leveling off at about 52.3% by 14-19 months. When separating patients based on age (above and below 55 years), two different trends were observed. Patients under 55 years of age exhibited the same dynamic changes that the collective analysis demonstrated, but to a greater extent. The facial volume initially declined, reaching a nadir at 6 months, but later increased to an average of 75.3% of original fat injected), peaking at around 14 months (range, 7-19 months). Patients above 55 years of age exhibited a linear decay beginning with an initial average volume improvement of 60.6% and steadily declining to 29.5% by the 14-19 month range. The curves remained statistically valid regardless of the amount of fat grafted. Patients’ weight change over the time of the study was negligible, with an average of 0.31 pounds gained postoperatively.

Conclusion

:

Isolated fat grafting using a standardized approach of anatomic fat replacement and regeneration based on topographic evaluation in patients under 55 showed dynamic improvement in facial volume over the 19 months of study. Patients over 55 who underwent fat grafting alone using the ITR² technique showed similar improvement in facial volume in the initial phases, but gradually declined to around 30% improvement at 19 months. To our knowledge, this is the first study to evaluate dynamic changes of fat grafting at different post-treatment intervals and the first to show progressive improvement in facial volume 19 months after treatment in patients 55 years or younger using a new standardized approach.

Goals/Purpose

:

While skin resurfacing with lasers has been a mainstay of facial rejuvenation for decades, advances in regenerative medicine are rapidly changing the norm in facial rejuvenation. Multiple studies have shown promise in utilizing some form of progenitor cells in cosmetic treatment protocols of the face. Result from these studies have shown a decreased inflammatory reaction with reversal of skin aging in the reticular and papillary dermis. The efficacy of laser treatments has been offset by the prolonged healing time and significant discomfort during recovery. We hypothesized that immediately following CO2 laser treatment application of nanofat with microneedling creating opened channels to the reticular dermis through which the nanofat may improve analgesia and wound healing. Here we present a case series evaluating the impact of this combined approach on patient recovery and wound healing.

Methods/Technique

:

All patients were treated by the senior author with CO₂ laser delivered in two applications. The first treatment was performed in DP setting (25 watts, 1000 microseconds dwell time, 500 micrometers spacing, for 13% coverage). This was performed in the area with the deepest rhytids along the upper and lower lip. The subsequent second treatment, was in HP setting (3.5 watts, 0 spacing, for 78% coverage). Immediately thereafter, the patient underwent microneedling with depth set to 2mm, with an endpoint of pinpoint bleeding. The treated areas then underwent topical application of 3cc of harvested nanofat. This was isolated from a macrofat harvest through sequentially smaller connectors and subsequent separation through a Nanofilter to achieve a maximum 500 micron size. The nanofat was then microneedled into the surface. Patient characteristics, procedural details and outcomes were examined. Follow up visits and/or phone calls were performed at Post-op day 3 and 6. Patients were also asked when they felt they had a “full recovery” from the LaMiNa treatment , meaning they felt comfortable in going in public as they would prior to the procedure.

Results/Complications

:

10 patients underwent the described treatment. The mean age was 62.9 years (range 58–75), and mean BMI was 22.8 (range 18.8-30.6). No patients experienced rash/herpetic outbreak; 1 patient with a history of cold sores was given prophylactic antiviral medication. All patients reported a 0 pain score (on a scale of 1–10) immediate after the procedure, as well as on Day 3 and Day 6. A full recovery was reported on average by 5.3 days.

Conclusion

:

Addition of topical biologics to the wound bed immediately following combined CO₂ laser and microneedling resulted in a relatively painless recovery and accelerated wound healing. Biologic additions to multiple facial rejuvenation techniques have been described in recent literature. None of these, however, have utilized the three phase approach that the LaMiNa treatment protocol does. Attempts to apply biologicals either topically or by intradermal injection have resulted in either poor dermal penetration or non-uniform distribution. The microneedling of the nanofat creates thousands of new pathways into the reticular dermis for all of the regenerative factors from the adipose derived stromal vascular fraction. By decreasing the acute and sub-acute pain of facial rejuvenation this approach provides a comfortable experience and technically optimal outcome for patients undergoing facial rejuvenation.

Goals/Purpose: Surgical outcomes and recovery time are paramount for physicians and patients. Preparing the skin prior to surgical procedures has become a recognized concomitant treatment in addition to that used post procedurally to aid in healing and outcomes. Regenerating Skin Nectar with TriHex Technology^®(RSN) has been shown clinically to promote healing and outcomes post procedures. TransFORM Body Treatment with TriHex Technology^®(TFB) has been demonstrated clinically to improve lipid droplet dissolution and patient reported outcomes post procedure. Histologically both have proven to regenerate collagen and elastin.

This split body, randomized, blinded study was designed to incorporate the pre procedural topical application of RSN and post procedural topical application of RSN and TFB to determine gene expression changes, histological alterations, recovery and outcomes. Liposuction of the medial thighs was determined to be the most advantageous, thus avoiding cross over contaminating of the two sides. In addition, the manipulation of adipose tissue with lipid droplet breakdown products likely caused by liposuction, made this a suitable model for testing skin changes subjectively and objectively in this patient group.

