The Use of Emotional Artificial Intelligence in Plastic Surgery.
Levites Heather A,Thomas Analise B,Levites Jim B,Zenn Michael R
Plastic and reconstructive surgery
BACKGROUND:The use of social media to discuss topics related to and within plastic surgery has become widespread in recent years; however, it remains unclear how to use this abundance of largely untapped data to propagate educational research in the field of plastic surgery. In this prospective, observational study, the authors aimed to delineate which plastic surgery-related topics evoked a significant emotional response within the study population and to assess the utility of motivational artificial intelligence within the field of plastic surgery. METHODS:Over a 4-month period (January to April of 2018), Cognovi Lab's artificial intelligence technology was used to search and analyze emotional reactions to several commonly hashtagged words. This innovative software uses several key metrics to describe its findings, including awareness, engagement, and motivation. RESULTS:Of the search terms examined, "nose job" had the most awareness during the study period, and the topic that most engaged consumers emotionally was "liposuction." Interestingly, "liposuction" ranked only fifth in terms of awareness. Consumers showed the strongest positive motivation toward the subjects of "plastic surgery" and "cosmetic surgery," and the lowest motivation toward the topic of "tummy tucks." CONCLUSIONS:This analysis by Cognovi Labs is the first quantitative effort to use the plethora of data on social media to interpret patient motivations and subsequent behavior. Moving forward, artificial intelligence technology will make it possible to predict which plastic surgery products, procedures, and practices will be successful. The findings presented in this article describe the unique viewpoint and power that this technology can deliver.
10.1097/PRS.0000000000005873
"Pediatric Tissue Expansion: Predictors of Premature Expander Removal in A Single Surgeon's Experience with 472 Expanders".
Wang Howard D,Ibrahim Zuhaib,Quan Amy,Bai Jennifer,Ostrander Benjamin T,Redett Richard J
Plastic and reconstructive surgery
BACKGROUND:Tissue expansion is an important technique for soft tissue reconstruction in pediatric patients. However, the expansion process can be complicated by infection and extrusion, leading to expander removal and reconstructive delays. The aim of this study was to identify risk factors associat0065d with premature expander removal due to infection or extrusion in pediatric patients. METHODS:A retrospective study of all pediatric patients who underwent tissue expander insertion by the senior author over a twelve-year period was performed. Predictor variables included age, sex, race, indication, the anatomic location, the number of expanders inserted, serial expansion, and expander size. Bivariate and multivariate analyses were performed to identify risk factors for premature expander removal. RESULTS:A total of 139 patients with 472 expanders were included in this study. One or more complications occurred with 78 (16.5%) expanders. Overall, premature expander removal due to infection or exposure occurred with 51 (10.8%) expanders. In terms of location, the highest rates of premature removal occurred in the lower extremity (20.0%) and scalp (16.3%). Multivariate analysis identified that younger age (Age 0-6 compared to age 13-17: OR 3.98, CI 1.13 - 14.08, P=0.03), greater number of expanders inserted (OR 1.45, CI 1.03 - 2.03, P=0.03), and lower extremity location (OR 4.27, CI 1.45 - 12.53, P=0.008) were associated with an increased odds of premature expander removal. CONCLUSIONS:Infection or extrusion leading to expander removal occurred in approximately 10% of tissue expanders. Odds of premature removal is increased with younger age, greater number of expanders placed, and lower extremity location.
10.1097/PRS.0000000000006550
"Decreased Length of Post-Operative Drains, Parenteral Opioids, Length of Stay and Complication Rates in Patients Receiving 'Meshed' Versus 'Un-Meshed' Acellular Dermal Matrix (ADM) in 194 Sub-Muscular Tissue Expander Based Breast Reconstructions; A Single Surgeon Cohort Study."
Hagarty Sarah E,Yen Lawrence L,Fosco Christopher,Gomez Kayeromi,Khare Manorama
Plastic and reconstructive surgery
BACKGROUND:Studies have cited possible complications and increased fluid accumulation in implant based breast reconstruction using acellular dermal matrix (ADM). We propose a novel approach, manually meshing ADM using a skin graft mesher prior to use in expander based breast reconstruction. We investigated postoperative drain time, complication rates, pain, and length of hospital stay in meshed versus unmeshed ADM cohorts. METHODS:114 patients and 194 reconstructed breasts were included over all. Of these, 99 patients were included in the pain and post-operative length of hospital stay analysis (LOS). Independent T-test and chi-square analyses were employed for bivariate comparisons. Multiple linear regression analyses were used to further delineate impact of meshing ADM on drain time, post-operative parenteral narcotic requirements and LOS between the two cohorts. RESULTS:The meshed ADM cohort had lower overall complication rates compared to the unmeshed cohort. Multiple linear regression analyses showed meshing the ADM alone decreased drain time by 7.3 days, and decreased postoperative parenteral narcotic requirements by 77% decrease (20 mg morphine). Furthermore, it was the only significant predictor for a decrease in LOS. CONCLUSIONS:Meshing ADM significantly decreased the time needed for post-operative drains. Statistical analysis showed significantly decreased overall and minor complication rates in the meshed cohort. Meshing significantly decreased parenteral narcotic requirements, and importantly also decreased the length of stay. All of these factors bear important implications to cost and quality of care in expander based breast reconstruction.
10.1097/PRS.0000000000006635
The Evolution of Breast Satisfaction and Well-Being after Breast Cancer: A Propensity-Matched Comparison to the Norm.
