Residents and Fellows Forum
Capsular contracture is a challenging problem for patients and plastic surgeons despite advances in surgical technique and breast implants. Breast pocket irrigation has been shown to play an important role in decreasing bacterial bioburden. Recent studies have shown 0.025% stable hypochlorous acid (PhaseOne) to effectively penetrate and disrupt biofilms; however, there is limited data on clinical outcomes of this irrigation when used in breast augmentation. Our study investigates the safety and efficacy of hypochlorous acid pocket irrigation in revision breast augmentation by evaluating rates of capsular contracture recurrence, infection, and allergic reactions.
Methods/Technique:
After IRB approval, a retrospective chart review of patients who underwent bilateral revision breast augmentation for Baker grade III or IV capsular contractures was performed. Data was obtained from three board-certified plastic surgeons. Triple-antibiotic solution with or without betadine was used at the time of primary breast augmentation. 0.025% stable hypochlorous acid was used during revision breast augmentation.
All surgeons used similar preoperative practices and surgical technique, adhering to the principles of Tebbetts and the following modified 14-point plan:
1- Single dose of preoperative antibiotics
2- Inframammary incisions
3- Nipple shields
4- Capsulectomy and removal of old implant
5- Meticulous hemostasis
6- Maintain submuscular plane
7- Breast sizers placed in pocket
8- Irrigation with normal saline; evacuation
9- Irrigation with hypochlorous acid; evacuation
10- 60 cc hypochlorous acid placed in pocket; tension on retractor is released to allow contact with all pocket surfaces for a minimum of 5 minutes
11- Surgeon gloves changed
12- Implant is delivered into pocket with “no-touch” technique
13- Layered closure
14- One of the three surgeons gives post-operative antibiotics
Patient factors recorded included the following:
1) Presence of infection within 30 days as evidenced by breast redness, painful swelling, positive culture or incisional drainage
2) Capsular contracture Baker grade
3) Timing of contracture recurrence
4) Allergic reactions including rash, itching, hives, anaphylaxis
5) Follow-up duration
6) Irrigation used
Results/Complications:
There were 135 breasts in 71 patients included in the study. Patient age range was 27-77 years. Follow-up duration ranged from 12-41 months, with a mean of 20.2 months. There were 3 major complications from two unilateral Baker grade III/IV recurrences after 12 months and one bilateral Baker grade II recurrence at 3 months post-op. There was one reoperation for a recurrence. There were no infections or allergic reactions. The overall capsular contracture Baker grade III/IV recurrence rate was zero at 3 and 12 months and 1.5% at 15 months.
Conclusion:
Breast pocket irrigation is a key factor in controlling bioburden which may influence capsular contracture recurrence rates. Our study evaluated three varied applications of .025% stable hypochlorous acid in revision aesthetic breast surgery and found that it is a safe and effective adjunct to pocket irrigation. Hypochlorous acid has no allergic potential and it is non-toxic to native tissue. We plan to report our findings with hypochlorous acid in primary breast augmentation in the future as well as other studies being conducted on the efficacy of hypochlorous acid in aesthetic surgery.
Body-contouring procedures, and specifically abdominoplasty, have a known higher incidence of venous thromboembolic events, which includes deep vein thrombosis (DVT) and pulmonary embolism(PE), compared to other plastic surgery procedures. While the true etiology is unknown, the increased risk is likely due to a combination of increased intra-abdominal pressure leading to venous dilatation and stasis as well as limited ambulation post-operatively. Sequential compression devices(SCDs) has been proven to be beneficial in preventing the formation of DVTs when used in the peri-operative period. Previous research shows that SCDs prevent DVT formation by preventing venous stasis. This is accomplished by mimicking the contraction of the calf muscles to limit venous stasis and venous dilatation. It also been shown that these devices can stimulate both local and systemic fibrinolytic activity. The American Association of Plastic surgeons recommend the use of SCDs in the peri-operative period.
There remains significant controversy over the recommendations regarding VTE prophylaxis for patients undergoing plastic surgery. The controversy arises due to a lack of generally accepted consensus regarding prophylaxis recommendations; continued concerns for post-operative bleeding and/or hematoma due to the wide operative dissection; as well as arguments about the lack of evidence specific to plastic surgery regarding the use of chemoprophylaxis. While the Caprini score is widely regarded as a template for risk assessment, there is also wide latitude on the treatment protocols for VTE prophylaxis. The trend towards performing these procedures on an outpatient basis causes more concern regarding how to properly prevent VTEs from occurring while the patient recovers at home.
The purpose of this study was to retrospectively analyze the utilization of a maximal prophylactic regimen that combines both low molecular weight heparin and at home, portable SCDs and demonstrate its safety and efficacy in preventing VTEs in abdominoplasty patients.
Methods/Technique
:A retrospective review of patient data was performed on all patients who underwent abdominoplasty over a 18 month period from March 2019, when the practice began using at-home SCDs, to September 2020 (n=34 patients). All abdominoplasty patients over this time period were provided at-home sequential compression devices to wear post-operatively for two weeks. They were also required to administer LMWH (Lovenox) to themselves beginning 24 hours after the procedure and continuing it for one week. Teaching regarding the use of both of these adjuncts was done at multiple time points by both the surgeon and clinical staff. The primary outcome analyzed was incidence of VTE and secondary outcome was incidence of hematoma formation.
Results/Complications
:Data analysis showed the average age of the patients was 44 years old (+/- 7.78 yrs) and their average BMI was 27.7 kg/m2(+/-4.5 kg/m2). The average preoperative Caprini risk score VTEs was 4 (+/- 1.2, max score of 7). There was 100% compliance based on discussions between the senior surgeon and the patients. Among this group of patients there was no clinically evident DVTs or PEs in any of the patients on the post-operative VTE prophylaxis regimen of LMWH and at-home SCD use. In addition, no patients developed post-operative bleeding complications or hematomas. One patient out of the thirty-four reviewed developed a seroma(2.9%).
Conclusion
:Venous thromboembolic events represent a serious post-operative morbidity, which can also extend to mortality. Due to the obvious concerns regarding VTEs there have been numerous studies looking at the ideal combination of both chemoprophylaxis and mechanical prophylaxis to prevent VTE in the post-surgical patient. Despite recommendations by the American Association of Plastic Surgeons and the American Society of Plastic Surgeons VTE Task Force, there has not been a standardized approach to both chemo- and mechanical prophylaxis in patients undergoing plastic surgery. This has mostly been due to concerns for bleeding and hematoma formation in the post-operative period, after leaving the operating room. In addition to concerns regarding hematomas, patients undergoing abdominoplasty surgery demonstrate a low incidence of DVT/PE which operationally translates to a low risk situation. This may be interpreted by some practitioners as acceptable risk and thus not necessitate prophylaxis.
The current retrospective review demonstrated that the post-operative use of LMWH did not cause any hematomas or bleeding complications and that the combination of LMWH and at-home SCDs led to a complete absence of clinically evident DVTs in this patient cohort. There was also a very small incidence of seroma formation in this patient cohort. For this reason, we believe that it is not only safe, but effective to use both LMWH and at-home portable SCDs on a more routine basis in plastic surgery patients. In addition, at-home portable SCDs could potentially be used as the singular modality for VTE prevention in patients with a high-risk of bleeding post-operatively.
Methods/Technique: From 2014 to 2019, one hundred thirty-three patients (n=133) were treated by 11 surgeons. The surgical approaches utilized were direct excision or subcutaneous mastectomy alone, liposuction alone, a combination of both, and with or without simultaneous nipple-areola complex (NAC) reduction or free nipple grafting. Descriptive statistics on the 133 patients in the study included means, medians and measures of variability. Comparisons between gynecomastia patients who had complications and those who did not were made by Student’s t-tests and c2 tests. Statistical significance was set at p < 0.05. All patients were assigned a gynecomastia grade based on the ASPS Gynecomastia Scale adapted from the McKinney and Simon, Hoffman and Kohn scales. Four independent raters completed a 5-point Likert scale (1-least desirable to 5-most desirable) to subjectively assess aesthetic outcomes (i.e. chest shape, scar severity, symmetry, nipple/NAC position and appearance, and overall appearance). We used univariate analyses to determine which variables significantly influenced the outcome score.