Methods/Technique: Participants were randomized to apply RSN pre and post procedure and TFB post procedure to one thigh and a bland moisturizer to the other. All products were in identical blinded bottles. After topical pre-treatment for approximately 2-3 weeks participants underwent bilateral medial thigh liposuction. Assessments included induration measurements, ultrasounds, blinded investigator assessments, participant assessments, photography, biopsies and gene expression. Follow-up visits were for 10 weeks.

Results/Complications: Blinded investigator assessments of induration, edema and subcutaneous fibrous banding had less severity at weeks 1, 2 and 4 on the RSN/TFB thigh corresponding with induration measurements. Ultrasound images showed (less fluid infiltration, edema, and induration) on the RSN/TFB side over the bland moisturizer at 2 weeks. Gene expression confirmed a hastened inflammatory phase converting more rapidly to the anti-inflammatory regenerative healing environment with evidence of extracellular modelling only present on the RSN/TFB side at week 4 and histological biopsies demonstrated improved collagenesis and elastogenesis.

Conclusion: Using RSN to prepare the skin for surgical procedures combined with RSN and TFB post procedure has been correlated through clinical study outcomes, histological evidence and finally gene analysis demonstrating remodeling of the extracellular matrix, accelerating healing and initiation of anti-inflammatory genes¹. The investigator assessments, participant assessments and induration measurements align with less severe post procedural events and match up with the genes being expressed within the period 4 weeks post procedure.

Reference:

1. Mary E Ziegler, PhD, Brannon Claytor, MD, FACS, Michaela Bell, BS, MBA, Laurie Casas, MD, FACS, Alan D Widgerow, MBBCh, MMed, FCS, FACS, Gene Expression Changes in the Skin of Patients Undergoing Medial Thigh Liposuction With Pre-Surgical and Post-Surgical Application of Topical Products, Aesthetic Surgery Journal Open Forum, ojaa033, https://doi.org/10.1093/asjof/ojaa033

Goals/Purpose

:

The COVID-19 pandemic has caused significant changes for aesthetic plastic surgeons. Understanding patient interests in various parts of medical aesthetics will be important as plastic surgeons prioritize aspects on their reopening to maximize efforts and allocation of resources. This study aims to passively and actively query public interest in aesthetics.

Methods/Technique

:

In Part I, Google Trends was used to see relative search volumes over the course of 4 years for a variety of aesthetic related categories: surgery or surgeons, patient chief complaints, injectable procedures, breast procedures, face procedures, and body procedures. Data were deseasonalized and represented graphically. Significance of each time-point differing from the expected values was determined using least squares regression. In Part II, Amazon’s Mechanical Turk platform was used to crowdsourced public opinions regarding aesthetic interventions from April 30-May 3, 2020. The survey discussed prior experience with and interest in six aesthetic interventions before and during the pandemic, and reasons for changing interest.

Results/Complications

:

In Part I, of the 156 significantly anomalous search term data points in 2020, 126 (80.8%) occurred after week 11 (national emergency declaration) (Fig 1). 61% of searches in all all time-points after week 11 were significantly different, and 21/26 (80.8%) of search terms experienced significant changes after week 11. Eighteen terms saw decreased interest with variable recovery. Onset of declining interest varied between weeks 10-12 (with the exception of “bbl” OR “brazilian butt lift” in week 9). Six of these terms recovered to normal or increased search volumes between weeks 15-18; another sixare approaching full recovery, while five show slow or stalled recovery. Procedural nadirs (lowest search volume) for search volume troughs occurred between weeks 12-14. Four patient-related chief complaints saw increased search interest, with onset during weeks 10-14, peak interest between weeks 12-15, and no return to expected levels. In Part II, 704 out of 838 responses were included. Half of respondents were female; median age group was 25-34 years. During the pandemic, 21% of respondents had increased and 33% decreased interest in at least one intervention. Non-invasive procedures (7.3%), facial aesthetic surgery (6.6%) and medical-grade skincare (5.9%) elicited the greatest interest increase. Seeing themselves in the mirror more often (43.2%), desire to look better after the crisis (41.8%), and increased time on social media (40.4%) were the top reasons for increased interest. The most common reasons for decreased interest were changing spending priorities (58%), focusing on other health aspects (49.8%) and worrying about infection in medical facilities (46.3%). Almost half of respondents considered virtual consultations for interventions of increased interest.

Conclusion

:

Conclusions: This is the first study to assess real-time, national data about the impact of COVID-19 on public interest in aesthetics. Google search data serves as an interest proxy and demonstrates an almost universal change in public interest from expected norms and varied rates of normalization. Amazon Mechanical Turk survey analysis enabled a segmentation of the public into groups of patients and how and why their interest has changed. Offering telemedicine, establishing detailed COVID-19 infection control policies, and discussing these with patients will be critical to address patient needs and concerns. Understanding the public’s dynamic interest in aesthetic offerings can facilitate resource allocation and procedure prioritization as practices reopen.

Goals/Purpose

:

A major cause of patient discomfort after orthognathic surgery is facial swelling. The purpose of this study is to investigate whether perioperative TXA administration reduces post-operative swelling.