Mundy Lily R,Rosenberger Laura H,Rushing Christel N,Atisha Dunya,Pusic Andrea L,Hollenbeck Scott T,Hyslop Terry,Hwang E Shelley
Plastic and reconstructive surgery
BACKGROUND:Breast cancer survival continues to improve, with women living longer after treatment. It is not well understood how long-term satisfaction and well-being differ following treatment or how types of reconstruction differ when compared to the norm. METHODS:In a propensity-matched sample, the authors compared patient-reported outcomes in breast cancer patients at various time intervals from surgery with normative BREAST-Q data. All data were obtained using the Army of Women, an online community fostering breast cancer research. Breast cancer patients were stratified by surgical treatment and reconstruction type. Regression lines were estimated and differences in slope tested between cancer patients and noncancer controls. RESULTS:The authors compared normative (n = 922) and breast cancer (n = 4343) cohorts in a propensity-matched analysis. Among the breast cancer patients, 49.4 percent underwent lumpectomy, 17.0 percent underwent mastectomy, 21.7 percent underwent implant reconstruction, and 11.9 percent underwent autologous reconstruction. Median time since surgery was 4.7 years, with 21.1 percent more than 10 years after surgery. At the time of survey, breast cancer patients reported higher Satisfaction with Breasts and Psychosocial Well-being scores compared to noncancer controls (p < 0.01), with the cohorts undergoing lumpectomy and autologous reconstruction both reporting higher scores than the normative controls. After mastectomy, scores averaged lower than the noncancer controls, but improved over time. However, all breast cancer groups reported significantly lower Physical Well-being scores than the noncancer cohort (all p < 0.01). CONCLUSIONS:Breast cancer patients undergoing lumpectomy or autologous reconstruction reported higher psychosocial well-being compared to noncancer controls. These differences were influenced both by time since treatment and by choice of surgical procedure.
10.1097/PRS.0000000000006535
The Nonsurgical Rhinoplasty: A Retrospective Review of 5000 Treatments.
Harb Ayad,Brewster Colin T
Plastic and reconstructive surgery
BACKGROUND:Nonsurgical rhinoplasty with injectable dermal fillers has become an increasingly popular alternative to surgical procedures, in view of its relative low cost, convenience and rapid recovery, and low risk profile. The safety and efficacy of nonsurgical rhinoplasty remains a relatively contentious and ambiguous matter, given that there are few large-scale series reporting results or complications. This study reports the experience of a single clinician performing nonsurgical rhinoplasty in the largest cohort to date. METHODS:Patient demographics, indications, treatment details, and outcomes of patients treated between March of 2016 and January of 2019 were reviewed. The nonsurgical rhinoplasty technique described previously by Harb was used using hyaluronic acid dermal filler. RESULTS:Nonsurgical rhinoplasty was performed in 5000 patients. The commonest indication was dorsal hump (44 percent). Swelling and erythema were self-limiting side effects encountered in approximately half of patients. Infection was seen in two patients, and localized skin necrosis was observed in three patients. CONCLUSIONS:Nonsurgical rhinoplasty is a safe procedure with positive aesthetic results when performed by an experienced clinician. Knowledge of nasal anatomy, comprehensive training, and use of appropriate materials are key in ensuring safety and results. CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, IV.
10.1097/PRS.0000000000006554
Incidence of Postoperative Adverse Events after Rhinoplasty: A Systematic Review.
Sharif-Askary Banafsheh,Carlson Anna R,Van Noord Megan G,Marcus Jeffrey R
Plastic and reconstructive surgery
BACKGROUND:Adverse events after rhinoplasty vary in etiology and severity, a fact that is reflected in the current American Society of Plastic Surgeons rhinoplasty consent form. However, there is currently no literature providing a comprehensive summation of evidence-based quantifiable risk of adverse events after rhinoplasty. Given this limitation, patients considering rhinoplasty are unable to fully ascertain preoperative risk, and the ability of physicians to obtain true informed consent is similarly flawed. This systematic review provides the first rigorous, comprehensive, and quantitative reporting of adverse events after rhinoplasty. METHODS:This review was registered on the International Prospective Register of Systematic Reviews (PROSPERO) database (registration no. CRD42018081826) in April of 2018. Eligible articles were published in peer-reviewed journals with available abstracts and full-text articles. Interventions included primary functional, aesthetic, and combined functional/aesthetic rhinoplasty. The following data were extracted: study size, population characteristics, indication, surgical approach, concomitant procedures, and incidence of adverse events. RESULTS:A search yielded 3215 publications for title and abstract screening. Three hundred twenty-two were eligible for full-text review. Thirty-six met final inclusion criteria. A total of 13 adverse events were reported among these studies and included need for revision (0 to 10.9 percent), infection (0 to 4 percent), dehiscence (0 to 5 percent), bleeding (0 to 4.1 percent), septal perforation (0 to 2.6 percent), nasal airway obstruction requiring revision (0 to 3 percent), and hypertrophic scarring (0 to 1.5 percent). CONCLUSIONS:This systematic review presents the first comprehensive and quantitative reporting of adverse event frequency after rhinoplasty. This is a crucial tool for preoperative patient counseling and an essential adjunct in the acquisition of informed consent. Future investigations will benefit from transparency and standardization of reporting to further quantify adverse event rates.
10.1097/PRS.0000000000006561
Complications after Breast Augmentation with Fat Grafting: A Systematic Review.
