The Value of Integrating Fluorescent Imaging and Immunohistochemistry for Future Anatomical Studies in Aesthetic Surgery: Lessons From the Cerebrospinal Fluid Circulatory System of Human Nerves and Brain.

BACKGROUND: During their work on the cerebrospinal fluid (CSF) circulatory system of human nerves and brain, the authors applied imaging and tissue techniques that complemented basic anatomical dissection. OBJECTIVES: The authors sought to show how integrating fluorescent imaging and basic immunohistochemistry (IHC) with facial anatomy can address current problems in aesthetic surgery. METHODS: The authors developed an algorithm and a set of principles from their work on the CSF circulatory system and applied these to 3 problems in aesthetic surgery: the functional anatomy of the vermilion-cutaneous junction; chemosis; and the functional anatomy of periosteal fixation. RESULTS: Integrating fluorescent imaging and IHC with anatomical dissection characterizes structural and functional anatomy. Fluorescent imaging helps to identify and locate easily missed structures. IHC defines cell type and function. The vermilion-cutaneous junction is defined by a major lymphatic vessel. Lymphatic flow from the medial limbus to the lateral canthus suggests the etiology of chemosis. Periosteal sites of fixation prevent shear where dural CSF vessels drain directly to subcutaneous lymphatics. CONCLUSIONS: Integrating anatomical dissection with fluorescent imaging and basic IHC characterizes structural and functional anatomy and helps to better understand many problems encountered in aesthetic surgery.

Characterization of Adipose Tissue Product Quality Using Measurements of Oxygen Consumption Rate.

BACKGROUND: Fat grafting is a common procedure in plastic surgery but associated with unpredictable graft retention. Adipose tissue (AT) "product" quality is affected by the methods used for harvest, processing and transfer, which vary widely amongst surgeons. Currently, there is no method available to accurately assess the quality of AT. OBJECTIVES: In this study, we present a novel method for the assessment of AT product quality through direct measurements of oxygen consumption rate (OCR). OCR has exhibited potential in predicting outcomes following pancreatic islet transplant. Our study aim was to reapportion existing technology for its use with AT preparations and to confirm that these measurements are feasible. METHODS: OCR was successfully measured for en bloc and postprocessed AT using a stirred microchamber system. OCR was then normalized to DNA content (OCR/DNA), which represents the AT product quality. RESULTS: Mean (±SE) OCR/DNA values for fresh en bloc and post-processed AT were 149.8 (± 9.1) and 61.1 (± 6.1) nmol/min/mg DNA, respectively. These preliminary data suggest that: (1) OCR and OCR/DNA measurements of AT harvested using conventional protocol are feasible; and (2) standard AT processing results in a decrease in overall AT product quality. CONCLUSIONS: OCR measurements of AT using existing technology can be done and enables accurate, real-time, quantitative assessment of the quality of AT product prior to transfer. The availability and further validation of this type of assay could enable optimization of fat grafting protocol by providing a tool for the more detailed study of procedural variables that affect AT product quality.

What's Your Micromort? A Patient-Oriented Analysis of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL).

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) continues to be a rare and elusive malignancy. Because BIA-ALCL does not behave like traditional lymphomas, additional research needs to be conducted to further delineate the lymphoproliferative nature of BIA-ALCL. An estimated 35 million women worldwide have breast implants and the total reported deaths from BIA-ALCL is 12 to date. The term micromort was introduced in 1979 by Ronald Howard as a person's risk of dying as 1 in a million. Drinking 0.5 L of wine or walking 17 miles all increase your risk of death by 1 micromort. Risk of death from BIA-ALCL is 0.4 micromorts for a woman having bilateral breast implants. This information is important for counseling new patients and those presenting with delayed onset seromas.

Clinical Evaluation of Shaped Gel Breast Implant Rotation Using High-Resolution Ultrasound.