Results/Complications: The average age and weight at the time of intervention was 16 ± 2 kg and 87.1 ± 2 kg, respectively (Table 1). Among our patients, 13.6% (n=18) had a complication that is categorized as either major or minor (Table 2). Overall there were a total of 21 major and minor complications (15.7%). There were 17 major complications, defined as a hematoma, seroma, nipple necrosis, and DVT, and 4 minor complications, defined as wound dehiscence, nipple contraction, and excess skin requiring re-excision. BMI was not found to be a statistically significant predictor of complications (p=0.15) (Table 3). Patients with greater liposuction volumes and excision weights lead to higher observed complications although these results were not statistically significant (Tables 4 and 5). Placement of a drain and type of drain did not lead to significant differences on outcomes (p=0.16 & p=0.49, respectively). A group of independent physician reviewers rated aesthetic outcomes based on standardized postoperative photographs.
Conclusion: Reported complication rates after gynecomastia surgery historically have been significantly high.1-3 We report our reduced complication rate of 13.6% in a large cohort of patients at a major pediatric burn center. BMI, age at intervention, excision weight, placement of a drain, and surgical technique did not lead to significantly higher adverse events. Contributing factors to our lower rates observed may in part be due to our aggressive immediate post-operative use of anti-emetics, a 6-week course of compression wrapping, and a reduced physical activity regiment. Based on our results from independent reviewers, we have developed a treatment algorithm to optimize aesthetic outcomes based on gynecomastia grade. Proper counseling of patients is necessary to ensure adequate understanding of gynecomastia surgery, postoperative course, and outcomes. Ultimately, results from this analysis has led our institution to reconsider timing and intervention on patients previously excluded, which may correlate to earlier improvements in mental health.
1 Fagerland A, Lewin R, Rufolo G, Elander A, Pompeo FS, Selvaggi G. Gynecomastia: A systematic review. J Plast Surg Hand Surg. 2015;49(6):311-8.
2 Lanitis S, Starren E, Read J, et al. Surgical management of gynaecomastia: outcomes from our experience. Breast. 2008;17:596-603.
3 Wiesman IM, Lehman JA, Parker MG, et al. Gynecomastia: an outcome analysis. Ann Plast Surg. 2004;53:97-101.
The iPhone X is the first smartphone to be released with a high-fidelity 3D scanner. At present, half of all US smartphone users use an iPhone. Recent data suggest that the majority of these 230 million individuals will upgrade to the iPhone X within two years. This represents a profound expansion in access to 3D scanning technology not only for plastic surgeons but for their patients as well. Given these implications, the purpose of this study was to compare the iPhone X scanner against a popular, portable 3D camera used in plastic surgery (Canfield Vectra H1).
Methods/Technique
:Sixteen human subjects (n=16) underwent 3D facial capture with the iPhone X and Canfield Vectra H1 and results were compared using color map analysis and surface distances between key anatomical landmarks. To assess repeatability and precision of the iPhone X 3D scanner, six (n=6) facial scans of a single participant were obtained and compared using color map analysis. In addition, three (n=3) 3D-printed facial masks were captured with each device and compared.
Results/Complications
:For iPhone X vs. Canfield H1 experiments, average (root mean squared) RMS was 0.44mm following color map analysis and 0.46mm for surface distance between anatomical landmarks. For repeatability and precision testing, average RMS difference following color map analysis was 0.35mm. For the 3D-printed facial mask comparison, average RMS difference was 0.28mm.
Conclusion
:The iPhone X offers 3D scanning that accurate and precise to within half a millimeter when compared to a commonly used, validated, and expensive 3D camera. This represents a significant reduction in the barrier to access 3D scanning technology for both patients and surgeons.
Augmented reality (AR) technology is a type of three-dimensional (3D) technology that allows for visualization and interaction with holograms in the real environment. One potential application of this technology is the use of intraoperative holograms to help guide surgical decision-making and precision. In the present study, the authors sought to investigate the accuracy with which aligned holographical markings could be translated by surgeons into surgical markings on a phantom patient.
Methods/Technique
:A total of 15 trials (n=15) were performed on phantom patients. To create a hologram, surgical markings consisting of 14 points were placed on a mannequin and this was captured with 3D photography. The resulting 3D photograph was converted into a hologram using a third-party application and visualized using an AR headset. The holographic markings were aligned to an unmarked phantom patient using a step-wise manual alignment method. Using a surgical pen, the real phantom was marked based on the position of the overlaid holographical markings. 3D photographs of the resulting marked real phantom were taken, and the accuracy of markings were analyzed using 3D analysis software.
Results/Complications
:Holographic overlay proved to be a highly accurate method of guiding intervention, with an average total error in placement of markings of 1.35 ± .24mm. In addition, there were no significant differences in the accuracy of landmark placement between trials. ANOVA investigation identified a greater error in the accuracy of surgical markings that were further from the midline of the face (p < 0.05).
Conclusion
:This study demonstrates that holographic markings can be accurately translated onto a real-world phantom patient with an average error of less than one millimeter. These data support the notion that AR navigation in facial plastic surgery is feasible in a controlled setting. Future studies should seek to investigate the feasibility of AR navigation in live surgery and assess the impact of intraoperative implementation of AR technology on operating room workflow and efficiency.
Methods/Technique: An anonymous, online survey was conducted to PS residents to get an in-depth and updated analysis on training in GAS. Questions included type and quantity of formal education in GAS, hands-on exposure to each GAS non-surgical/surgical procedure, resident self-rated preparedness to perform GAS after residency, and reasons underlying possible deficiencies in training.
Results/Complications: The survey had a 14.5% response rate (168/1,160 US PS residents). Hands-on exposure is reported by 83.3% of respondents. Female-to-male mastectomy is the most common procedure respondents are exposed to (90.7%): 18% of residents were exposed to >15 cases. Metoidioplasty is the least common procedure by exposure (12.9%): only 5% of residents were exposed to >15 cases. The majority of residents (64.6%) feel adequately trained to perform Female-to-Male mastectomies; however, 53.4-79.7% of them do not feel adequately trained to perform other GASs. Residents in the West are exposed to significantly more GASs compared to those in the South. Lack of patient volume and interested and/or trained faculty are identified as areas that need the most improvement. About one-third of residents (34.3%) report no dedicated faculty surgeon or any formal transgender clinic in their program. Two-thirds of residents (66.9%) believe a dedicated fellowship is important to perform GASs after residency.
Conclusion: While most PS residents have some training in GAS, the majority do not feel adequately trained in most procedures. Higher patient volumes, trained faculty, and dedicated fellowships are identified as main options to improve training.
Lower eyelid blepharoplasty is a powerful procedure for periorbital rejuvenation. The two reported lower lid blepharoplasty techniques include the transconjunctival and subcilliary approaches, both of which can have the serious consequence of lower lid ectropion. An alternative technique of minimal access lower lid recontouring was previously described in 2013 with zero incidence of lower lid retraction at that time. This approach allows for no incision in the functional muscle in the anterior or posterior lamella of the central lid. The purpose of this study was to evaluate the 13-year experience of this technique in regard to aesthetic outcome and lower lid retraction.
Methods/Technique:
A retrospective review was performed from a single surgeon’s practice of patients who underwent minimal lateral access lower lid recontouring for eyelid rejuvenation over a 13-year period. Patients with at least 6 months follow up were evaluated for complications and patient satisfaction. This minimal access technique is carried out through a small lateral lower lid incision only. Fat is recontoured after the technique of Lobe with progressive muscle lifting after the technique of Hinderer.