Ørholt Mathias,Larsen Andreas,Hemmingsen Mathilde N,Mirian Christian,Zocchi Michele L,Vester-Glowinski Peter V,Herly Mikkel
Plastic and reconstructive surgery
BACKGROUND:Breast augmentation with fat grafting is used as an alternative to breast implants. However, a systematic evaluation of the complication rates after fat grafting using only studies with consecutive patients has not previously been performed. In this study, the authors compiled studies reporting complication rates and radiologic changes in consecutive patients undergoing cosmetic breast augmentation with fat grafting. METHODS:Studies reporting on consecutive patients undergoing breast augmentation with fat grafting were included. Complication rates, radiologic changes, Breast Imaging Reporting and Data System assessments, and the number of patients undergoing revision surgery were extracted. Mean complication rates and radiologic changes were calculated with meta-analytical methods. RESULTS:Twenty-two studies with 2073 patients were included. The rates of major complications were low (hematoma, 0.5 percent; infection, 0.6 percent; and seroma, 0.1 percent). None of these patients needed revision surgery. The most frequent minor complication was palpable cysts in 2.0 percent of the patients; 67 percent of these were treated with aspiration. The radiologic changes in the patients after fat grafting were as follows: oil cysts, 6.5 percent; calcifications, 4.5 percent; and fat necrosis, 1.2 percent. The risk of being referred for additional radiologic imaging (e.g., to exclude malignant changes) was 16.4 percent, and the risk of being referred for biopsy was 3.2 percent. CONCLUSIONS:The complication rates after breast augmentation with fat grafting are low and support fat grafting as an alternative to breast augmentation with implants. The rates of radiologic changes are high after fat grafting, but the changes do not seem to have any therapeutic consequences for the patients.
10.1097/PRS.0000000000006569
Mouth Corner Lift with Botulinum Toxin Type A and Hyaluronic Acid Filler.
Jeong Tae-Kwang
Plastic and reconstructive surgery
An upturned mouth corner is associated with brightness, optimism, and friendliness, whereas a downturned mouth corner not only conveys negative feelings such as sadness, depression, and tiredness, but also makes a person appear years older than they are. Surgical approaches to the correction of a downturned mouth corner can result in predictable and long-lasting results. However, because of their fear of postsurgical scars and long downtimes, many patients are reluctant to undergo surgery involving the mouth corner. As a consequence, minimally invasive procedures have become increasingly popular in recent years. Among these, botulinum toxin type A and injectable fillers play a significant role. The author uses botulinum toxin type A and hyaluronic acid filler injections as complementary procedures for lifting flat or downturned mouth corners in young patients. This method has produced reliable and consistent outcomes without severe complications such as necrosis or infection in over 100 patients, as reflected in high patient satisfaction. The combination of botulinum toxin type A and hyaluronic acid filler provides excellent results in young patients who desire an uplifted mouth corner and are reluctant to undergo surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.
10.1097/PRS.0000000000006605
Quantifying the Crisis: Opioid-Related Adverse Events in Outpatient Ambulatory Plastic Surgery.
Crystal Dustin T,Blankensteijn Louise L,Ibrahim Ahmed M S,Brownstein Gary M,Reed Lawrence S,Watts David C,Lin Samuel J
Plastic and reconstructive surgery
BACKGROUND:The United States is currently in the midst of an opioid epidemic precipitated, in part, by the excessive outpatient supply of opioid pain medications. Accordingly, this epidemic has necessitated evaluation of practice and prescription patterns among surgical specialties. The purpose of this study was to quantify opioid-related adverse events in ambulatory plastic surgery. METHODS:A retrospective review of 43,074 patient profiles captured from 2001 to 2018 within an American Association for Accreditation of Ambulatory Surgery Facilities quality improvement database was conducted. Free-text search terms related to opioids and overdose were used to identify opioid-related adverse events. Extracted profiles included information submitted by accredited ambulatory surgery facilities and their respective surgeons. Descriptive statistics were used to quantify opioid-related adverse events. RESULTS:Among our cohort, 28 plastic surgery patients were identified as having an opioid-related adverse event. Overall, there were three fatal and 12 nonfatal opioid-related overdoses, nine perioperative opioid-related adverse events, and four cases of opioid-related hypersensitivities or complications secondary to opioid tolerance. Of the nonfatal cases evaluated in the hospital (n = 17), 16 patients required admission, with an average 3.3 ± 1.7 days' hospital length of stay. CONCLUSIONS:Opioid-related adverse events are notable occurrences in ambulatory plastic surgery. Several adverse events may have been prevented had different diligent medication prescription practices been performed. Currently, there is more advocacy supporting sparing opioid medications when possible through multimodal anesthetic techniques, education of patients on the risks and harms of opioid use and misuse, and the development of societal guidance regarding ambulatory surgery prescription practices.
10.1097/PRS.0000000000006570
Postoperative Antibiotic Prophylaxis in Reduction Mammaplasty: A Randomized Controlled Trial.