Background: Clinical trials have demonstrated through core and independent studies that anatomical devices are safe and effective with low complication rates. The rotation rate of shaped breast implants in the literature is 0 to 8.2%. Currently there are no studies evaluating the efficacy of in office ultrasound or clinical rotation vs actual rotation rates seen on high-resolution ultrasound (HRUS). Objectives: The purpose of the study is to demonstrate the ease and reliability of HRUS for evaluating the rotation rate of 2 different brands of anatomic implants and to correlate this with the presumed clinical rate, as well as independent evaluators assessments. Methods: A total of 69 patients were followed up at routine intervals and were evaluated for rotation. Any implant rotated past >30° off of midline (outside 5-7 o'clock) was considered to be rotated. To determine if radiographic rotation was clinically evident, 20 composite patient photos were blindly evaluated. Results: A random total of 69 patients underwent bilateral augmentation mammoplasty with form stable anatimic gel implants using 138 implants. Twenty-nine of the 69 (42%) patients and 37 of the 138 (27%) implants were found to be rotated-using HRUS. Eight of the 69 (12%) patients had bilateral rotations. Independent evaluators were able to identify two of 12 (17%) possible rotations, or 2 rotations in 40 (5%) total implants. Conclusions: Anatomic form stable gel implants are actually rotated up to 25 times more frequently than previously thought, but these rotations do not translate into clinically significant sequela. High-resolution ultrasound is a simple alternative for breast implant surveillance and is better accepted by patients than magnetic resonance imaging (MRI). The clinical value of HRUS is also discussed and recommendations for FDA implant labeling changes are provided in this article. Level of Evidence: 4

Characterization of adipose tissue for autologous fat grafting.

Fat grafting is a common procedure in aesthetic and reconstructive plastic surgery, but variable graft retention limits its utility. Unpredictable clinical outcomes with fat grafting can be explained in part by the lack of standardized protocols for harvesting, processing, and transplanting adipose tissue (AT). Historically, plastic surgeons have relied on trial and error and their clinical experience to develop fat grafting protocols. Optimization of fat grafting protocols requires systematic assessment of the impact that key variables have on the quality of the AT preparation at each step of the procedure. In this article, we review recent findings regarding the composition and quality of AT prepared for fat grafting and the strengths and limitations of existing AT characterization assays. We discuss the need for an assessment of the viability of intact AT (ie, conventionally harvested AT that has not been disrupted further) by means of an operator-independent, quantitative assay that can be performed in real time and generates reproducible data. Promising assays for the characterization of cell product quality have been developed for other therapeutic applications, such as transplantation of pancreatic islet cells. The development or adaptation of a gold-standard assay to determine the quality of an AT preparation may help to standardize fat grafting protocols and improve clinical outcomes.

Getting the Best Results in Abdominoplasty: Current Advanced Concepts.

LEARNING OBJECTIVES: After studying this article and viewing the videos, the participant should be able to: 1. Describe the safe techniques recommended for patients undergoing a lipoabdominoplasty. 2. Demonstrate safe planning techniques for marking a patient for a lipoabdominoplasty. 3. Summarize the various techniques for performing rectus plication. 4. State the current understanding of chemoprophylaxis for outpatient surgical patients. 5. Determine the appropriate placement and shape of the ideal umbilicus. SUMMARY: Abdominoplasty and lipoabdominoplasty surgery is one of the core procedures performed by plastic surgeons in the United States. As with most plastic surgery, it is part art and part science. In this article, the authors try to summarize the science behind this procedure, and point to the generally accepted artistic aspects that are currently still under debate. As this procedure has one of the highest morbidity and mortality rates in the specialty, the authors have also reviewed safe practices.

Synchronous Breast Implant-associated Anaplastic Large Cell Lymphoma and Invasive Carcinoma: Genomic Profiling and Management Implications.

A 59-year-old woman with a history of cosmetic implants developed ipsilateral synchronous breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) and invasive ductal carcinoma in the left breast. Each tumor was subjected to next-generation sequencing, and separate analyses revealed mutually exclusive aberrations: an activating STAT3 mutation in the lymphoma and a PIK3CA in-frame deletion in the carcinoma. The patient was treated with removal of implants, capsulectomy, partial mastectomy, sentinel node biopsy, radiotherapy, and endocrine therapy with no evidence of recurrence for 1 year. This case illustrates the importance of obtaining thorough evaluation for concomitant malignancies in the breast at the time of diagnosis of BIA-ALCL. Herein, we review the current recommendations for evaluation and management of BIA-ALCL.

Bioengineered Approach to the Design of a Fat Graft Based on Mathematical Modeling that Predicts Oxygen Delivery.