Results/Complications:
Two hundred fifty-five patients underwent minimal access lower lid recontouring during the 13-year period. A total of 171 patients had at least 6 months follow up and were included in the study. There were 12 cases of secondary surgeries of lower eyelids including fat pad excision (N3), excess lower lid skin removal (N1), correction of contour recurrence issue (N1), scar revision (N3) and removal of prominent canthopexy suture (N4). There were no major complications including no instances of lower lid ectropion.
Conclusion:
This study demonstrates that minimal access lower lid blepharoplasty is a safe and effective way to recontour the lower lid. There is a very low revision rate and no instances of lower lid retraction. Additionally, one may conclude that avoidance of cutting functional muscle in the central lid with this technique may contribute to the zero incidence of lower lid retraction seen with this approach.
Tranexamic acid (TXA) has gained increasing recognition in plastic surgery as a dependable adjunct capable of minimizing blood loss, ecchymosis, and edema. To date, there has been limited data on the use of TXA to mitigate liposuction donor site ecchymosis. As such, the authors investigate whether local infiltration of TXA safely reduces the degree of ecchymosis at liposuction donor sites.
Methods/Technique
:A single-center, single-surgeon retrospective cohort study was performed to analyze all consecutive patients undergoing liposuction and autologous fat transfer as part of second-stage breast reconstruction between 2016-2019. In all patients, the donor site was infiltrated with Klein’s tumescent solution. Once lipoaspiration was complete, patients in the intervention group received a total of 75mL of TXA (3g in NaCl 0.9%) into the harvest donor sites, whereas the patients in the historical control group did not receive TXA. The primary endpoint was degree of donor site ecchymosis, which was graded on an ordinal assessment tool previously published by Hunstad et al. (1= no bruising” through 10= extremely bruised”). Secondary outcome measures included hematoma, seroma, and thromboembolic events. A double-blinded randomized assessment of postoperative photographs of the donor sites was performed by senior plastic surgery residents and research fellows. Comparative analysis of continuous variables and categorical variables were performed using the Mann-Whitney-Wilcoxon and Fisher’s exact tests, respectively. A value of p<0.05 was considered significant.
Results/Complications
:A total of 120 consecutive autologous fat grafting procedures for breast reconstruction were reviewed. Overall, 60 patients received TXA, whereas 60 patients did not. Patient demographics and comorbidities were similar amongst the groups. There was no difference between groups with regards to donor site locations. There was no difference in volume of tumescent injected amongst the groups. The median tumescent volume infiltrated in the TXA group was 1600mL (range: 1200-2400mL), and 1750mL (range: 800-2500mL) in the non-intervention group (p=0.86). Median volume of lipoaspirate amongst the TXA and control groups was similar: 317.5mL (range: 45-750) vs. 267.5mL (range: 55-905), p=0.44. A total of 10 blinded evaluators completed the assessment (7 senior plastic surgery residents and 3 research fellows). Average time to postoperative photograph for the TXA group was 14±13 days vs. 10.3±6.2 days for the non-intervention group (p=0.11). The median bruising score of patients who received TXA was significantly lower than the patients who did not (1.6/10 vs. 2.3/10, p=0.01). Postoperative complications, including hematoma, seroma, and thromboembolic events were similar amongst the groups. Adverse effects of TXA were not observed.
Conclusion
:Although, further prospective randomized studies are warranted, the authors demonstrate that patients who received local infiltration of TXA into the liposuction donor sites were found to have less donor site ecchymosis compared to patients who did not receive TXA.
Methods/Technique: A retrospective review from January of 2015 through October 2020 was performed for all patients that underwent placement of P4HB mesh in primary and secondary breast surgeries by three surgeons. Review of the indications for use of mesh was evaluated as well as complications and overall outcomes.
Results/Complications: During the 5-year period, P4HB mesh was used in 161 patients. 57% of patients underwent mesh placement for primary breast procedures. Primary breast surgeries included mastopexy, augmentation mammoplasty, reduction mammoplasty, and augmentation mastopexy. 43% of patients underwent mesh placement for secondary revisional breast procedures. Secondary breast procedures included correction of malposition, symmastia, stretch deformities, and capsular contracture. The overall complication rate was 20% and included hematoma, recurrence of malposition related to mesh malposition, infection, hypertrophic scarring and wound dehiscence. Of these complications, 39% of the complications were related to the mesh and included recurrent malposition and exposed mesh. Secondary procedures were required for 92% of patients who experienced a complication related to mesh.
Conclusion: The use of P4HB can be used successfully in primary and secondary breast procedures with predictable long-term results and minimal risk of complications. Mesh can be an excellent addition to primary breast procedures to decrease risk of inferior malposition or stretch deformity. Mesh can also be used for secondary breast procedures to correct malposition and stretch deformities. Patients undergoing secondary procedures are at higher risk of complications needing revisional surgery and should be properly counseled.
Methods/Technique: A retrospective analysis was performed on patients who presented to a single practice for elective breast implant removal and total periprosthetic capsulectomy over a 12 month period. In all cases, capsule tissue was sent for gross pathologic identification, as well as microbiologic examination for aerobic, anaerobic, fungal, and acid-fast bacteria. Aerobic cultures were held for 48 hours, anaerobic cultures were held for seven days, fungal cultures were held for four weeks, and acid-fast cultures were held for six weeks. The resulting data was analyzed to determine the percent of implants which had bacterial growth. Furthermore, the types of bacteria were identified to determine the most commonly encountered microorganisms.
Results/Complications: A total of 200 patients underwent bilateral implant removal with total periprosthetic capsulectomy during the defined period. Of these 400 implants, 27.50% (n=110) were found to have bacterial growth from the cultured capsule tissues, despite the fact that none of the patients were preoperatively exhibiting clinical signs of overt infection. Once speciated, 80.91% (n=89) of the implants with positive cultures were found to be growing Propionibacterium acnes. Other, minor, microorganisms identified included various Staphylococcus species (7.27%, n=8), Streptococcus species (1.81%, n=2) and fungal species (5.45%, n=6)
Conclusion: The presence of bacteria on breast implants and capsules occurs at a relatively high frequency, with Propionibacterium acnes being the overwhelmingly dominate species identified. Given the known correlation between Propionibacterium acnes and nonspecific musculoskeletal complaints from the orthopedic literature, future studies are needed to further understand if there is also a potential link between the presence of Propionibacterium acnes on breast implants and the non-specific symptoms some breast implant patients manifest.
Methods/Technique: Women aged 40-65 were recruited and consented. Patients were excluded if they had a prior history of facial rejuvenation procedures, underwent prior minimally invasive procedures within the last 12 months, had a history of congenital facial paralysis or asymmetry, and/or were currently on blood thinners. Patients were injected in four areas using the following: Restylane-L® in the nasolabial folds and marionette lines, Restylane-L Lyft® in the malars, and Restylane Silk® in the cutaneous vermillion border. Patients completed 12 independent domains of the FACE-Q quality of life questionnaire and were photographed pre-injection (baseline), immediately post-intervention, 2 weeks post-injection, and 4 weeks post-injection using 3D Vectra® M3 Imaging Software. For volumetric analysis, two 3D images were layered and matched. Subjects were included if calibration of images met current standards for 3D facial analysis. The FACE-Q was scored for overall satisfaction in each domain.
Results/Complications: Thirty-one women were consented, enrolled, and received intervention. Six subjects were excluded from volumetric analysis due to inadequate image calibration. For the 25 subjects included in analysis, median age was 52.8 (interquartile range [IQR] 50-57) and follow-up was 4 weeks post-injection. On 3D image analysis, a median of 88.2% of injected volume was maintained at 2 weeks post-injection (IQR 69-124) and 81.4% of injected volume was maintained at 4 weeks post-injection (IQR 57-140, FIGURE 1a). In terms of PROs, improvement was seen from baseline to immediately post-injection in appraisal of facial appearance, marionette lines, cheekbones, cheeks, lower face/jawline, psychological function, and social function (n=31, all p<0.05). Continued improvement was seen from baseline to 4 weeks post-injection across all 12 FACE-Q domains (all p<0.05, FIGURE 1b). There were no significant differences in domains from 2 weeks to 4 weeks post-injection (all p>0.05).