Garcia Edgard S,Veiga Daniela F,Veiga-Filho Joel,Cabral Isaías V,Pinto Natália L L,Novo Neil F,Sabino-Neto Miguel,Ferreira Lydia M
Plastic and reconstructive surgery
BACKGROUND:Reduction mammaplasty is a well-established procedure. Studies have shown benefits of using antibiotics in this procedure. Nevertheless, there is no solid evidence to support postoperative antibiotic prophylaxis. The authors evaluated the influence of postoperative antibiotic delivery on infection rates after reduction mammaplasty. METHODS:The authors conducted a randomized trial of noninferiority, with two parallel groups, with triple blinding. The participants were 124 women with breast hypertrophy, with reduction mammaplasty already scheduled, selected consecutively. All patients underwent reduction mammaplasty, performed by the same surgical team, using the superomedial pedicle technique for ascending the nipple-areola complex. All patients received cephalothin (1 g) intravenously at the anesthetic induction and every 6 hours for 24 hours. At hospital discharge, they were assigned randomly to either the placebo (n = 62) or antibiotic group (n = 62) and were instructed to take identical capsules containing 500 mg of cephalexin or placebo, respectively, every 6 hours, for 7 days. Patients were assessed weekly, for 4 weeks, regarding the occurrence of surgical-site infection, by a surgeon who was unaware of the allocation. The criteria and definitions of the Centers for Disease Control and Prevention were adopted. RESULTS:There was no statistical difference between groups regarding age, body mass index, or resected breast tissue weight. The overall surgical-site infection rate was 0.81 percent. Only one patient, allocated to the antibiotic, presented infection, classified as superficial incisional (p = 1.00). In the placebo group, surgery time was higher (p = 0.003). CONCLUSION:The maintenance of antibiotics in the postoperative period of reduction mammaplasty did not influence the rates of surgical-site infection. CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, I.
10.1097/PRS.0000000000006809
Dual-Plane versus Prepectoral Breast Reconstruction in High-Body Mass Index Patients.
Gabriel Allen,Sigalove Steven,Storm-Dickerson Toni L,Sigalove Noemi M,Pope Nicole,Rice Jami,Maxwell G Patrick
Plastic and reconstructive surgery
BACKGROUND:Breast reconstruction in patients with a high body mass index (BMI) (≥30 kg/m) is technically challenging and is associated with increased postoperative complications. The optimal reconstructive approach for these patients remains to be determined. This study compared outcomes of prepectoral and dual-plane reconstruction in high-BMI patients to determine whether there was an association between postoperative complications and the plane of reconstruction. METHODS:High-BMI patients who underwent immediate dual-plane or prepectoral expander/implant reconstruction were included in this retrospective study. Patients were stratified by reconstructive approach (dual-plane or prepectoral), and postoperative complications were compared between the groups. Multivariate logistic regression analysis was performed to determine whether the plane of reconstruction was an independent predictor of any complication after adjusting for potential confounding differences in patient variables between the groups. RESULTS:Of 133 patients, 65 (128 breasts) underwent dual-plane and 68 (129 breasts) underwent prepectoral reconstruction. Rates of seroma (13.3 percent versus 3.1 percent), surgical-site infection (9.4 percent versus 2.3 percent), capsular contracture (7.0 percent versus 0.8 percent), and any complication (25.8 percent versus 14.7 percent) were significantly higher in patients who had dual-plane versus prepectoral reconstruction (p < 0.05). Multivariate logistic regression identified dual-plane, diabetes, neoadjuvant radiotherapy, and adjuvant chemotherapy as significant, independent predictors of any complication (p < 0.05). Dual-plane reconstruction increased the odds of any complication by 3-fold compared with the prepectoral plane. CONCLUSION:Compared with the dual-plane approach, the prepectoral approach appears to be associated with a lower risk of postoperative complications following immediate expander/implant breast reconstruction and may be a better reconstructive option in high-BMI patients. CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, III.
10.1097/PRS.0000000000006840
Outcomes of Immediate Implant-Based Mastectomy Reconstruction in Women with Previous Breast Radiotherapy.
Olinger Thomas A,Berlin Nicholas L,Qi Ji,Hamill Jennifer B,Kim Hyungjin M,Pusic Andrea L,Wilkins Edwin G,Momoh Adeyiza O
Plastic and reconstructive surgery
BACKGROUND:The objective of this study was to determine whether women with a history of radiation therapy before mastectomy experience a risk for postoperative complications and patient-reported outcomes similar to those of women undergoing postmastectomy radiation therapy in the setting of immediate implant reconstruction. METHODS:The cohort included patients undergoing immediate implant reconstruction at 11 centers across North America. Women were categorized into three groups: prior breast conservation therapy, postmastectomy radiation therapy, and no radiation therapy. Mixed effect logistic regressions were used to analyze the effects of radiation therapy status on complication rates and patient-reported outcomes. RESULTS:ONE THOUSAND FIVE HUNDRED NINETY-FOUR: patients were analyzed, including 84 women with prior breast conservation therapy, 329 women who underwent postmastectomy radiation therapy, and 1181 women with no history of radiation therapy. Compared with postmastectomy radiation therapy, breast conservation was associated with lower rates of all complications and major complications (OR, 0.65; 95 percent CI, 0.37 to 1.14; p = 0.13; and OR, 0.61; 95 percent CI, 0.33 to 1.13; p = 0.12). These differences were not statistically significant. Rates of reconstructive failure between the two cohorts were comparable. Before reconstruction, satisfaction with breasts was lowest for women with prior breast conservation therapy (p < 0.001). At 2 years postoperatively, satisfaction with breasts was lower for women with postmastectomy radiation therapy compared with breast conservation patients (p = 0.007). CONCLUSIONS:Higher postoperative complication rates were observed in women exposed to radiation therapy regardless of timing. Although women with prior breast conservation experienced greater satisfaction with their breasts and fewer complications when compared to women undergoing postmastectomy radiation therapy, there was a similar risk for reconstruction failure. CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, II.
10.1097/PRS.0000000000006811
Deconstructing the Reconstruction: Evaluation of Process and Efficiency in Deep Inferior Epigastric Perforator Flaps.