Methods/Technique

:

This was a retrospective cohort study of consecutive patients who underwent Lefort I osteotomy, bilateral sagittal split osteotomy, and genioplasty on the same day by the senior author (DS) between 2013 and 2019. Patients included in the study had 3D photographs taken at consistent post-operative timepoints, including at first post-op visit (1-2 weeks) and at long term visit (9-14 months). Patients were naturally divided into two groups: those who underwent the procedure before 2017 did not receive TXA, while those after 2017 received a 1g bolus preoperatively and 10mg/kg infusion over 4 hours intra-operatively. Soft tissue volume of the mid- and lower-face region was measured from 3D images using post-processing software (3D VECTRA photosystem, Canfield, Fairfield, NJ). Total post-operative edema volume (TPEV) was defined as the volume change between the first post-op visit and last follow up visit. This volume was compared between TXA and control groups using the Welch two sample t-test.

Results/Complications

:

Forty-three patients, including 26 females and 17 males were included in the analysis. The mean TPEV was 54.0±30.1cm³ and 95.2±47.9cm³ in the TXA and control groups, respectively. This was found to be statistically significant (p=0.006).

Conclusion

:

This study provides evidence that TXA is effective for reducing edema after orthognathic surgery. This is an important finding, as it may improve the post-operative experience for patients.

Goals/Purpose

:

Rhinoplasty is among the top 5 most popular cosmetic surgery procedures in the US. Edema following rhinoplasty is a known sequelae, and is a common cause of anxiety for patients. The purpose of this study was to use three-dimensional morphometric analyses to identify patient factors that influence post-operative edema.

Methods/Technique

:

This was a retrospective, three-dimensional (3D), morphometric study of patients who underwent open septorhinoplasty by the senior author (DS). Subjects with at least 6 months post-operative 3D images were included. Images were assessed using 3D stereophotogrammetry post-processing software (3D VECTRA photosystem, Canfield, Fairfield, NJ). Post-operative edema was defined as the difference in nasal volume at the first post-operative visit (1-2 weeks), and at >6 months follow up. Age, gender, and use of intra-operative TXA were examined.

Results/Complications

:

Thirty-nine patients met the inclusion/exclusion criteria and were included in the analysis. Male patients had more swelling than female patients (p=0.02), and older patients were found to have more swelling on multivariate regression (p=0.04). TXA did not have a effect on post-operative edema.

Conclusion

:

This study provides evidence that male patients and older patients experience more edema following open septorhinoplasty. This information is especially important for counseling and managing the expectations of the cosmetic septorhinoplasty patient.

Goals/Purpose:

In studies of CCH for the treatment of moderate to severe cellulite in the buttocks of adult women, injection site bruising was the most frequently reported adverse event (AE). Histology studies were designed to better characterize the subdermal impact of CCH subcutaneous (sc) injections and investigate injection site bruising. The first study used Yorkshire pigs (domestic swine) as a model due to the similarities to human skin, and the second study, human abdominal tissue.

Methods/Technique:

Porcine Study: Four female Yorkshire pigs (35-45 kg) were to receive CCH (0.07 mg/0.3 mL) or placebo (0.3 mL) sc into 10 sites on the pigs’ left (L) and right (R) ventral side. The dosing schedule was as follows:

	2 Doses/Site		1 Dose/Site
Treatment	Day (s)	Sites	Day (s)	Site
CCH	-42, -21	R1	-21	L1
	-29, -8	R2	-8	L2
	-25, -4	R3	-4	L3
	-23, -2	R4	-2	L4
Placebo	-23, -2	R5	-2	L5

AEs were collected during the study. After euthanization on Day 0, the ventral side with the muscle tissue was excised as a single piece.

Abdominoplasty Study: Prior to abdominoplasty, 8 females, divided into 6 groups (G) will receive 1 or 2 doses of CCH into laterally marked areas of the surgical region (Areas 1 and 2), with the middle region marked as a control. The dosing schedule is as follows:

Groups	Area 1	Area 2
G1, G4; n=2, each	Days -43, -22	Day -14
G2, G5; n=1, each	Days –24, -3	Day -3
G3, G6; n=1, each	Days -22, -1	Day -1

Four subjects, each, will receive either CCH 0.07 mg as 3 x 0.1 mL aliquots (G1, G2, G3) or 0.0653 mg as 14 x 0.1 mL aliquots (G4, G5, G6). AEs will be collected during the study. On the day of abdominoplasty, the tissue incorporating the treatment areas will be excised as a single piece. The pathologist will be blinded to the dosing schedule.

Results/Complications:

Porcine Study: One pig experienced a leg injury unrelated to CCH administration and was euthanized. Histologic findings in the CCH-injected specimens of the three other pigs showed enzyme-induced lysis or disintegration of thick interlobular sub-dermal collagen septae. As collagen support was lost, leakage of blood from the thinner endothelial venules was observed in L3 (Day -4), L4 (Day -2), R3 (Days -25, -4), and R4 (Days -23, -2) injection sites. This correlated with the mild to moderate bruising and edema observed at these sites in all pigs.