Conclusion: Our preliminary results support that hyaluronic acid dermal facial fillers maintain volume at 4 weeks post-injection. FACE-Q scores demonstrate improved quality of life immediately after injection, and this improvement is maintained through 4 weeks-post injection across domains. This study is ongoing with an enrollment goal of 100 patients and a 3-month follow-up evaluation to examine long-term results of these hyaluronic acid dermal facial fillers.
With the increase in immediate, implant-based breast reconstruction, surgeons continue to expand the application of this technique with regards to nipple preservation and shaping of the skin envelope. Classically large, ptotic breasts have been a contraindication for nipple preservation. Here we present a technique to both reduce the excess skin envelope and preserve the nipple areolar complex (NAC) at the time of mastectomy. Unlike the transverse pattern mastopexy where only vertical excess is addressed, the “smile” pattern allows a reduction in the vertical, as well as horizontal excess while avoiding a “T-Junction”, which is notorious for wound healing complications. The design of the final scar allows for future adjustments of nipple position and skin envelope refinements in the event of lower pole stretching.
Methods/Technique
:This is a retrospective review of single surgeon experience performing the “smile mastopexy” for implant-based breast reconstruction. The smile mastopexy is designed at the time of pre-operative marking. In a standing position, the new nipple location is determined using Pitanguy’s point. The upper incision is marked in parallel of the lower border of the breast making sure that the medial extent does not extend beyond the assumed location of a brassiere. Next 8cm is measured from the IMF towards Pitanguy’s point, which then becomes the new N-IMF distance. The excess skin between these marks is de-epithelialized and the nipple-areolar complex (NAC) is kept on this adipo-dermal flap. The mastectomy is then performed through the upper incision. After placement of the tissue expander, the dermal flap is advanced under the superior mastectomy flap and secured, providing additional thickness to the upper pole. Lastly, a full thickness window is created in the superior flap for NAC inset at the previous marked location, and all incisions are closed (see figures 1-6). All reconstructions were performed in the pre-pectoral plane without the use of acellular dermal matrices although this technique can also be used for subpectoral technique. In addition, a similar technique can be used in case of proximity of tumor to the nipple in which case the nipple is removed, the defect is closed in a pursed string fashion while the areola is preserved.
Results/Complications
:A smile pattern mastopexy was designed for each patient pre-operatively. In all cases a tissue expander with an integrated drain port was placed at the time of mastectomy. Our study included 19 patients and a total of 34 breasts. Mean age was 50 years old, mean BMI kg/m2 was 31.6, and mean mastectomy specimen weight was 690 grams. All patients had either class 2 (2/19, 10%) or class 3 (17/19, 90%) ptosis preoperatively. There were no cases of complete nipple loss, however one patient experienced partial nipple loss. There was one case of partial mastectomy skin flap necrosis which required debridement. The most common complications were minor wound healing issues (2/19, 10%), which were treated with conservative measures. There were no reconstructive failures in our group.
Conclusion
:The “smile mastopexy” is a reliable method that can be used during immediate stage 1 implant-based breast reconstruction to preserve the nipple areolar complex while reducing the excess skin envelope in large, ptotic breasts. It is a powerful technique that can lead to improved aesthetic outcomes in patients that may otherwise not be candidates for NAC preservation. The additional thickness to the upper flap also reduces the appearance of rippling. Because of the dermal flap, the option for free NAC grafting if needed, is also preserved. Lastly, this technique allows for future adjustments in nipple position and the lower pole length without the addition of new scars, especially in the setting of radiation induced asymmetry.
Methods/Technique: Patients undergoing breast augmentation with AFG as well as with implants between 1/2/2017 and 7/31/2019 were identified within the prospectively enrolled CosmetAssureTM database (Birmingham, AL). The primary outcome was the occurrence of covered major complication(s) requiring emergency department visit, hospital admission, or reoperation within 45 days postoperatively. Age, gender, body mass index, smoking, diabetes, type of facility, ASA class, and type of anesthetic were evaluated as risk factors. The secondary outcome was the comparison of breast augmentation with AFG to breast augmentation with implants.
Results/Complications: Among the 76,128 patients enrolled in CosmetAssureTM, 789 (1.0%) underwent breast augmentation with AFG, while 18,544 (24.3%) underwent breast augmentation with implants. The AFG cohort was more likely to be >40 years, female, obese, ASA class III/IV, operated on at an ASC/hospital under general anesthesia, and less likely to use tobacco compared to the implant cohort (Table 1). The incidence of any major complication in the AFG cohort and implant cohort was 3.2% and 2.3%, respectfully. Infection was significantly higher in the AFG cohort compared to the implant cohort (1.1% vs 0.5%, p<0.05). The most common complications in the AFG cohort were infection (1.1%), hematoma (1.1%), suspected/confirmed VTE (0.5%), and pulmonary dysfunction (0.3%). Table 2 and 3 depict complication rates for breast augmentation with AFG and with implants, respectively. On univariate analysis, for the AFG cohort, tobacco users were more likely to have any complication, infection and pulmonary dysfunction/hypoxia; ASA class III/IV was more likely to have any complication and infection (Figure 1). On multivariate analysis, smoking was an independent risk factor for any complication (RR=17.1, CI 2.2- 134.3, p<0.05) and infection (RR=20.2, CI 1.5-264.8, p<0.05).
Conclusion: Infection and hematoma are the most common major complications in breast augmentation with AFG. Tobacco use is the only independent risk factor for overall complications and infection. Breast augmentation with autologous fat grafting has a higher infection rate than breast augmentation with implants. These findings pose the question for the possible need for antibiotic coverage after breast augmentation with AFG, particularly for tobacco users.
Gluteal augmentation (GA) has significantly increased in the past decade and continues to gain popularity. The safety profile is a common topic of debate with the true incidence of major complications, particularly in gluteal augmentation with autologous fat, being largely unclear. The purpose of this study is to report the incidence of major complications following gluteal augmentation.
Methods/Technique:
Patients undergoing gluteal augmentation with either implant or autologous fat between 1/2/2017-7/31/2019 were identified within the prospectively enrolled CosmetAssure™ database. The primary outcome was the occurrence of covered major complications requiring emergency department visit, hospitalization or reoperation within 45 days postoperatively. Risk factors for complications and number of deaths were also investigated.
Results/Complications:
Among 76,128 patients enrolled, 2687 (3.5%) underwent gluteal augmentation with autologous fat and 187 (0.25%) underwent gluteal augmentation with implant. The autologous fat cohort was more likely to be diabetic, age >40 years, female, and obese, and less like to be ASA class III/IV, and surgery performed at ambulatory surgery center (ASC) or hospital compared to the implant cohort (Table 1). The incidence of any major complication in the autologous fat cohort was 2.6% and 4.3% for patients undergoing gluteal augmentation with implant. The most common complication in both cohorts was infection. Two (0.1%) patients undergoing fat augmentation and no patient undergoing implant augmentation were found to have a pulmonary embolism. Tables 2 and 3 highlight the complication profile of each group. On univariate analysis, within the autologous fat cohort, age >40 years was a risk factor for pulmonary dysfunction/hypoxia (0.3% vs 0%, p<0.05), office based surgical suites (OBSS) was a risk factor for infection (2.9% vs 0.9%, p<0.05) compared to ACS/hospital, and anesthetic with local/sedation was more likely to have any complication or fluid overload compared to general anesthesia (6.5% vs 2.3% and 1.3% vs 0.1%, respectively, p<0.05). No gluteal augmentations resulted in death.
