Incidental Abdominal Wall Endometriosis in Plastic Surgery: Two Cases and Review of the Literature.

Endometriosis is a common cause of pain and infertility. Abdominal wall endometriosis (AWE) is a form of extrapelvic endometriosis that can be encountered during abdominal surgery such as abdominoplasty or free flap harvest. We report two cases of AWE; one found intraoperatively in a 32-year-old woman desiring body contouring after undergoing cesarean section, and a second in a 36-year-old woman requiring resection and reconstruction of a left chondroid tenosynovial giant cell tumor of her temporomandibular joint. During free flap planning, she was found to have endometriosis of her right hemi-abdomen. Both patients underwent resection of their AWE and were referred to their obstetrics and gynecology physicians for consideration of menstrual suppression to decrease their risk of recurrence.

Revision Rhinoplasty Finesse with Digital Osteotomies.

SUMMARY: Revision rhinoplasty is a finesse procedure requiring careful consideration of all of its requisite steps. Lateral osteotomies are required in many cases and, in the setting of prior lateral osteotomies, can often be recreated with digital pressure alone, without the use of an osteotome. The advantages of doing so include decreased dead-space creation and preservation of attachments between the skeleton and overlying soft tissue.

Systematic Review of Capsular Contracture Management following Breast Augmentation: An Update.

BACKGROUND: Capsular contracture is one of the most frequent indications for revision following breast augmentation. Management goals focus on restoring breast aesthetics and minimizing subsequent recurrence of capsular contracture. As new data emerge, close review of the data are merited to build evidence-based clinical guidelines to inform surgical practice and management of capsular contracture. METHODS: A systematic review of the MEDLINE, Embase, and Cochrane Database of Systematic Reviews databases was conducted to characterize the surgical management of capsular contracture in revision breast augmentations. The primary endpoint was capsular contracture recurrence rate. RESULTS: The review was conducted in November of 2021. Primary search revealed 14,163 results. Initial screening by title left 1223 articles. Abstract review left 90 articles for full-text review, of which 34 were ultimately included and were all observational in nature. CONCLUSIONS: Capsular contracture management remains an important topic, with limited high-level evidence for establishing clear evidence-based treatment guidelines. Although more evidence is required to assess the effects of capsulectomy, implant exchange, and plane change, these appear to be useful mechanisms for reducing recurrent capsular contracture. There is more evidence regarding the use of acellular dermal matrix, although this still requires long-term follow-up studies. New developments regarding textured implants limit the revision breast augmentation surgeon to smooth devices.

Neuromodulator Finesse for Masseter Hypertrophy and Bruxism.

SUMMARY: A particularly prominent mandibular angle or a hypertrophied masseter muscle can result in an excessively wide facial appearance, which some individuals may find less aesthetically pleasing. Although normally a benign condition and strictly an aesthetic concern, a hypertrophied masseter can also cause pain, bruxism, and headaches. Neuromodulator for masseter reduction and treatment of bruxism has become first-line treatment. In this article, the authors present the senior author's (R.J.R.) anatomic approach to neuromodulator injection of the masseter, with a corresponding video of the injection technique.

Neuromodulator Injection for Gummy Smile.

SUMMARY: Neuromodulators have become a treatment of choice for the management of excess gingival show, or "gummy smile." There have been many proposed algorithms for the optimal placement and dosage of neuromodulator to inject in these locations. The authors aim to clarify these points and provide surgeons with a reliable way to manage the gummy smile that results from hyperactive muscles of the midface.

Management of the Post Hemangioma Nose - 5 Key Rhinoplasty Components.

Hemangiomas of the nasal tip are a relatively uncommon presentation of a common tumor. While optimal medical and surgical management of nasal tip infantile hemangiomas has been described and debated extensively in the literature, to our knowledge, there is no report of secondary aesthetic and functional rhinoplasty in these patients at skeletal maturity until now. This special topic provides an excellent example of the five key technical elements to revision rhinoplasty in the skeletally mature patient with history of nasal tip infantile hemangioma.

Differential Fat Grafting to Address Facial Asymmetry in Facelifting.

The modern facelift is a complex operation involving the repositioning of tissues and the refilling of volume atrophy. Preoperative analysis is key to the successful diagnosis of aging changes. Facial asymmetry is universal, and must be recognized and incorporated into surgical planning. In this paper, we address the role of fat grafting to manage facial aging in the setting of facial asymmetry.