Signs of collagen neogenesis and subdermal structural reorganization were evident as early as 4 days after CCH in L3 (Day -4) and R3 (Days -25, -4) and clearly defined in L2 (Day -8) and R2 (Days -29, -8) injection sites. Marked sub-dermal fat and collagen structural reorganization was evident at L1 (Day -21) and R1 (Days -42, -21) injection sites. No histologic changes were observed in sites injected with placebo.

Abdominoplasty Study: Histological findings are pending.

Conclusion:

Histologic findings in the porcine model demonstrate both early and later impacts of CCH-induced subdermal architectural remodeling of the collagenous septae as well as the fat lobules. Early after treatment, CCH induced enzymatic subcision of subdermal collagen macrostructures. Later, enzyme induced collagen neogenesis and marked sub-dermal fat and collagen microstructural reorganization was observed.

Goals/Purpose:

Clinical data on body contouring treatment with poly-L-lactic acid are sparsely reported in published literature. This report describes the lead author’s clinical experience of body contouring treatment with poly-L-lactic acid in various anatomic locations.

Methods/Technique:

Twenty consecutive patients undergoing body contouring treatments with PLLA (Sculptra Aesthetic, Galderma Laboratories, L.P., USA) were prospectively followed. All treatments were performed at a single clinic between February 2017 and February 2019. Treatment details such as reconstitution, injection volume, and dosage were documented. Treatment outcomes were assessed independently by patients and the treating physician via comparison of pre- and post-treatment photographs taken at baseline and after the final treatment session. Improvement was defined as volumization and/or increased visible fullness of the injected area. Agreement between patient-reported and physician-reported outcome was required for the treatment area to be rated as improved. Adverse events were recorded during treatment and follow-up visits.

Results/Complications:

Twenty patients (85% women) received poly-L-lactic acid for body contouring treatments such as volumization of buttocks, cellulite, and skin quality treatment. In most patients (65%), poly-L-lactic acid treatment was administered to correct post-surgical soft tissue deformities. Overall, patients had a mean of 5.1 treatment sessions in a mean of 1.4 anatomic locations. The most commonly treated anatomic locations were buttocks (80% of patients), thighs (20% of patients), and abdomen (15% of patients). 5%-10% of patients were treated in other anatomic locations (knee, arm, hand, and supraumbilical concavity). Dosage and injection volume varied between patients depending on anatomic location and desired outcome. Most treatment sessions (86%) resulted in improvement of the treated area. Adverse events included bruising, edema, numbness, and tenderness. One patient (5%) reported a nodule of mild severity which resolved spontaneously after 38 days.

Conclusion:

According to the lead author’s clinical experience, PLLA injection is effective and well-tolerated when used for body contouring treatments in appropriate patients. Preliminary data suggests PLLA may be a viable nonsurgical option for correcting post-surgical body contouring deformities.

Goals/Purpose

:

Instagram has overtaken Facebook as the social media platform of choice for 18- to 34-year olds. With the rise of social media use, there has been a commensurate increase in resources being devoted to understanding how information propagates across these platforms. Previous studies have described virality and influence in social media marketing, by modelling the spread of content and seeking to maximize the number of users reached. More recently, studies have used artificial intelligence (AI) and a combination of image features, text analysis, and social context to predict the popularity of images online/ on social media. In commercial settings, accurately predicting popularity can help value sponsored content. The aim of this study was to predict the popularity of images posted by plastic surgeons and quantify the social context and content- specific factors that contribute to their popularity. More generally, we sought to answer the question: “What makes a plastic surgery- related image popular?”

Methods/Technique

:

A list of US- listed plastic surgeons, current as of December 1st, 2019, was generated from the ASAPS webpage. Instagram accounts (and all posts associated to all accounts) associated to individual surgeons were identified manually. For prediction purposes, we deployed a random forest machine learning algorithm on the dataset to train it to predict the log- scaled popularity of Instagram posts. We used Spearman’s rank correlation (ρ) to quantify relationships between popularity and 1) social context input features (number of followers, followers- to- following ratio, number of posts, mean number of likes/ comments, Instagram verified status, Instagram engagement rate, and timestamp analysis and 2) content- specific input features (object classification, dominant color analysis, and caption length).

Results/Complications

:

Across 2,183 US- based ASAPS members, we identified accounts associated to 58.2% (n= 1,272) of plastic surgeons. Across all accounts, we identified 395,537 posts. The mean number of likes was 133 (range 0- 45,588). When we used indicators as input features to predict Instagram likes, mean number of likes (ρ= 0.64) and DL- assisted object classification (ρ= 0.19) achieved the highest Spearman rank correlations of all social context and content- specific indicators respectively. When combined, all social context indicators achieved a rank correlation of 0.22, while the combination of all content- specific indicators achieved a rank correlation of 0.67. The combination of all content- specific and social context indicators generated a rank correlation of 0.74. Our deep learning content analysis revealed that “swimming trunks”, “lab coat”, and “gas mask” had a strong positive impact on popularity. “Convertible car”, “desk”, and “screen” had a moderately positive impact on popularity.

Conclusion

:

While previous studies evaluated virality of text and images unrelated to plastic surgery on the internet, this study achieved a significant rank correlation between the predicted and actual popularity of Instagram posts by ASAPS- member plastic surgeons.