Conclusion:
Gluteal augmentation with autologous fat is more commonly performed than with implant. The most common major complication after gluteal augmentation, irrespective of method, is infection. Gluteal augmentation appears to be safe, with incidence of major complications, including pulmonary embolism and death being low when performed by ABPS board-certified plastic surgeons or ASPS candidate members. Extra caution to utilize safe techniques should continue to be employed.
Stromal vascular fraction (SVF) is the matrix portion of fat containing a heterogenous population of stem and regenerative cells. SVF can be obtained with enzymatic or mechanical dissociation. Nanofat was a term introduced by Tonnard in 2013 to describe a mechanical means of dissociating fat into a stromal vascular fraction that could be injected through a 27G needle. Cell optimization of nanofat was described more recently as a means to increase the number of regenerative cells in the nanofat, while preserving the ability to inject through smaller needles and to compound with a liposomal transport agent as a unique biocream. Herein, we describe a method of making cell optimized nanofat and discuss the clinical applications.
Methods/Technique
:Under local anesthesia, a 14G needle puncture is made and gently dilated. Fat is harvested using a Khoury cannula with a 2 mm hole size (Marina Medical, Stuart, Florida). The fat is then cleaned with Ringer’s lactate and decanted. The fat is now placed in a 10- or 20-ml syringe and processed into a cell optimized nanofat (Lipocube, London, UK). This involves passing the fat through a mechanical cutting screen to create a 1 mm parcel size, then passing the 1 mm product 10X through a 1 mm tunnel for smoothing and lastly, through a 500-micron cutting screen. The end product is a cell optimized nanofat that can be injected through a 27G needle, placed as a graft through a cannula, microneedled into the dermis, or compounded with a liposomal transport agent into a biocream for home application.
Results/Complications
:Nanofat has been used by cannula injection into the subcutaneous lower eyelid, by microneedling into the entire face, neck, décolletage, hands, arms; and by sharp needle injection intradermally into the radial wrinkle lines of the lips and into the deep creases of the neck. Nanofat biocream is routinely used with fractional lasers and after facial fat grafting with and without facelifting. Nanofat is an important component of our treatment for vaginal rejuvenation and is routinely microneedled into the vaginal mucosa and clitoral region. In addition, nanofat is used for alopecia. Clinical cases will be shown to demonstrate the techniques and outcomes.
Conclusion
:Nanofat and SVF have become widely available. This report clarifies the differences between Nanofat and SVF as well as between different techniques of obtaining Nanofat. Nanofat in conjunction with lasers have improved the clinical outcomes and have both sped up healing as well as promoted ongoing repair to the skin. More objective studies are required to further define the use of nanofat in alopecia and vaginal rejuvenation although preliminary results have been promising.
Methods/Technique: This study was a retrospective evaluation of 3D preoperative and postoperative photographs of patients who underwent submental liposuction alone or with other facial rejuvenation procedures by the senior author (DS) between 2014 and 2019. The preoperative and postoperative photographs of patients were split into 2 surveys. The pre and post-operative images were randomized, and the same patient’s images were not included in the same survey to avoid recall bias. A total of 148 survey responses were obtained from laypersons with each individual rating perceived age, health, attractiveness, and likeability. Photogrammetric assessment of patient images was completed using 3D VECTRA software (Canfield, Fairfield, NJ). Differences between pre- and postoperative labiomental angle, cervicomental angle, chin-throat distance, and facial angle were recorded. Paired t-tests were used to assess differences pre- and post-operatively. Multivariate regression was utilized to identify the influence of photogrammetric changes on perceived ratings.
Results/Complications: Twelve patients met the study criteria. All received submental liposuction, 67% received concurrent genioplasty, and 33% received simultaneous neck and face-lift. After surgery, the cervicomental angle decreased by 7.3º (p = 0.0171), chin-throat distance increased by 3.9 mm (p < 0.001), and the facial angle increased by 3.6º (p = 0.001). Decreases in perceived age (-2.43 years, p = 0.028) relative to the post-operative true age was seen in all patients. After controlling for other concurrent procedures, larger decreases in perceived age were seen among patients who, in addition to submental liposuction, received neck lift (p = 0.010). After controlling for other facial angle changes, greater decreases in age were associated with greater decreases of the labiomental (-0.33 years per degree decrease, p = 0.024) and cervicomental (-0.31 years per degree decrease, p = 0.04510) angles (R2 = 0.7348). There was a small but insignificant increase in health following surgery (p = 0.086). No statistically significant difference was noted for attractiveness (p = 0.49) or likeability (p = 0.803).
Conclusion: Submental liposuction is effective in reducing perceived patient age. This effect is more pronounced when preformed with neck lift. Furthermore, decreases in labiomental and cervicomental angle are associated with decreased perceived age.
Labiaplasty has quickly become a popular cosmetic procedure sought after by women. Hematoma is the most common acute post-operative complication of this procedure, while ecchymosis is expected in all patients who undergo this procedure due to the vascularity within and around the labia. Tranexamic acid (TXA) is an antifibrinolytic which competitively inhibits conversion of plasminogen to plasmin. Studies have demonstrated safe outcomes, along with favorable results using intravenous, oral, local injection and topical forms of TXA in aesthetic surgery. Experience with TXA use in labiaplasty surgery has not been yet described. We sought to evaluate the efficacy of TXA at reducing post-operative hematoma and ecchymosis following labiaplasty surgery.
Methods/Technique:
All patients who were undergoing bilateral labiaplasty by a single surgeon were candidates for this study. Each patient served as their own control. The left labia minora served as the control, injected with 10 ml of local anesthesia (5 ml of 1% lidocaine with epinephrine and 5 ml of 0.25% Marcaine). TXA was included within the local anesthesia injection on the right labia minora (0.5mg TXA, 5 ml of 1% lidocaine with epinephrine and 4.5 ml Marcaine 0.25%). Patients were evaluated at post-operative day one, three (when patients are usually the most swollen and most ecchymosis present). Patients will then be seen at one- and three-weeks post procedure. Each visit will include photo documentation evaluating left and right sides for any hematoma, presence of ecchymosis, swelling and subsequently pain. Standardized pain score will be utilized for patients to document their pain levels.
Results/Complications:
This is an ongoing study in the finishing stages, with expected total of 25-30 patients. Patient demographics, operative time and any intraoperative complications were recorded. Ecchymosis and hematoma rates are both subjectively and objectively evaluated and recorded. Any other complications were recorded.
Conclusion:
This is the first known study to evaluate the use of TXA in labiaplasty surgery. Local administration of TXA has great effects of reducing ecchymosis and swelling in the post-operative period following labiaplasty. This could potentially reduce the incidence of addition common complications seen with labiaplasty surgery, such as dehiscence, bubbling of skin edges along the incision and need for revision surgery. These benefits make recovery post procedure much more comfortable for the patient and increases their satisfaction in your work.
Progressive tension sutures are a widely accepted technique used in abdominoplasty to advance and secure the abdominal flap. This technique reduces dead space and distributes tension over a greater surface area, thereby reducing tension on the incisional closure. Progressive tension sutures have many benefits, including but not limited to reduced seroma risk, reduced wound healing complication rate, and elimination of the need for surgical drains. Nevertheless, the progressive tension suture technique is often criticized for adding significant time to the abdominoplasty operation. Other studies have measured total operative times with and without the use of progressive tension sutures but fail to quantify the time required for the progressive tension suture portion of the procedure in isolation.
In an attempt to reduce operative time, some surgeons have used running, bidirectional barbed sutures for progressive tension suture placement in abdominoplasty. Warner et al estimated the time required for the progressive tension suture technique, using a running, bidirectional barbed suture, at about 9 minutes. However, many surgeons are reluctant to use barbed suture due to the increased cost. The amount of time required solely for the progressive tension suture portion of the surgery, using standard non-barbed suture, has not been precisely quantified.