Plastic and reconstructive surgery
BACKGROUND:With advances in technology and technique, the goal of microvascular breast reconstruction has transitioned from flap success to minimizing complications and maximizing aesthetic outcome and efficiency. In an effort to evaluate efficiency, the authors implemented a rigorous process analysis in their practice to evaluate deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS:A prospective implementation of process analysis was instituted on 147 DIEP flaps. The eight critical maneuvers for a DIEP flap are (1) skin to perforator identification, (2) perforator decision making, (3) perforator dissection, (4) pedicle dissection, (5) flap harvest, (6) preparation for microsurgery, (7) venous anastomosis, and (8) arterial anastomosis. Surgeons with variable experiences (faculty, faculty with senior resident/fellow, and supervised chief resident) used these eight steps to perform DIEP flap reconstruction. The outcomes and time of each maneuver were tracked. RESULTS:The total flap harvest time among the three groups was 54.8 minutes for faculty surgeons, 98.3 minutes for senior resident/fellow working with faculty, and 178.8 minutes for supervised chief resident (p < 0.001). The largest difference was seen in perforator dissection. Increasing the number of perforators resulted in longer flap harvest times. Perforator location did not have an impact on times, but harvesting multiple rows took longer for less experienced surgeons. Body mass index and flap weight did not have an impact on time. CONCLUSIONS:The authors share their experience using process analysis for DIEP flap reconstruction. They defined eight critical maneuvers to maximize efficiency and safety. By communicating efficient processes and integrating them into the workflow of a given operation, surgeons can continue to improve throughout the arc of their careers.
10.1097/PRS.0000000000006630
Improvement in Jowl Fat following ATX-101 Treatment: Results from a Single-Site Study.
Plastic and reconstructive surgery
BACKGROUND:Jowl fat overhang can reduce jawline definition. The most common treatment to reduce jowl fat is liposuction. ATX-101 (deoxycholic acid injection), a minimally invasive treatment approved for submental fat reduction, may also be an effective treatment for jowl fat. The current study evaluated the efficacy and safety of ATX-101 treatment for reducing jowl fat. METHODS:In this prospective single-site study, 66 adults were treated for excess jowl fat with ATX-101 (area-adjusted dose: 2 mg/cm). Eligible patients had pinchable fat on the jawline and relatively minimal skin laxity in the jowl. Depending on the size of the treatment area, ATX-101 injections of 0.2 ml spaced 1.0 cm apart or 0.1 ml spaced 0.50 to 0.75 cm apart were administered. Improvement in jowl appearance was assessed 6 months or more after the last treatment in person by the clinician. Improvement was also assessed by the patient and two independent plastic surgeons using blinded before/after treatment photographs. Safety was evaluated via adverse events. RESULTS:The mean number of ATX-101 treatments received was 1.8, with a mean injection volume of 0.8 ml per treatment per jowl. The majority of patients (98 percent) experienced an improvement in jowl appearance. Common adverse events were injection-site edema, numbness, tenderness, and bruising. Injection-site marginal mandibular nerve paresis and alopecia were experienced by three patients each; all events resolved without sequelae. CONCLUSIONS:ATX-101 effectively reduced jowl fat and was well tolerated in this small cohort. Care should be taken when injecting ATX-101 into jowl fat to avoid underlying anatomic structures such as the marginal mandibular nerve. CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, IV.
10.1097/PRS.0000000000006680
Subcutaneous Fat Reduction with Injected Ice Slurry.
Plastic and reconstructive surgery
BACKGROUND:Cryolipolysis is a noninvasive method for removal of subcutaneous fat for body contouring. Conventional cryolipolysis with topical cooling requires extracting heat from subcutaneous fat by conduction across the skin, thus limiting the amount and the location of the fat removed. The authors hypothesized that local injection of a physiological ice slurry directly into target adipose tissue would lead to more efficient and effective cryolipolysis. METHODS:Injectable slurries containing 20 percent and 40 percent ice content were made using common parenteral agents (normal saline and glycerol), then locally injected into the subcutaneous fat of swine. Ultrasound imaging, photography, histological, and gross tissue responses were monitored before and periodically up to 8 weeks after injection. RESULTS:Fat loss occurred gradually over several weeks following a single ice slurry injection. There was an obvious and significant 55 ± 6 percent reduction in adipose tissue thickness compared with control sites injected with the same volume of melted slurry (p < 0.001, t test). The amount of fat loss correlated with the total volume of ice injected. There was no scarring or damage to surrounding tissue. CONCLUSION:Physiological ice slurry injection is a promising new strategy for selective and nonsurgical fat removal.
10.1097/PRS.0000000000006658
A Simplified Approach to Nasal Tip Shaping: The Five-Suture Technique.
Cochran C Spencer,Afrooz Paul N
Plastic and reconstructive surgery
Techniques for nasal tip shaping have evolved from destructive to nondestructive techniques. These techniques have proven to be effective, yet they are often applied incrementally and require repeated intraoperative evaluation and manipulation to assess their efficacy. We describe a simple, effective, and reliable five-suture technique to achieve consistent results in tip shaping based on previously described ideals for nasal tip aesthetics.
10.1097/PRS.0000000000006709
Male Rhinoplasty: Update.
Plastic and reconstructive surgery
Male rhinoplasty is unique in that it requires precise preoperative planning to achieve a successful result. Better communication and clarity are paramount with male rhinoplasty patients because the patients may be less attentive. It is important for the surgeon to screen the patients for any psychosocial disorders. Through a series of cases, male rhinoplasty techniques are highlighted. Masculine features should be preserved, and the nose should not be feminized or oversculpted. Another key component in any rhinoplasty case is proper skin care, especially during the postoperative period. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.