Goals/Purpose:

Rhinoplasty is one of the most common and complex procedures performed by plastic surgeons yearly. The evolution of this intricate technique has led surgeons to utilize a wide range of cartilaginous grafts for functional and aesthetic purposes. To visualize the evolution of cartilaginous graft use, we decided to evaluate the trends over the course of 15 years and evaluate to track adverse events.

Methods/Technique:

This is a retrospective cohort review from 2003 to 2018 using the Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database. The dataset was queried using Current Procedural Terminology (CPT) codes for primary and secondary rhinoplasties with grafts and indication codes (20910, 20912, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30520, 21230, 21235). These codes correspond to costochondral cartilage, nasal septum grafts, primary rhinoplasty (lateral and alar cartilages and/or elevation of nasal tip), complete primary rhinoplasty (external parts including bony pyramid), primary rhinoplasty including major septal repair, secondary rhinoplasty minor revision, secondary rhinoplasty intermediate revision, secondary major revision, osteotomies with repair of vestibular stenosis, repair of nasal vestibular stenosis, septoplasty or submucous resection, rib cartilage and auricular cartilage, respectively. Of note, nasal septal graft code is counted as separate if used for sites other than septum. Septal graft is inherently attached to the rhinoplasty codes. We paired every consecutive year for interpretability of results and graphs. The frequency of auricular, costochondral, rib and septal grafts were analyzed by year groups. Categorical variables are described as frequencies and compared with Fisher’s exact or Pearson’s Chi-squared test. Continuous variables, based on normality, are described as means (SD) or medians (IQR) and compared with Wilcoxon Rank-sum or Student’s T-test.

Results/Complications:

A total of 11,800 rhinoplasties were included (median age 30y [21-43]) and 75.61% female). We analyzed 10,050 (85.2%) primary and 1,750 (14.83%) secondary or revision rhinoplasties. We found a statistically significant change in frequency of rib (p:0.01), costal (p:<0.001) and auricular graft (p:<0.001) with auricular graft showing the most significant decrease (3.99% in 2003-04 to 0.67% in 2017-18) and costochondral with an increase (0.52% to 2.01%). For primary rhinoplasties a similar statistically significant trend for grafts was seen, with the highest change in auricular (2.62% in 2003-04 vs. 0.5% in 2017-18; p: <0.001) and costal with a trend towards increase (0.25% in 2003-04 vs. 1.5% in 2017-18; p: <0.001) (Figure 1A). Interestingly, in the secondary rhinoplasty group there was only a statistically significant difference for auricular graft with a noticeable decrease from 10.73% in 2003-04 to 2.13% in 2017-18 (p: 0.001) and costochondral having an increase from 1.58% in 2003-04 to 6.38% in 2017-18 ( p:0.004) (Figure 1B). Septal graft remained stable in all groups; however, as stated above, the “septal graft” group on the reported data is strictly used as a separate code when used on a separate site other than septum. In addition, there was no statistically significant difference in adverse event rate throughout the years for overall (p:0.38), primary (p:0.48) and secondary rhinoplasties (p:0.52). We found the highest rate of adverse events in the 2009-10 group in overall (1.97%) and primary rhinoplasties (1.85%). This group had septal graft used most frequently. While for secondary rhinoplasties, the highest frequency of 3.22% was seen in 2007-08 when rib and additional septal graft were used with the same frequency.

Conclusion:

The results from this study show that there is a recent preference in the use of costal grafting predominantly in revision rhinoplasties, while the use of auricular grafts have decreased over time. Nevertheless, this does not seem to have an impact on adverse events and may correlate with potential benefits in functional and aesthetic outcomes.

Goals/Purpose:

Prepectoral breast reconstruction has again become increasingly performed and reported upon. There have been concerns regarding capsular contracture, implant visibility, rippling, and malposition. The majority of recent prepectoral techniques within the literature are performed with a variable amount of Acellular Dermal Matrix (ADM) coverage without clear evidence-based guidelines regarding the indications and degrees of periprosthetic coverage with ADM. Poly-4-hydroxybutyrate mesh (P4HB mesh) has been shown to be beneficial for tissue reinforcement in the breast, such as in mastopexy. The purpose of this study was to assess our technique of prepectoral breast reconstruction with P4HB mesh for pocket control, mainly of the lateral breast border.

Methods/Technique:

A retrospective review of a single surgeon’s experience was performed. A search of the medical records was undertaken for 67 consecutive patients who had undergone prepectoral implant-based breast reconstruction in two stages. P4HB mesh was used for lateral pocket support; the mastectomy typically violates the lateral pocket and lateral malposition is common. The lateral pocket was first reestablished based on the location of the anterior axillary line. The skin flap was sutured to the lateral chest wall at the anterior axillary line, which was then reinforced with a 7.5 x 10 cm piece of the mesh. Biopsies of the capsule at the junction of normal and meshed-capsule were obtained during the first subsequent intraoperative evaluation of the pocket. The charts were reviewed for documentation of all complications including seroma, capsular contracture, malposition, implant visibility, infection, skin necrosis and explantation.