The purpose of this study is to quantify the amount of time placement of progressive tension sutures adds to the abdominoplasty operation by a practiced plastic surgeon.
Methods/Technique
:This is a prospective multicenter study of patients undergoing standard, primary, full abdominoplasty by the senior surgeons. A total of 100 subjects will be included in the study, with 50 consecutive abdominoplasty patients from each senior surgeon. Any other concomitant procedures, including liposuction, will be noted. All patients will have progressive tension sutures placed in the routine manner of each senior surgeon and no surgical drains will be placed. The start and finish times will be recorded for the operation as a whole, the abdominoplasty portion of the operation, the progressive tension suture placement, and umbilical inset. Intraoperatively, the number of progressive tension sutures will be counted. The surface area of the abdomen will be calculated for each subject (xiphoid process to pubic symphysis and ASIS to ASIS).
Any complications in the post-operative period will be documented, including dimpling (from progressive tension suture placement), wound healing problems, seroma, hematoma, and umbilical necrosis. Patients will be monitored for at least 3 months post-operatively.
Results/Complications
:The mean time of progressive tension suture placement is 13.95 minutes for an abdominoplasty by one fo the senior surgeons, according to initial results for 20 patients. This includes placement of a running vertical progressive tension suture (with a mean of 10.6 loops, requiring a mean time of 3.95 minutes to complete) and placement of a mean of 25.3 interrupted sutures, requiring a mean of 10 minutes to complete. For an individual interrupted progressive tension suture, the mean time required is 23.7 seconds. The Spearman rank correlation (rs) calculates the degree of correlation between BMI and progressive tension suture placement time as 0.295, indicating a weakly positive correlation without statistical significance. The degree of correlation between abdominal surface area and progressive tension suture placement time is -0.432 (rs – Spearman rank correlation) and the degree of correlation between abdominal surface area and number of progressive tension sutures required is -0.126 (rs – Spearman rank correlation), indicating a weakly negative correlation for both. No complications have been noted. Ongoing data analysis for abdominoplasty patients of the other senior surgeon is being performed.
Conclusion
:Progressive tension suture placement in abdominoplasty is not time intensive. Our study suggests that the amount of time required to complete progressive tension suture placement is not strongly correlated to abdominal surface area or BMI. This technique can be efficaciously included in abdominoplasty regardless of patient size. Progressive tension suture placement should be strongly considered in abdominoplasty, given the numerous benefits and the short amount of time required for completion.
Skin laxity at the neck is often a primary concern of patients who present for facial/neck rejuvenation surgery consultation. Despite standard undermining, re-draping, and excising excess skin of the neck with a necklift, central neck skin laxity often persists post-operatively. In many cases, postoperative dressings and garments will advance undermined neck skin centrally and shift skin flaps forward over the platysma creating submental skin laxity. Overtightening of the neck skin can cause tension at the closure site and result in wound healing problems and flap necrosis. Techniques such as external quilting sutures have been described to reduce hematoma risk and internal quilting sutures (i.e. progressive tension sutures) have been described to more evenly re-drape skin and distribute tension across the flap. However, inconveniences and potential risks exist with both external and internal quilting sutures, including the risk of flap ischemia, nerve entrapment, hypopigmentation or hyperpigmentation, temporary dimpling, and added operative time.
In order to optimize skin re-draping after necklift while avoiding the aforementioned inconveniences and potential risks, the bolster equalization suture technique (BEST) was developed. The purpose of this study is to assess the safety of the BEST addition to a necklift, as well as the efficacy at eliminating residual central neck skin laxity.
Methods/Technique
:This is a prospective cohort study of patients of the senior surgeon who will undergo necklift with the BEST addition. A total of 30 patients will be included. All patients will undergo subcutaneous facelift with SMAS flap elevation and plastysmal plication/anterior digastric myotomy, as is customary for the senior surgeon. In addition, three separate external quilting sutures will be placed over protective bolsters, so as to protect the skin from the suture causing focal pressure. One bolster suture will be placed at the subhyoid depression along midline, after smoothing any residual skin laxity. Laterally, the neck skin will be re-draped in a superolateral direction while supine to accentuate the cervicomandibular groove. Then, below the angle of the mandible on each side, another bolster suture will be placed to maintain the position of the re-draped neck skin.
Patients will have the bolster sutures removed on post-operative day 5. Any complications such as skin necrosis, skin ischemia, dimpling, hypopigmentation, hyperpigmentation, and scarring will be documented. Photographs will be obtained 2-3 months after surgery and compared to pre-operative photographs. The cervicomental angle will be measured in pre-operative and post-operative photographs, and the degree of improvement of the cervicomental angle will be determined.
As a control, the last 30 patients who have previously undergone the same surgery by the senior surgeon but without the BEST addition will be selected. Their pre-operative and 2-3 month post-operative photographs will be obtained and degree of improvement of cervicomental angle measured. This will be compared to the degree of improvement noted in the necklift with BEST addition group.
For all 60 patients (30 with BEST addition, 30 without), the presence or absence of residual central neck skin laxity will be determined. Post-operative photographs for all patients will be reviewed by 2 plastic surgeons (not the senior surgeon) blinded to the type of surgery. Correlation of the BEST addition to necklift with absence of residual central neck skin laxity will be calculated.
Results/Complications
:In patients who underwent necklift with BEST addition, the cervicomental angle improved post-operatively. The degree of improvement was compared to the control group. The BEST addition to the necklift had a weakly positive correlation to a reduction of residual central neck skin laxity. Additionally, there were no cases of skin necrosis or skin ischemia with utilization of the bolster suture. There were no cases of dimpling, hypopigmentation, hyperpigmentation, or significant scarring post-operatively.
Conclusion
:The BEST addition to the necklift is a straightforward, efficient maneuver to equalize tension on the flap and improve skin re-draping. This reduces the risk of persistent central neck skin laxity which is often challenging to eliminate entirely with standard necklift techniques. The BEST addition to the necklift provides improved neck contour with no apparent increased risk of flap ischemia or necrosis, pigmentation changes, dimpling, or significant scarring.
Skin redundancy and volume deflation following massive weight loss (MWL) surgery is a common aesthetic and functional problem that affects MWL patients. Even moderate weight loss and/or genetic predisposition can result in significant skin laxity, ptosis and soft tissue contour irregularity. Surgical excision of the excess skin and lifting is the only effective treatment. MWL patients present with distinct common physical findings: skin laxity and excess, loss of skin tone, gluteal ptosis, flat ”board-like” appearance with loss of natural curvature transition from the lower back to gluteal region. Many techniques have been described to remove the excess skin and correct gluteal ptosis with autologous rotation flap augmentation and or fat grafting, but there is a paucity of descriptions addressing the lateral hips. Those previous described lower body lifting techniques can leave the female patient with a masculinized, flattened hip region, instead of smooth curvy transition from a narrow waist to a fuller hip projection. We present a single surgeon’s 10-year experience, successfully performing over 450 cases using this unique technique with excellent outcome.
Methods/Technique:
Each patient recommended for lower body lift surgery was treated with circumferential body lift with a sliding fat fascial hip flap and gluteal fat grafting technique. In the lateral decubitus position, sub-SFS (Superficial Fascial System) liposuction of the flanks and minimal liposuction in the superficial subcutaneous plane beneath the planned excision is performed and followed by wedge excision of redundant skin and superficial subcutaneous beveling from inferior to superior. Careful attention is given to not excise all superficial fat over deep lateral fat compartment by beveling from inferior to superior. The inferior skin and subcutaneous fat including SFS are elevated inferiorly by continuous dissection until sufficient lift is achieved of the hip and buttock region. Additional discontinuous dissection with the Lockwood elevator is performed over the inferolateral buttock and outer thigh to fully mobilize the soft tissue. Creation of the sliding fat fascial hip flap from the hip prominence to the midline posteriorly is then elevated inferior to superior including SFS and deep fat for about 50% of the vertical dimension of the flap. The lateral hip flap is advanced “slid” inferiorly over the continuously dissected lateral most aspect of the hip prominence and secured with running progressive tension suture (PTS) technique. The inferior skin flap is then advanced over the previously secured fat fascial flap using same PTS technique. This allows tension free closure of inferior and superior skin flaps, providing smooth transition from a thinner waste to fuller lateral hip region. Autologous fat grafting is then performed, injecting into the discontinuously dissected lateral gluteal depression, outer thigh and remaining buttock region within a subcutaneous plane. Patient is then turned to the contralateral decubitus position and the same technique is again performed. Once complete, the patient is returned to supine position where the abdominoplasty portion is performed. Complete procedure details are described.