10.1097/PRS.0000000000006835
Practical Things You Should Know about Wound Healing and Vacuum-Assisted Closure Management.
Singh Devinder,Chopra Karan,Sabino Jennifer,Brown Emile
Plastic and reconstructive surgery
LEARNING OBJECTIVES:After reading this article, the participant should be able to: 1. Understand the basics of negative-pressure wound therapy and practical uses of various vacuum-assisted closure dressings. 2. Understand the mechanisms of action of negative-pressure therapies and other important adjuncts, such as perfusion imaging. 3. Discuss the evidence for hyperbaric oxygen therapy in wound care. SUMMARY:Wound healing requires creating an environment that supports the healing process while decreasing inflammation and infection. Negative-pressure wound therapy has changed the way physicians manage acute and chronic wounds for more than 20 years. It contracts wound edges, removes exudate, including inflammatory and infectious material, and promotes angiogenesis and granulation tissue formation. These effects have been consistently demonstrated in multiple animal and human randomized controlled trials. Recent innovations that include instillation therapy and closed incision have further increased our arsenal against difficult-to-treat wounds and incisions at high risk of complications. Instillation of topical wound solutions allows physicians to cleanse the wound without return to the operating room, resulting in fewer debridements, shorter hospital stays, and faster time to wound closure. Other concepts have yielded negative-pressure therapy on top of closed surgical incisions, which holds incision edges together, reduces edema, promotes angiogenesis, and creates a barrier to protect incisions during the critical healing period, thereby reducing surgical-site complications, especially infection. Other practical adjuncts to the modern-day treatment of acute and chronic wounds include indocyanine green angiography, which allows real-time assessment of perfusion, and hyperbaric oxygen treatment, which has been suggested to augment healing in acute, chronic, specifically diabetic foot ulcers and radiation-related wounds.
10.1097/PRS.0000000000006652
Photographic and Video Deepfakes Have Arrived: How Machine Learning May Influence Plastic Surgery.
Crystal Dustin T,Cuccolo Nicholas G,Ibrahim Ahmed M S,Furnas Heather,Lin Samuel J
Plastic and reconstructive surgery
Advances in computer science and photography not only are pervasive but are also quantifiably influencing the practice of medicine. Recent progress in both software and hardware technology has translated into the design of advanced artificial neural networks: computer frameworks that can be thought of as algorithms modeled on the human brain. In practice, these networks have computational functions, including the autonomous generation of novel images and videos, frequently referred to as "deepfakes." The technological advances that have resulted in deepfakes are readily applicable to facets of plastic surgery, posing both benefits and harms to patients, providers, and future research. As a specialty, plastic surgery should recognize these concepts, appropriately discuss them, and take steps to prevent nefarious uses. The aim of this article is to highlight these emerging technologies and discuss their potential relevance to plastic surgery.
10.1097/PRS.0000000000006697
Outcome of Quality of Life for Women Undergoing Autologous versus Alloplastic Breast Reconstruction following Mastectomy: A Systematic Review and Meta-Analysis.
Eltahir Yassir,Krabbe-Timmerman Irene S,Sadok Nadia,Werker Paul M N,de Bock Geertruida H
Plastic and reconstructive surgery
BACKGROUND:This review aimed to meta-analyze the quality of life of alloplastic versus autologous breast reconstruction, when measured with the BREAST-Q. METHODS:An electronic PubMed and EMBASE search was designed to find articles that compared alloplastic versus autologous breast reconstruction using the BREAST-Q. Studies that failed to present BREAST-Q scores and studies that did not compare alloplastic versus autologous breast reconstruction were excluded. Two authors independently extracted data from the included studies. A standardized data collection form was used. Quality was assessed using the Newcastle-Ottawa Scale. The mean difference and 95 percent confidence intervals between breast reconstruction means were estimated for each BREAST-Q subscale. Forest plots and the I statistic were used to assess heterogeneity and funnel plot publication bias. The Z test was used to assess overall effects. RESULTS:Two hundred eighty abstracts were found; 10 articles were included. Autologous breast reconstruction scored significantly higher in the five subscales than alloplastic breast reconstruction. The Satisfaction with Breasts subscale indicated the greatest difference, with a mean difference of 6.41 (95 percent CI, 3.58 to 9.24; I = 70 percent). The Satisfaction with Results subscale displayed a mean difference of 5.52. The Sexual Well-Being subscale displayed a mean difference of 3.85. The Psychosocial Well-Being subscale displayed a mean difference of 2.64. The overall difference in physical well-being was significant, with high heterogeneity (mean difference, 3.33; 95 percent CI, 0.18 to 6.48; I = 85). CONCLUSION:Autologous breast reconstruction had superior outcomes compared with alloplastic breast reconstruction as measured by the BREAST-Q.
10.1097/PRS.0000000000006720
Does Pregnancy Predict Incisional Hernia Repair after Abdominally Based Autologous Breast Reconstruction? A Retrospective Review of 890 Free Flaps.