Results/Complications:

The surgeries were performed from 2018 through 2020. The retrospective review yielded 110 breasts in 67 patients who had undergone prepectoral two-stage implant-based breast reconstruction with P4HB mesh for lateral pocket support. 62 patients’ (105 breasts) reconstructions were performed in an immediate fashion, with the other 4 patients (6 breasts) were performed in a delayed immediate manner due to a high BRA score (Breast Reconstruction Risk Assessment Score, www.BRAscore.org). The mean age was 48 years (range: 28-73 years). The mean BMI was 29 kg/m² (range: 20-43). The mean weight of the mastectomy specimen was 494 grams (range 104-1396g). The average follow up was 11 months (range: 4-24 months). Time to drain removal was on average 3 weeks after stage I surgery with 4 breasts (3.6%) developing seroma which required aspiration. We found 2 patients (3 breasts, 2.7%) with lateral malposition of the tissue expanders which were corrected with capsular flaps during the second stage. There was one case of non-integration of mesh which also happened to be in one of the two patients who had developed lateral malposition. One breast (0.9%) developed baker class II capsular contracture in the setting of postoperative radiation. 9 breasts (8 %) required tissue expander explantation for infection (4 breasts, 3.6%) or exposure (5 breasts, 4.5%) noting that the mesh had completely integrated in all. Of the explanted patients, 3 breasts had a history of previous radiation (2 had infection and one had exposure). Histologic assessment of 9 capsules with P4HB mesh were obtained for varying reasons at time intervals of 3 and 6 weeks (replacement of deflated TE’s) and 5, 6, 7, 10, 14, 15, and 22 months (during Stage II reconstruction), which demonstrated progressively less inflammatory response and ultimately normal tissue by 22 months, with full integration at all timelines.

Conclusion:

To our knowledge this is the first reported study for prepectoral implant-based breast reconstruction with Poly-4-hydroxybutyrate mesh for lateral pocket support without the use of ADM. The use of P4HB promises to be both safe and efficacious with much less cost to the healthcare system and with high patient and surgeon satisfaction. Long-term prospective multicenter studies of a larger patient population comparing no mesh to P4HB mesh to the ADM cohorts are necessary to establish future guidelines.

Goals/Purpose

:

Hyaluronic acid (HA) soft-tissue fillers are the most popular degradable injectable products used for facial volumization. Their viscoelastic properties under shear-stress conditions have been characterized by rheological testing, and the data have been applied to product selection and indications. The purpose of these studies was to determine key rheological properties of a novel purified agarose gel filler derived from an algal source that is CE-marked for use in Europe and for which North American clinical studies are anticipated. Like HA, agarose is a biodegradable polysaccharide that gives immediate and durable clinical results. It differs from HA in that it is stable in vivo and provides durable results after tissue implantation without the need for crosslinking chemicals or other additives.

Methods/Technique

:

Rheologic testing was performed on agarose gel filler and on a crosslinked HA comparator that is CE-marked and US FDA approved for deep (subcutaneous and/or supraperiosteal) injection for cheek augmentation to correct age-related volume deficit. Testing was performed in an independent laboratory, using a parallel plate-to-plate rheometer at fixed ambient temperature and humidity. Oscillatory shear deformation testing comprised shear rate sweeps (0.1 to 100 s-1 range), time sweeps (1 s-1 shear rate) and frequency sweeps in shear. This measured elastic modulus (G’) and viscous modulus (G”); how the gels thinned out as applied force was increased (Eta*); and changes in rheological properties after agarose gel was mixed 1:1 by volume with normal (0.9%) saline and HA filler was mixed 1:1 with hyaluronidase. Static compression testing was also performed to provide a measure of each filler’s resistance to constant deformation (at a rate of 0.1 mm/s).

Results/Complications

:

Rheometric testing showed that agarose gel filler had a significantly higher elastic modulus (G’) and viscosity (G”) than the crosslinked HA comparator. Both agarose gel filler and the crosslinked HA comparator demonstrated a decrease in viscosity that was proportional to applied force – a phenomenon known as shear thinning. Agarose gel filler diluted 1:1 with normal saline showed a greater decrease in viscosity than the crosslinked HA filler diluted 1:1 with hyaluronidase. Viscosity decreased rapidly / almost instantaneously for both fillers and was maintained at the same low level over the ensuing 30-minute observation period. Agarose gel filler and the crosslinked HA comparator had qualitatively similar responses to static compression testing.

Mathematical calculations of tan delta (G’ / G”) showed that both agarose gel filler and the crosslinked HA comparator had a predominance of solid over fluid behavior within the frequency range of testing.

Conclusion

:

Based on these studies, agarose gel filler was found to have a rheological profile compatible with clinical behavior as a deep volumizer suitable for implantation in the subcutaneous or supraperiosteal tissue planes. Higher elasticity (G’) indicates potential for greater tissue volumizing capacity and more volume-efficient filling. Higher viscosity indicates potential for greater contour stability and less spread of the filler after implantation. The shear thinning behavior demonstrated by agarose gel filler is typical also of crosslinked HA fillers, representing a controlled and predictable thinning of the gel associated with maintenance of its elastic properties within a physiologically relevant range of testing (linear viscoelastic range). Static compression testing is especially relevant for deep volumizers which are exposed to the weight of overlying tissues.