Lip Lifting: The Missing Link in Central Facial Rejuvenation.

The lip lift is a powerful yet finesse operation in the realm of facial rejuvenation. In an era of booming non-surgical lip augmentation, the astute plastic surgeon must identify which patients will end up with a dreaded unnatural appearance should they receive volume enhancement alone in pursuit of central facial and perioral rejuvenation. In this paper, we review the ideal youthful lips, the characteristics of the aged lip and indications for lifting. We present our preferred surgical technique, the underlying principles that it respects, and adjunct procedures to optimize results in central facial rejuvenation.

Refinements in Component Dorsal Reshaping in Primary Rhinoplasty.

SUMMARY: Dorsal reduction and reshaping is an essential part of many rhinoplasty procedures. The steps of component dorsal reduction have been well established. The authors describe refinement of the dorsal reshaping process to improve the quality and consistency of results.

Finesse Buccal Fat Pad Excision.

SUMMARY: The buccal fat pad has long been noted for its complex anatomy and its significance to facial aesthetics. Its bulk is mostly deep facial fat immediately superficial to the buccinator muscle. The buccal fat pad has a main body and four extensions: buccal, pterygoid, superficial temporal, and deep temporal. It can be removed in patients with round, heavy faces and anterior buccal fullness to slim the lower face and contour the jawline. This article describes the authors' technique for buccal fat pad removal, with a goal of conservative fat pad reduction.

Longevity of ptosis correction in mastopexy and reduction mammaplasty: A systematic review of techniques.

Background: Mastopexy and reduction mammaplasty are commonly performed procedures in plastic surgery with many variations in incision pattern, pedicle design, and additional support maneuvers. Aesthetically pleasing on table results are widely accomplished; however, the longevity of the outcome and sustained correction of ptosis or pseudoptosis is not universal. A systematic review of mastopexy and reduction mammaplasty procedures was performed to investigate which techniques provided the greatest long-term correction of ptosis. Methods: A broad search of the literature was performed using the PubMed database from inception to December of 2021. Study characteristics, number of patients, number of breasts, technique, outcome, and average follow-up time were extracted for analysis. Study quality was assessed using the Newcastle-Ottawa Scale when applicable. Results: The primary search yielded 1123 articles. After two levels of screening, 24 articles were identified for analysis. This included 16 case series, seven cohort studies, and one randomized controlled study. From these studies, 1235 patients and 2235 breasts were analyzed. The majority of articles reported on a change in the nipple to inframammary fold and sternal notch to nipple distances. Conclusions: In the analytical studies, superior and superomedial pedicles tended to provide greater long-term stability than inferior pedicles. Mesh, dermal suspension flaps, and muscular slings showed promise in providing additional support over standard techniques. No single procedure is ideal for all patients; however, this systematic review provides a valuable description of techniques and long-term outcomes to guide surgical planning.

Hematoma After Non-Oncologic Breast Procedures: A Comprehensive Review of the Evidence.

BACKGROUND: Hematoma after non-oncologic breast surgery is a common concern requiring expeditious treatment. The purpose of this study is to perform an evidence-based review of perioperative factors that may contribute to hematoma in non-oncologic breast procedures. METHODS: A comprehensive literature review was performed of non-oncologic breast procedures: breast augmentation, single-stage augmentation-mastopexy, mastopexy, and reduction. In total, 28 studies highlighting incidence and potential risk factors for hematoma were included; overall level of evidence was established regarding each perioperative factor examined and hematoma rate. RESULTS: The hematoma rate in breast augmentation ranges from 0.2 to 5.7%. There is inconclusive evidence to support an association between pocket choice or incision location and hematoma rate (Level III) and no evidence of an association between implant type and hematoma (Level V). Single-stage augmentation-mastopexy may have a lower hematoma rate than augmentation alone (Level II). Hematoma may increase the risk of capsular contracture (Level III). In breast reduction, the hematoma rate ranges from 1.0 to 9.3%. Evidence of an association between incision choice and hematoma rate is inconclusive (Level III). Use of epinephrine-containing solution, pedicle choice, and resection weight do not appear to affect hematoma rate (Level V, II, and II, respectively). The use of postoperative drains and ketorolac do not affect the incidence of hematoma (Level I and III, respectively). Intraoperative hypotension may increase the risk of hematoma after breast reduction (Level III). CONCLUSIONS: Breast hematomas are not uncommon complications. Current literature lacks ample evidence for risk factors for hematoma after non-oncologic breast procedures, warranting further, high-powered investigations. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Evolution in Monitoring of Free Flap Autologous Breast Reconstruction after Nipple-Sparing Mastectomy: Is There a Best Way?