Results/Complications:
Between 2010 and 2020, over 450 patients have undergone this sliding fat fascia hip flap procedure. All procedures were performed by the senior surgeon. Patient demographics and complications, such as hematoma, skin necrosis, flap necrosis, seroma and wound dehiscence were recorded and analyzed.
Conclusion:
The sliding hip fat-fascia flap preserves hip fullness under the skin flap where fat grafting cannot be performed during LBL surgery, and provides a more harmonious transition from the waistline to the hips, It is an excellent use of otherwise discarded tissue, which fills a potential space where the inferior skin flap elevation is performed. When combined with autologous fat grafting of the buttocks a more natural feminine silhouette can be restored. The progressive tension sutures are key to advancing the sliding fat fascia closing the potential space reducing the risk of seroma and wound healing complications.
As 49% of all plastic surgery patients and the majority of patients undergoing cosmetic procedures are between 40 and 54 years old (according to the American Society of Plastic Surgeons [ASPS]), the rise of social media represents an opportunity for plastic surgeons to diversify their offering and educate/ communicate directly with a new patient demographic. While current guidelines exist to establish social media best practices and ensure the ethical use of these tools, there is no evidence- based consensus on how plastic surgeons can maximize the reach of their social media presence. The aim of this study is to provide the plastic surgery community with a comprehensive account of Instagram use and to leverage the large amount of publicly available data for optimal use by operators of active and future accounts.
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. Engagement rates were calculated as the quotient of mean likes on ten most recent posts and number of followers. Engagement rates were categorized as: very low (less than 1%), low (1 to 6%), average (6 to 12%), high (12 to 20%), and very high (greater than 20%). Accounts were ranked by engagement rate, number of followers, and date of first post.
Results/Complications
:Across 2,183 US- based ASAPS members, we identified accounts associated to 58.2% (n= 1,272) of plastic surgeons. The mean number of followers was 5,894 (range 0- 521,896), while the mean number of accounts following was 805 (range 0- 7,507). The mean number of posts per account was 311 (range 0- 4,909). The first account was created in July 2011 (Figure 1). Mean engagement was 7.5% (range 0- 660%) (Figure 2). Across all accounts, we identified 395,537 posts. The mean number of likes was 133 (range 0- 45,588). The mean caption length was 46 words (range 0- 441) and 354 characters (range 0- 2,283 characters). The most common hashtags used were #plasticsurgery (28.1%, n= 111,023), #plasticsurgeon (13.9%, n= 54,787), and #cosmeticsurgery (9.3%, n= 36,840). The most common discrete words used were “patient(s)” (23.2%, n= 91,775), “skin” (18.1%, n= 71,646), and “call” (15.9%, n= 62,952).
Conclusion
:Previous studies have summarized use of social media, specifically Instagram, by plastic surgeons. Others have described ethical best practices for sound adoption. This is the first study to 1) exhaustively quantify adoption of Instagram by members of a professional society of plastic surgeons and 2) plot adoption over time and elucidate the period of exponential adoption between January 2013 and December 2016 (r2= 0.98 over that range). This is consistent with worldwide adoption of social media, and with a previous finding published by Chartier et al. that a few cautious early adopters in the field of plastic surgery pave the way for rapid adoption by the critical mass. With nearly 60% of ASAPS- affiliated plastic surgeons having an Instagram account, our data supports the claim that members of the plastic surgery community have made it a priority to establish themselves on social media. It is also worth noting we identified seventeen plastic surgeons with “influencer” accounts (> 100,000 followers) and 102 with micro- influencer accounts (between 10,000 and 100,000 followers). Further study of “influencer” plastic surgeons is necessary to gain a more granular understanding of their outsized popularity.
To evaluate patient outcomes and complications associated with primary and secondary cosmetic rhinoplasties using the Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database.
Methods/Technique
:This is a retrospective cohort review from 2003 to 2018 of the (TOPS) database, where Current Procedural Terminology (CPT) codes for primary and secondary rhinoplasties, autogenous grafts and indications were used to evaluate outcomes and complications (20910, 20912, 30400, 30410, 30420, 30430, 30435, 30450, 30460, 30462, 30465, 30520, 21230, 21235). The 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. The main comparison groups were divided into primary and secondary rhinoplasties. Categorical variables are described as frequencies and compared with Fisher’s exact or Pearson’s Chi-squared test. Continuous variables, based on normality test, are described as means (SD) or medians (IQR) and compared with Wilcoxon Rank-sum or Student’s T-test. A stepwise multivariate regression analysis was performed to assess the effect size of risk factors for adverse events, variables with p-value <0.1 were included in the model and alfa error was set at 0.05 for significance.
Results/Complications
:A total of 11,800 rhinoplasties were analyzed, median age was 30 years and 75.61% were female. We report 10,050 (85.2%) primary and 1,750 (14.83%) secondary or revision rhinoplasties. The secondary rhinoplasty group showed a higher rate of male gender (21.3% vs. 18.78%; p: 0.01), older age (35y vs. 31y; p:<0.001), higher rate of >3 procedures at same time of index case and lower rate of white race (61% vs. 64%; p: 0.03). Comparing perioperative factors, secondary rhinoplasties had higher rates of autogenous grafts (rib: 1.2% vs 0.33%; p:<0.001, septal: 1.83% vs 1.19%; p: 0.03, costochondral: 1.14% vs. 0.25%; p: <0.001, and auricular: 5.31% vs. 0.78%; p: <0.001), higher rate of septoplasty (13.14% vs. 7.5%; p: <0.001) and lower rate of vestibular stenosis (2.6% vs. 4.1%; p: 0.002). Type of anesthesia was similar between the groups. Overall complication rate was 1.78%; additionally, even though statistical significance was not reached, secondary rhinoplasties appear to have higher rates of overall complications in univariate analysis (2.1% vs 1.5%; p:0.07). Individual complication rates of seroma, hematoma, wound disruption, superficial surgical site infection (SSI), and return to OR were similar between the groups; however a trend towards higher deep SSI (0.17% vs 0.04%; p:0.07) and readmission (0.17% vs 0.05%; p:0.1) was seen without reaching significance (Table 1). On multivariate regression analysis, using rib graft (OR 2.65 95%CI 1.54-4.46; p:<0.001), performing >3 procedures at same time of index surgery (OR 1.5 95%CI 1.05-2.15; p:0.27) and obesity (OR 1.47 95%CI 1.11-1.94; p:0.007) show a higher likelihood for overall complications. For primary rhinoplasties, >3 surgeries at same time of index surgery (OR 1.7; p: 0.28) increases the likelihood for complications while auricular graft (OR: 0.28; p:0.32) and male gender (OR 0.42, p:0.001) appear to lower the probability. For secondary rhinoplasties, costochondral graft (OR 14.4, p: <0.001) and Asian race (OR 3.88, p: 0.003) increase the likelihood for a postoperative complication
Conclusion
:Results from this study show a prevalence of 1.8% complication rate in overall rhinoplasties. These complications are negatively impacted by performing more than 3 concurrent procedures at time of index surgery, using rib grafts and obesity. Looking into primary and secondary rhinoplasties, the use of auricular graft and male gender are protective factors while costochondral and Asian race increase the probability for postoperative complications.