The rapid dispersal of agarose gel filler on mixing with saline, as evinced by instantaneous decrease in viscosity, correlates with in vitro testing showing dispersal of agarose gel filler with saline and gentle agitation. In contrast, HA filler under the same testing conditions takes up water hygroscopically and is not dispersed. (Videos will be shown to demonstrate this). Water uptake within the blood vessel lumen is understood to play a significant role in the occlusive potential of HA filler. This suggests that, under the right conditions, saline may be effective to disperse agarose gel filler without the need for enzymes or other additives. Further studies must be conducted to define the relevance of these findings to in vivo behavior during and after tissue implantation. While rapid dispersal by saline may be a promising property if a filler is inadvertently injected into a blood vessel, the effects of blood components that are not present in saline such as plasma proteins must also be taken into consideration in order to accurately define whether agarose gel filler has lower occlusive or embolic tendencies. Further studies are now in progress with a particular focus on injectable safety.

Goals/Purpose

:

Live demonstrations are a hallmark of aesthetic training, with common characteristics including complimentary treatment for patient volunteers, educational and/or promotional objectives, and direct or indirect industry support. Demonstrations of injectables (fillers and botulinum toxins) are commonly performed and cited as low-risk procedures with high-yield educational value. Although intended to empower attendees to treat patients themselves, demonstration conditions invariably do not replicate clinical settings.

The purpose of this initiative was to frame guidelines for live injectables demonstrations from the suggestions of a group of core aesthetic faculty with experience in organization and execution of educational programs. Objectives were to define existing concerns, and to provide recommendations to minimize complications, facilitate consistent and ethical practice, and maximize educational benefits. To our knowledge, this is the first initiative to develop adaptable best practices for multinational implementation. The consensus guidelines have applicability to all aesthetic demonstrations, and other situations of non-standard/discontinuous patient care, including itinerant practice and medical tourism.

Methods/Technique

:

The Global Aesthetics Alliance Procedural Safety Consensus Group comprised 40 plastic surgeons and dermatologists from 25 countries and territories: 15 faculty who convened a facilitated meeting in Singapore in March 2018, plus 25 additional respondents of commensurate qualifications and experience, who shared responses primarily via structured interviews with a trained facilitator (Table 1). The consensus questionnaire addressed experiences serving as injectors, faculty, chairs, conference organizers, workshop instructors and audience members at live injectables demonstrations, as well as strategies for improvement. In accordance with established consensus methodology, group review and revision of these suggestions in a Delphi process yielded recommendations (suggestions that received a minimum of 66% support), and position statements (suggestions that did not meet this threshold).

To develop a statement of need, faculty provided case reports on significant adverse events or deviations from standard of care. After sufficient information was provided to remove duplicate reports, incidents were de-identified and tabulated. For all case reports, the respondent was directly present during the event, or personally verified details with other faculty in attendance.

Results/Complications

:

Case reports fell into four non-exclusive categories: (1) Procedural Complication including sequelae; (2) Potential for Procedural Complication, as established through Delphi process; (3) Treatment Planning & Implementation (logistical and methodological issues); and/or (4) Patient Welfare (Table 2). Thirty-nine case reports were documented, including similar incidents confirmed to have occurred at different demonstrations. Two incidents of vascular compromise and four incidents of intravascular entry without sequelae were reported. Overtreatment was the most common methodological issue. Compromises of patient welfare ranged from pain and acute distress to seizure, loss of consciousness, and death.

Consistent disparities between live demonstrations and in-clinic standard of care were summarized (Table 3). Faculty reported which aspects of demonstrations had concerned them in the past (Figure 1). 57.1% of faculty respondents reported addressing concerns with demonstration organizers or company representatives and characterized their experiences (Figure 3). The consensus group identified barriers to addressing concerns in demonstration settings.

77.4% and 83.9% of respondents stated concerns with demonstration rooms and facilities. 100% identified immediate needs for general and procedure-specific emergency equipment and protocols, based on in-clinic standards and adverse events at demonstrations during which equipment was unavailable. Relationships with local hospitals and specialists were also recommended. Pre-treatment concerns included recruitment, history-taking, informed consent, and clinical indication for the planned procedure. 93.6% of respondents reported inadequate pre-treatment consultation. Recommendations were framed to standardize recruitment and informed consent. 93.55% of faculty members reported suboptimal/nonexistent post-procedural communication. Guidelines were developed to foster continuity of care and routinize follow-up for all patients.

80% of respondents cited concerns regarding injector qualifications and provision of evidence of competency. Some respondents recommended existing demonstration staff/faculty to serve as patient liaisons during consent, treatment and follow-up, while others supported creating a formal, separate position. 77.1% of respondents supported a “code word” to halt demonstrations, but opinions varied regarding who should be aware of this word. Suggestions to delineate procedure- versus results-focused demonstrations were provided to minimize discrepancies between educational objectives and audience impact.

Conclusion

:

Divergence from standard of care raises questions regarding live aesthetic demonstrations as they currently exist. This consensus identified numerous strategies to facilitate more effective education and ensure ethical and appropriate treatment of patients.