BACKGROUND: Free flap monitoring in autologous reconstruction after nipple-sparing mastectomy remains controversial. The authors therefore examined outcomes in nipple-sparing mastectomy with buried free flap reconstruction versus free flap reconstruction incorporating a monitoring skin paddle. METHODS: Autologous free flap reconstructions with nipple-sparing mastectomy performed from 2006 to 2015 were identified. Demographics and operative results were analyzed and compared between buried flaps and those with a skin paddle for monitoring. RESULTS: Two hundred twenty-one free flaps for nipple-sparing mastectomy reconstruction were identified: 50 buried flaps and 171 flaps incorporating a skin paddle. The most common flaps used were deep inferior epigastric perforator (64 percent), profunda artery perforator (12.1 percent), and muscle-sparing transverse rectus abdominis myocutaneous flaps (10.4 percent). Patients undergoing autologous reconstructions with a skin paddle had a significantly greater body mass index (p = 0.006). Mastectomy weight (p = 0.017) and flap weight (p < 0.0001) were significantly greater in flaps incorporating a skin paddle. Comparing outcomes, there were no significant differences in flap failure (2.0 percent versus 2.3 percent; p = 1.000) or percentage of flaps requiring return to the operating room (6.0 percent versus 4.7 percent; p = 0.715) between groups. Buried flaps had an absolute greater mean number of revision procedures per nipple-sparing mastectomy (0.82) compared with the skin paddle group (0.44); however, rates of revision procedures per nipple-sparing mastectomy were statistically equivalent between the groups (p = 0.296). CONCLUSION: Although buried free flap reconstruction in nipple-sparing mastectomy has been shown to be safe and effective, the authors' technique has evolved to favor incorporating a skin paddle, which allows for clinical monitoring and can be removed at the time of secondary revision. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Le Fort III Distraction With Internal vs External Distractors: A Cephalometric Analysis.

OBJECTIVE: This study compares the change in midface position following Le Fort III advancement using either rigid external distraction (group 1) or internal distraction (group 2). We hypothesized that, with reference to right-facing cephalometry, internal distraction would result in increased clockwise rotation and inferior displacement of the midface. DESIGN: Le Fort III osteotomies and standardized distraction protocols were performed on 10 cadaveric specimens per group. Right-facing lateral cephalograms were traced and compared across time points to determine change in position at points orbitale, anterior nasal spine (ANS), A-point, and angle ANB. SETTING: Institutional. PATIENTS, PARTICIPANTS: Twenty cadaveric head specimens. INTERVENTIONS: Standard subcranial Le Fort III osteotomies were performed from a coronal approach and adequately mobilized. The specified distraction mechanism was applied and advanced by 15 mm. MAIN OUTCOME MEASURE(S): Changes of position were calculated at various skeletal landmarks: orbitale, ANS, A-point, and ANB. RESULTS: Group 1 demonstrated relatively uniform x-axis advancement with minimal inferior repositioning at the A-point, ANS, and orbitale. Group 2 demonstrated marked variation in x-axis advancement among the 3 points, along with a significant inferior repositioning and clockwise rotation of the midface ( P < .0001). CONCLUSION: External distraction resulted in more uniform advancement of the midface, whereas internal distraction resulted in greater clockwise rotation and inferior displacement. External distraction appears to provide increased vector control of the midface, which is important in creating a customized distraction plan based on the patient's individual occlusal and skeletal needs.

An Update on Genital Reconstruction Options for the Female-to-Male Transgender Patient: A Review of the Literature.