Mauch Jaclyn T,Kozak Geoffrey M,Rhemtulla Irfan A,Nathan Shelby L,Tecce Michael,Broach Robyn B,Serletti Joseph M
Plastic and reconstructive surgery
BACKGROUND:The abdomen is a common donor site in autologous breast reconstruction. The authors aimed to determine whether pregnancy following autologous breast reconstruction increases the risk of incisional hernia repair. METHODS:All women younger than 50 years who underwent abdominally based autologous breast reconstruction between 2005 and 2016 were identified. Patients with less than 20 months of follow-up were excluded. Demographics, operative details, outcomes, incisional hernia repair occurrence, and pregnancy history were analyzed. RESULTS:Five hundred nineteen patients underwent autologous breast reconstruction with 890 free flaps [free transverse rectus abdominis musculocutaneous, n = 645 (72.5 percent); deep inferior epigastric perforator, n = 214 (24.0 percent); pedicled transverse rectus abdominis musculocutaneous, n = 18 (2.0 percent); and superficial inferior epigastric artery, n = 13 (1.5 percent)]. Average follow-up was 57.2 months (range, 9.5 to 312.8 months). Fourteen women became pregnant, with mean postpregnancy follow-up of 31.2 months (range, 5.4 to 70.8 months; pregnancies, n = 18). Age of nonpregnant patients (mean, 43.1 years; range, 20.6 to 50.0 years) was higher than that of pregnant patients (mean, 32.1 years; range, 27.1 to 37.9 years) (p < 0.0001); in univariate analysis, age was not associated with incisional hernia repair. Twelve pregnant patients (66.7 percent) underwent cesarean delivery. No statistically significant differences existed between groups regarding flap type and closure technique. Zero pregnant patients underwent incisional hernia repair, compared with a 6.1 percent incisional hernia repair rate in nonpregnant patients (p = 0.339). In multivariate analysis, prior incisional hernia, hematoma, fascial dehiscence, and reoperation predicted incisional hernia repair. CONCLUSION:The authors' results demonstrate that there may not be an increased risk of incisional hernia repair associated with pregnancy following autologous breast reconstruction despite additional weakening of the abdominal wall. CLINICAL QUESTION/LEVEL OF EVIDENCE:Risk, II.
10.1097/PRS.0000000000006723
Early Surgical Management of Medical Tourism Complications Improves Patient Outcomes.
Adabi Kian,Stern Carrie S,Kinkhabwala Corin M,Weichman Katie E,Garfein Evan S,Tepper Oren M,Conejero J Alejandro
Plastic and reconstructive surgery
BACKGROUND:Complications from medical tourism can be significant, requiring aggressive treatment at initial presentation. This study evaluates the effect of early surgical versus conservative management on readmission rates and costs. METHODS:A single-center retrospective review was conducted from May of 2013 to May of 2017 of patients presenting with soft-tissue infections after cosmetic surgery performed abroad. Patients were categorized into two groups based on their management at initial presentation as either conservative or surgical. Demographic information, the procedures performed abroad, and the severity of infection were included. The authors' primary outcome was the incidence of readmission in the two groups. International Classification of Diseases, Ninth Revision; International Classification of Diseases, Tenth Revision; and CPT codes were used for direct-billed cost analysis. RESULTS:Fifty-three patients (one man and 52 women) presented with complications after procedures performed abroad, of which 37 were soft-tissue infections. Twenty-four patients with soft-tissue infections at initial presentation were managed conservatively, and 13 patients were treated surgically. The two groups were similar in patient demographics and type of procedure performed abroad. Patients who were managed conservatively at initial presentation had a higher rate of readmission despite having lower severity of infections (OR, 4.7; p = 0.037). A significantly lower total cost of treatment was shown with early surgical management of these complications (p = 0.003). CONCLUSIONS:Conservative management of complications from medical tourism has resulted in a high incidence of failure, leading to readmission and increased costs. This can contribute to poor outcomes in patients that are already having complications from cosmetic surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, III.
10.1097/PRS.0000000000006728
What Is Driving Paradigm Shifts in Plastic Surgery and Is Cosmetic Surgery Keeping Up?
Yao-Mei Tang Jasmine,Pawliuk Colleen,Bucevska Marija,Mulpuri Varshita,Arneja Jugpal S
Plastic and reconstructive surgery
BACKGROUND:Cosmetic surgery represents 20 to 30 percent of total plastic surgical volume. The authors hypothesize that with current capitalization and market share, cosmetic surgery should be proportionally represented in scientific innovation. METHODS:All journals that may contain articles relevant to plastic surgery were selected from the 2016 edition of Journal Citation Reports. The authors identified, reviewed, and analyzed the 100 top-cited plastic surgery clinical articles using the Science Citation Index Expanded (1900 to 2017) as a proxy for innovation. RESULTS:The top-100 articles were cited a median of 329.5 times (range, 240 to 1709 times). Sixteen journals were represented, led by Plastic and Reconstructive Surgery (45 percent) and Annals of Surgery (15 percent). Fifty-six percent were reconstructive, 13 percent were breast, 11 percent were pediatric/craniofacial, 11 percent were cosmetic, and 9 percent were hand/peripheral nerve articles. Only 11 percent of articles represented level of evidence I or II, with the majority (79 percent) of articles being level IV. Sixty-seven percent of publications originated from United States. The 11 cosmetic articles originated from different subspecialties: injectables, fillers, and fat grafting (n = 7); contouring (n = 2); facial cosmetic (n = 1); and general cosmetic (n = 1). CONCLUSIONS:Cosmetic innovation is not keeping up with reconstructive innovation; it is unknown why cosmetic surgery is lacking. The authors offer several speculations as to why there is a gap in cosmetic surgical research and, by proxy, innovation.
10.1097/PRS.0000000000006732
The Impact of Race, Age, Gender, Income, and Level of Education on Motivations to Pursue Cosmetic Surgery and Surgeon Selection at an Academic Institution.