All consensus faculty serve as industry consultants, clinical investigators, speakers, etc. Recommendations strove to balance the important role of industry in aesthetic education with faculty concerns regarding extent of involvement. Industry representatives have expressed support for this initiative, to reinforce and actualize their existing commitments, and to minimize situations with medicolegal implications.

This work initiates a multistage initiative to address challenges specific to live aesthetic demonstrations. The feasibility of these evidence-based guidelines across variable settings will be investigated in a global pilot project, for which sites have already been identified. Further consideration of the legal and liability aspects of international practice and the uses of technology to promote patient safety is also needed.

Goals/Purpose

:

Seroma formation and poor wound healing following major surgical procedures are the most common complications in plastic surgery Strategies have been reported to reduce complications related to seroma formation, but none have proven superior. Current technology and surgical approaches are often inadequate in closing surgical dead space, and largely fail at reducing post-operative fluid collections. Surgical drains are the most common device used to manage this problem; however their suction effect diminishes exponentially as fluid accumulates. Drains only manage fluid directly around them leading to potential fluid collections and seromas at distant sites within the surgical plane (Fig.1-2).

We describe a novel system including a branching 4-channel internal manifold attached to a one-way connector and portable, enclosed pump canister system designed to deliver a constant -125mmHg throughout the entire surgical space without electrical power. A First-in-Man pilot clinical study was undertaken to evaluate the clinical safety and functionality of the system in 24 full abdominoplasty patients. Clinical assessments and ultrasound were performed during the 30-day post-operative period to assess wound healing, presence of seroma, and adverse events. Surgeon and patient assessment of system performance were also evaluated.

Methods/Technique

:

A WIRB pilot clinical study (#20162287) was performed at 3 separate practice locations by 3 board-certified plastic surgeons in 24 patients. Full abdominoplasty was performed in female patients, average age 40.6 years [Range 25-63] and average BMI of 25.1 [Range 20-29]. All four branches of the manifold were opened completely and evenly distributed throughout the surgical field following flap elevation (Fig.3). The connector was attached to the tubing and secured to the pump/canister (Fig. 4-5). Patients were evaluated on POD 1,3,7 and POD 30 for final assessment.

Per protocol, all manifolds were removed on POD 7 (fluid drainage was <20 ml in preceding 24 hours). High resolution ultrasound was performed in 8 patients at each follow-up visit at Site #1. Wound and exit site assessments for seroma, erythema, swelling, adverse events were documented at each follow-up visit. Surgeons and patients provided a subjective assessment of their personal experience with the system as well as the ease of removal.

Results:

The average volume of drainage recorded a mean of 551mL [Range 240mL - 2205mL]. One outlier patient was identified who experienced 2205mL of postoperative drainage following 5L of lipoaspirate without developing a postoperative seroma.

The average tissue flap resected measured 764 cm2 [Range 288 cm2-1350cm2]. Erythema of the surgical site at POD’s 7 and 30 was essentially zero. Swelling at the operative site POD 7 was 0.3 (0-4.0 scale) and essentially zero at day 30. No adverse events were reported including no skin edge necrosis, no wound dehiscence and no wound infections. Importantly, there were no clinical seromas reported on physical exam in any patient at any Site (n=24) and no fluid collection detectable on ultrasound in any patient at Site #1 (n=8) at any postop visit and including POD 30 (Fig 6-7).

Subjectively, 100% patients were very satisfied with the system function and pain reported was 0.5 (Pain scale 0-5.0). Independent testing, reported separately, of the pump/canister demonstrates maintenance of constant negative pressure from no fill to maximal fill.

Results/Complications

:

See "Conclusion: "

Conclusion

Multiple strategies have been described for closing surgical dead space and minimizing postoperative fluid collections reducing associated surgical complications. Suturing techniques, drains and glues are perhaps the most common approaches employed to address this challenge; however, drain technology has not significantly changed in decades. Recent studies have reported the mechanism of action and benefits of constant negative pressure wound therapy (Orgill, 2009). Likewise, two independent studies (Walker, 2016 and Janis, 2018) have demonstrated that standard closed suction drains do not maintain suction or negative pressure as canisters fill with fluid.

We describe the use of a novel 4-prong, branching manifold capable of delivering constant negative pressure (-125mmHg) in 24 abdominoplasty patients with no clinically identified (n=24) or ultrasound-detected (n=8) fluid collections at 30 days postoperatively or other significant complications. The system was well-tolerated by all subjects demonstrating an effective method of closing tissue planes and removing fluid in abdominoplasty patients and confirming the findings of previous reports comparing devices delivering constant vs diminishing internal negative pressure in the management of postoperative fluid collections.

Fig. 1 and 2. Standard single tube drain placement focuses pressure and fluid retrieval only along the tubing path. Negative pressure generated by closed-suction bulb reservoirs diminishes exponentially with fill volume (Walker, 2016, Janis, 2018).

Fig. 3-5. Branching manifold allows for broad distribution of negative pressure throughout the surgical space. One-way connector with back-flow valve is placed on the tubing connected to the portable canister designed to maintain a constant -125mmHg.

Fig. 6-7. Ultrasound images demonstrate plane of tissue closure with overlying subcutaneous tissue approximated to the underlying fascia with no identifiable fluid collection in the surgical tissue plane or surrounding any manifold branches shown here in cross-section.