Methods/Technique: A survey study of plastic surgeons practicing in New York City between February and March of 2020 was performed. The survey instrument was designed and pretested to optimize content validity, face validity, and utility, and administered online using Qualtrics software. Surgeons were queried about their perioperative antibiotic management of patients with reported non-anaphylactic penicillin allergies. All responses were anonymous.
Results/Complications: The survey response rate was 38%. Sixty-two percent of plastic surgeon respondents were male and 57% were in practice for more than 20 years. Fifty-two percent were in private practice and 48% in hospital-based practice. For antibiotic prophylaxis of “clean” (CDC Class I) surgical procedures among patients with reported non-anaphylactic penicillin allergies, 38% of respondents said they prescribe a first-generation cephalosporin and 62% prescribe one of the b-lactam alternatives: clindamycin (52%), vancomycin (5%), or ciprofloxacin (5%). For procedures involving placement of either closed-suction drains or permanent implants, the majority of respondents prescribe antibiotics for greater than 24 hours and 33% of respondents prescribe them for greater than 5 days. Lastly, 67% of respondents said they “never” recommend confirmatory penicillin allergy testing, but most were “more likely” to recommend it after being presented with supporting literature.
Conclusion: For patients with reported non-anaphylactic penicillin allergies, the majority of plastic surgeons prescribe perioperative β-lactam alternative antibiotics. Given that β-lactam alternatives are associated with increased complications and decreased efficacy compared to first-generation cephalosporins, and over 95% of patients labeled penicillin allergic may be tolerant, we would encourage all surgeons to consider recommending confirmatory allergy testing routinely in their clinical practices.
References:
- Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and Management of Penicillin Allergy: A Review. JAMA. 2019 Jan 15;321(2):188-199. PubMed PMID: 30644987.
- Castells M, Khan DA, Phillips EJ. Penicillin Allergy. N Engl J Med. 2019 Dec 12;381(24):2338-2351. Review. PubMed PMID: 31826341.
Structural stability is a key element of consistency in rhinoplasty. Long-term projection and rotation are perhaps the two most important and perceptible attributes of rhinoplasty. Columellar strut grafts and septal extension grafts are commonly used support structures, however their relative effectiveness remains debated. The purpose of this study was to compare the long-term stability of septal extension grafts to columellar strut grafts.
Methods/Technique:
Retrospective review of all primary open rhinoplasties performed by the senior author between 2016 and 2019 was performed. Inclusion criteria included all adult patients undergoing primary open rhinoplasty. Revisionary cases, those utilizing fresh frozen rib graft, and those combined with simultaneous procedures that directly included measurement landmarks (i.e. rhytidectomy) were excluded from study. Patients with less than one-year follow-up were excluded. Data captured included demographic information (age, sex, race) and operative techniques employed (grafts utilized). Standardized professional 2D post-operative imaging was assessed at 2-months (early) and at 12-month (long-term). Digital measurements of projection and rotation were measured on both sides of the face for all photos and averaged. Projection was defined as the distance from the most posterior extent of the ala to the most projecting point of the nasal tip on profile. Rotation was measured as the nasolabial angle. All measurements were normalized using a static landmark across all photos (the tragus-to-cornea distance) to account for minor inter-photo variability in subject distance. Statistical comparisons using the ANOVA test were performed to evaluate changes in projection and rotation over time by graft technique.
Results/Complications:
Chart query yielded 142 patients who met inclusion and exclusion. Of these, 37 patients were treated with a columellar strut and 34 with a septal extension graft. Measured projection loss at one-year was 2.9% for the Columellar Strut group compared to 0.02% for the Septal Extension Graft group (p<0.003). Rotation did not significantly differ between groups.
Conclusion:
Septal extension grafts result in effectively no loss of projection or rotation long-term and allow the surgeon to intra-operatively place the nose exactly where desired. A small degree of projection loss can be expected with the use of columellar strut alone. These long-term graft tendencies should be anticipated and accounted for appropriately during rhinoplasty.
Revision rhinoplasty is undoubtedly one of the most challenging procedures in facial plastic surgery. The complexity is compounded when there is a paucity of native septal cartilage to perform the required framework reconstruction. The traditionally reliable and robust cartilage source is autologous costal cartilage, but this can result in trepidation by the patient to pursue intervention due to the additional surgical site, and associated potential morbidity. Harvest of autologous costal cartilage also results in increased operative times, and possible secondary site complications like contour irregularity, poor scarring, and even pneumothorax. Irradiated rib graft has been criticized for its tendency to resorb in the long term, resulting in poor outcomes with external nasal distortion or loss of structure. Over the past 8 years, the senior author has utilized fresh frozen rib cartilage grafts ( FFRG) from MTF Biologics which is only treated with gamma radiation, similar to all food products over the past 60 years. The availability of FFRG provides the surgeon with various selections of age and contour of specific rib cartilage, while avoiding the morbidity associated with harvesting autologous rib graft, and the disadvantages of irradiated rib graft. Our study investigates the outcomes and rate of revision surgery associated with FFRG cartilage in comparison to autologous and irradiated costal cartilage in revision rhinoplasty.
Methods/Technique:
A retrospective review was conducted of the senior author’s (R.J.R.) patients from 2011 to 2020 who underwent primary or revision rhinoplasty. Long term outcomes were assessed for patients who had MTF FFRG used and any complications encountered in long term follow-up. Inclusion criteria included patients with fresh frozen ‘off the shelf’ cartilage used in revision rhinoplasty only with a minimum of 1-year follow-up. A total of 400 patients were reviewed and 220 met the inclusion criteria. Outcomes for evaluation were warping, resorption, displacement, and infection. Our data was compared to the reported complication rates in published plastic surgery literature utilizing autologous, and irradiated rib grafts.
Results/Complications:
In our retrospective cohort, there was a 4% warping rate (two required operative revision which were dorsal onlay grafts), a 3% infection rate but only one required operative dorsal graft removal and all others were successfully treated with antibiotics. Four patients experienced nasal tip erythema in the early post-operative period without additional findings for infection, which resolved within 2-3 weeks without surgical intervention.
Our results compare very favorably to reported rates of complication in autologous and irradiated rib graft ( see table 1) . Previously reported complication rates of autologous grafts included 3-10% for warping, 0.22% for resorption, 3% for infection, 0.39% for displacement, 5.45% for hypertrophic chest scarring, and 0%-0.32% (95% CI) for pneumothorax.1 Previously reported complication rates with irradiated rib included 5% for warping, 2% for resorption, 1% for contour irregularity and infection rates up to 2%.2
Table 1: Complications for Autologous, Irradiated and Fresh Frozen Rib Grafts
Conclusion:
The results in revision rhinoplasty are significantly enhanced with the creation of stable nasal framework using off the shelf, easily accessible, specifically tailored fresh frozen cadaveric rib grafts. The long-term outcomes and complication rate in our 8 year retrospective study demonstrates the safety of fresh frozen rib graft in comparison to autologous or irradiated rib graft.
References:
- Wee JH, Park MH, Oh S, Jin HR. Complications associated with autologous rib cartilage use in rhinoplasty: a meta-analysis. JAMA Facial Plast Surg. 2015 Jan-Feb;17(1):49-55. doi: 10.1001/jamafacial.2014.914. PMID: 25429595.
- Vila PM, Jeanpierre LM, Rizzi CJ, Yaeger LH, Chi JJ. Comparison of Autologous vs Homologous Costal Cartilage Grafts in Dorsal Augmentation Rhinoplasty: A Systematic Review and Meta-analysis. JAMA Otolaryngol Head Neck Surg. 2020 Apr 1;146(4):347-354. doi: 10.1001/jamaoto.2019.4787. PMID: 32077916; PMCID: PMC7042943.