Ligh Cassandra A,Lett Elle,Broach Robyn B,Enriquez Fabiola A,Jordan Atasha,Percec Ivona,Serletti Joseph M,Butler Paris D
Plastic and reconstructive surgery
BACKGROUND:Aesthetic surgery is a personal choice that appeals to a wide population of individuals. The authors investigated how race and ethnicity, age, gender, income, and education level affect patient motivation to pursue cosmetic surgery and selection of a plastic surgeon. METHODS:One hundred seventy-two consecutive patients from two surgeons (an African American man and a Caucasian woman) completed surveys from 2016 to 2017 that assessed their decision to pursue cosmetic surgery. Univariable cumulative logit models with odds ratios and 95 percent confidence intervals were calculated with the survey data. RESULTS:African American patients were more likely to be willing to travel greater than 100 miles for a surgeon who shared the same ethnicity or race, to consider international surgery, to report that social standards did not influence their decision for surgery, and to view the buttocks as the female feature that best defines attractiveness within their race or ethnicity. Patients with incomes over $125,000 and those over the age of 50 years were more likely to seek a surgeon of the same gender, think a same-gender surgeon could provide better results, be influenced by societal standards to pursue surgery, and view the face as the defining attractive female feature within their race or ethnicity. Patients with college or graduate degrees were more likely to believe a gender- and racially concordant surgeon would provide them with better a result and believed societal standards were unrealistic to obtain with diet and exercise. CONCLUSIONS:Plastic surgeons encounter patients of varying demographics, all of whom have differing perspectives about cosmetic surgery and motivations for its pursuit. Recognizing and defining these differences could enable surgeons to provide a more individualized cosmetic experience and inform future marketing strategies to attract a diverse patient population.
10.1097/PRS.0000000000006734
Breast Augmentation in the Transfemale Patient: Comprehensive Principles for Planning and Obtaining Ideal Results.
Coon Devin,Lee Erica,Fischer Beverly,Darrach Halley,Landford Wilmina N
Plastic and reconstructive surgery
BACKGROUND:A growing number of transgender women present to plastic surgeons seeking breast augmentation. Despite some advocating their technical similarity, the authors have found substantially different planning and techniques are needed to obtain aesthetic results in transgender patients versus cosmetic breast augmentation. The authors sought to develop an approach for operative planning and technique to elucidate these differences and obtain consistent results. METHODS:All patients who underwent breast augmentation at the Johns Hopkins Center for Transgender Health were included in this study. Anthropometric assessments were obtained and comparative statistics between operative and nonoperative cohorts were calculated. Outcomes were analyzed and a patient-reported survey was performed to evaluate patient satisfaction. RESULTS:Fifty-nine consecutive transfemale patients presented for evaluation. Anthropometric measurements included base width (median, 15.0 ± 2.1 cm), notch-to-nipple distance (median, 22.0 cm), nipple-to-midline distance (median, 12.0 cm), areolar diameter (median, 3.5 ± 1.5 cm), and upper pole pinch (mean, 1.8 ± 1.1 cm). Thirty-six patients underwent augmentation mammaplasty. Postoperative complications (8.3 percent) included a minor hematoma and grade III capsular contracture in two patients. Patients were asked to complete a brief outcomes survey and reported an improvement in psychosocial well-being and high satisfaction rate (100 percent) with the overall cosmetic result. CONCLUSIONS:Transgender female patients represent a unique patient population requiring special consideration of anatomical differences in key planning decisions. The authors delineate the first systematic algorithm that addresses these differences, emphasizing maneuvers such as routine inframammary fold lowering. This can allow experienced augmentation surgeons to obtain excellent aesthetic and patient-reported outcomes in this population. As with cosmetic breast augmentation, patient satisfaction rates are high. CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, IV.
10.1097/PRS.0000000000006819
Photoaged Skin Therapy with Adipose-Derived Stem Cells.
Charles-de-Sá Luiz,Gontijo-de-Amorim Natale Ferreira,Rigotti Gino,Sbarbati Andrea,Bernardi Paolo,Benati Donatella,Bizon Vieira Carias Rosana,Maeda Takiya Christina,Borojevic Radovan
Plastic and reconstructive surgery
BACKGROUND:The major intrinsic cause of facial skin degeneration is age, associated with extrinsic factors such as exposure to sun. Its major pathologic causes are degeneration of the elastin matrix, with loss of oxytalan and elaunin fibers in the subepidermal region, and actinic degeneration of elastin fibers that lose their functional properties in the deep dermis. Therapy using autologous adipose mesenchymal stem cells for regeneration of extracellular matrix in patients with solar elastosis was addressed in qualitative and quantitative analyses of the dermal elastic fiber system and the associated cells. METHODS:Mesenchymal stem cells were obtained from lipoaspirates, expanded in vitro, and introduced into the facial skin of patients submitted after 3 to 4 months to a face-lift operation. In the retrieved skin, immunocytochemical analyses quantified elastic matrix components; cathepsin K; matrix metalloproteinase 12 (macrophage metalloelastase); and the macrophage M2 markers CD68, CD206, and hemeoxygenase-1. RESULTS:A full de novo formation of oxytalan and elaunin fibers was observed in the subepidermal region, with reconstitution of the papillary structure of the dermal-epidermal junction. Elastotic deposits in the deep dermis were substituted by a normal elastin fiber network. The coordinated removal of the pathologic deposits and their substitution by the normal ones was concomitant with activation of cathepsin K and matrix metalloproteinase 12, and with expansion of the M2 macrophage infiltration. CONCLUSION:The full regeneration of solar elastosis was obtained by injection of in vitro expanded autologous adipose mesenchymal stem cells, which are appropriate, competent, and sufficient to elicit the full structural regeneration of the sun-aged skin. CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, IV.
10.1097/PRS.0000000000006867