Although many transgender individuals are able to realize their gender identity without surgical intervention, a significant and increasing portion of the trans population is seeking gender-confirming surgery (alternatively, gender reassignment surgery, sexual reassignment surgery, or gender-affirming surgery). This review presents a robust overview of genital reconstruction in the female-to-male transgender patient-an operation that, historically, was seldom performed and has remained less surgically feasible than its counterpart (male-to-female genital reconstruction). However, as the visibility and public awareness of the trans community continues to increase, the demand for plastic surgeons equipped to perform these reconstructions is rising. The "ideal" neophallus is aesthetic, maintains tactile and erogenous sensibility, permits sexual function and standing urination, and possesses minimal donor-site and operative morbidity. This article reviews current techniques for surgical construction, including metoidioplasty and phalloplasty, with both pedicled and free flaps. Emphasis is placed on the variety of techniques available for constructing a functional neophallus and neourethra. Preparative procedures (such as vaginectomy, hysterectomy, and oophorectomy) and adjunctive reconstructive procedures (including scrotoplasty and genital prosthesis insertion) are also discussed.

Heads-up 3D Microscopy: An Ergonomic and Educational Approach to Microsurgery.

Traditional microsurgery can lead surgeons to use postures that cause musculoskeletal fatigue, leaving them more prone to work-related injuries. A new technology from TrueVision transmits the microscopic image onto a 3-dimensional (3D) monitor, allowing surgeons to operate while sitting/standing in a heads-up position. The purpose of this study was to evaluate the feasibility of performing heads-up 3D microscopy as a more ergonomic alternative to traditional microsurgery. A feasibility study was conducted comparing heads-up 3D microscopy and traditional microscopy by performing femoral artery anastomoses on 8 Sprague-Dawley rats. Operative times and patency rates for each technology were compared. The 8 microsurgeons completed a questionnaire comparing image quality, comfort, technical feasibility, and educational value of the 2 technologies. Rat femoral artery anastomoses were successfully carried out by all 8 microsurgeons with each technology. There was no significant difference in anastomosis time between heads-up 3D and traditional microscopy (average times, 34.5 and 33.8 minutes, respectively; P = 0.66). Heads-up 3D microscopy was rated superior in neck and back comfort by 75% of participants. Image resolution, field of view, and technical feasibility were found to be superior or equivalent in 75% of participants, whereas 63% evaluated depth perception to be superior or equivalent. Heads-up 3D microscopy is a new technology that improves comfort for the microsurgeon without compromising image quality or technical feasibility. Its use has become prevalent in the field of ophthalmology and may also have utility in plastic and reconstructive surgery.

A Systematic Review of Metoidioplasty and Radial Forearm Flap Phalloplasty in Female-to-male Transgender Genital Reconstruction: Is the "Ideal" Neophallus an Achievable Goal?

INTRODUCTION: The complex anatomy and function of the native penis is difficult to surgically replicate. Metoidioplasty and radial forearm flap phalloplasty (RFFP) are the 2 most commonly utilized procedures for transgender neophallus construction. METHODS: A MEDLINE search for metoidioplasty and RFFP in female-to-male genital reconstruction was performed. Primary outcome measures were subsequently compared. A systematic review was planned in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyse guidelines. Grading of Recommendations Assessment, Development and Evaluation (GRADE) was utilized to evaluate the quality of evidence. RESULTS: Using Population, Intervention, Comparison and Outcomes tool criteria, a total of 188 articles were identified; 7 articles related to metoidioplasty and 11 articles related to RFFP met inclusion criteria. The GRADE quality of evidence was low to very low for all included studies. In studies examining metoidioplasty, the average study size and length of follow-up were 54 patients and 4.6 years, respectively (1 study did not report [NR]). Eighty-eight percent underwent a single-stage reconstruction (0 NR), 87% reported an aesthetic neophallus (3 NR), and 100% reported erogenous sensation (2 NR). Fifty-one percent of patients reported successful intercourse (3 NR), and 89% of patients achieved standing micturition (3 NR). In studies examining RFFP, the average study size and follow-up were 60.4 patients and 6.23 years, respectively (6 NR). No patients underwent single-stage reconstructions (8 NR). Seventy percent of patients reported a satisfactorily aesthetic neophallus (4 NR), and 69% reported erogenous sensation (6 NR). Forty-three percent reported successful penetration of partner during intercourse (6 NR), and 89% achieved standing micturition (6 NR). Compared with RFFP, metoidioplasty was significantly more likely to be completed in a single stage (P < 0.0001), have an aesthetic result (P = 0.0002), maintain erogenous sensation (P < 0.0001), achieve standing micturition (P = 0.001), and have a lower overall complication rate (P = 0.02). CONCLUSIONS: Although the current literature suggests that metoidioplasty is more likely to yield an "ideal" neophallus compared with RFFP, any conclusion is severely limited by the low quality of available evidence.