BACKGROUND: Fat grafting is a common procedure in plastic surgery. A major limitation is unpredictable graft retention, in part caused by inadequate oxygen delivery during the early posttransfer period. METHODS: The authors present a bioengineered approach to the design of a fat graft based on mathematical theory, which can estimate the limitations of oxygen delivery. To simplify the problem, four variables were defined: (1) recipient-site oxygen partial pressure; (2) adipose tissue oxygen permeability; (3) adipose tissue oxygen consumption rate; and (4) fat graft size. Recipient-site oxygen partial pressure and adipose tissue oxygen permeability were estimated from literature, whereas adipose tissue oxygen consumption rate was measured using stirred microchamber technology. Calculations were performed in both spherical and planar geometry to calculate the maximum allowable fat graft size from an oxygen delivery standpoint. RESULTS: As expected, planar geometry is less favorable for oxygenation but represents a realistic configuration for a fat graft. Maximum allowable fat graft thickness is only approximately 1 to 2 mm at external oxygen partial pressures of 10 to 40 mm Hg; any thicker and an anoxic or necrotic core likely develops. Given a reasonably large surface area and assuming several planes of injection, the maximum allowable fat graft volume is tens of milliliters. CONCLUSIONS: A systematic bioengineered approach may help better design a fat graft. Applying principles of mass transfer theory can predict whether a fat graft has a favorable chance of surviving from an oxygen delivery standpoint and can direct the development of strategies for improved fat graft oxygenation.

Noninvasive Methods for Lower Facial Rejuvenation.

Demand for noninvasive aesthetic medicine options is increasing because of the popularity of nonsurgical procedures and industry's focus on direct-to-consumer marketing. Such techniques as nonablative and ablative lasers, intense pulsed light, radiofrequency, high-intensity focused ultrasound, and skin care with peeling agents may also be used in conjunction with surgery to optimize overall aesthetic results. To maximize benefits, the provider must have a detailed understanding of the science behind each device. Combined therapy is safe and well tolerated by many patients in an office-based setting. Although surgery remains the gold standard, nonsurgical therapy should be a portion of surgical practices.

Finesse in Nasal Tip Refinement.

Nasal tip refinement is one of the most difficult aspects of rhinoplasty surgery. In this article, the senior author (R.J.R.) presents his technique for nasal tip analysis and identifies the factors that contribute to nasal tip shape. Various techniques for nasal tip modification using both sutures and soft cartilage grafts are described to help produce optimal results.

Extended Alar Contour Grafts: An Evolution of the Lateral Crural Strut Graft Technique in Rhinoplasty.

Modification of the lower lateral cartilage complex is the sine qua non of modern rhinoplasty, and the open approach to rhinoplasty has expanded the number of techniques available to help achieve an aesthetically pleasing tip. The ideal tip has been described as having a diamond-shaped configuration, with the lateral points formed by the tip-defining points, the superior point by the supratip, and the inferior point by the columellar break point. Over the years, various techniques have been described to minimize isolation of the tip and to help achieve the ideal tip configuration: lateral crural strut grafts, alar contour grafts (i.e., rim grafts), alar strut grafts, subdomal grafts, and suturing techniques such as alar flaring sutures. The authors present their technique of the extended alar contour graft, which represents an evolution of the lateral crural strut graft and its marriage with the alar contour graft. Lateral crural abnormalities do not usually occur singularly, but rather are the result of an interplay of several factors. Nevertheless, the recurring theme of orientation and alar support to prevent isolation of the tip by extended alar grooves remains. Extended alar contour grafts are a versatile technique to optimize tip shape and orientation by combining the many positive attributes of lateral crural strut grafts and alar contour grafts.

Neck Rejuvenation through the Lateral Platysma Window: A Key Component of Face-Lift Surgery.

Rejuvenating an aged face relies on maintaining facial harmony to provide optimal aesthetic results. Restoration of more youthful facial contours is dependent on blending the aesthetic facial topographic units. Many authors continue to debate the best approach for neck rejuvenation through a medial approach, a lateral approach, or a combination of the two. The authors present their approach to neck rejuvenation through medial platysma plication, inferior release, and lateral platysma window.

The Six-Step Lower Blepharoplasty: Using Fractionated Fat to Enhance Blending of the Lid-Cheek Junction.

Lower lid blepharoplasty is one of the most complex procedures performed by plastic surgeons and may cause significant long-term sequelae, including inadequate aesthetic outcomes if not performed with a thorough understanding of anatomy and proper technique. The authors' practice is consistently evolving to deliver the highest quality results for their patients. The purpose of this article is to introduce an additional sixth step to the lower lid blepharoplasty procedure involving the targeted injection of fractionated fat to better blend the lid-cheek junction. This added step will enhance overall facial rejuvenation, is reproducible, and will provide patients with exceptional outcomes.