The Aesthetic Surgery Education and Research Foundation (ASERF): A 30-Year Retrospective Analysis.

Federal government research grants provide limited funding to plastic surgeon-scientists, with reconstructive research taking precedence over aesthetic research. The Aesthetic Surgery Education and Research Foundation (ASERF) is a nonprofit, 501(c)(3) organization that seeks to support innovative, diverse research endeavors within aesthetic surgery. A total of 130 ASERF-funded studies and 32 non-funded applications from 1992 to 2022 were reviewed. Kruskal Wallis, Fisher's exact, and chi-squared tests were utilized to assess the potential relationship between self-identified gender, practice setting, geographical location, and study type with individual grant amounts and grant funding decision. Although significant differences were observed between male and female grant recipient h-indices (P < .05), there were no differences in the amount of funding they received (P > .05). Grant amounts were also consistent between study types as well as principal investigator practice settings and geographical locations (P > .05). The subanalysis revealed that the practice setting of the primary investigator (PI) was the only variable to exhibit a significant association with the decision to award funding (P < .05). Further, of the 61 applicants between 2017 and 2022, only 2 PIs self-identified as female. ASERF serves as an excellent funding source for global aesthetic surgery. To promote further research diversification, increased emphasis should be placed on recruiting applicants from outside academia and those who identify as female or gender nonbinary.

Invited Discussion on: Video-Assisted Septo-Rhinoplasty, the Future of Endonasal Rhinoplasty-A Technical Note.

This discussion critically evaluates the paper "Video-assisted septo-rhinoplasty, the future of endonasal rhinoplasty-A Technical Note." This discussion recognizes the substantial advantages offered by the novel endoscopic technique, such as improved visibility and the facilitation of surgical teaching. However, it also explores the inherent obstacles including potential restrictions in achieving full visibility of all nasal structures, a steeper learning curve for young surgeons due to the need to master endoscope manipulation, and difficulties in precision and accuracy during suture and graft placements in the confined operational field. This discussion underscores the importance of surgical adaptability as well as tailoring techniques to meet the specific anatomical and esthetic considerations of each patient. Even as the limitations of the endoscopic method are highlighted, its potential for advancing the field of rhinoplasty is affirmed. The inventiveness and dedication of the original authors are applauded, and we look forward to their continued innovation in this rapidly evolving discipline.Level of Evidence V 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 .

A Simple Alternative: A Minimal-Touch Technique for Placing Breast Implants.

This is a single-surgeon experience detailing the senior author's (J.G.) minimal-touch technique for placement of breast implants. Adams et al. 14-point plan has been incorporated into the technique, and the implant box paper cover sheet is used as a barrier between the patient and the implant near the incision during placement. Over a period of ten years, the senior author reports a less than 1% development in capsular contracture using this technique and no implant fractures. These findings elucidate the importance of describing this alternative technique to other barriers currently on the market.

Transaxillary Nonendoscopic Subpectoral Augmentation Mammaplasty: A 10-Year Experience With Gel vs Saline in 2000 Patients-With Long-Term Patient Satisfaction Measured by the BREAST-Q.

BACKGROUND: Transaxillary augmentation mammaplasty (TAM) is an option for patients who wish to avoid a visible breast incision from breast augmentation (BA). OBJECTIVES: The authors compared TAM outcome data for gel and saline implants and evaluated patient satisfaction using the BREAST-Q patient-reported outcome measure (BQ). METHODS: In this 10-year retrospective, comparative, and cross-sectional study, the authors reviewed results of saline implants placed with TAM in a surgeon's practice during the final 5 years of the moratorium of the US Food and Drug Administration (phase 1) and compared them with results for gel and saline implants placed with TAM during the 5 years after the moratorium (phase 2). Outcomes were assessed for the entire BA study population (n = 2430 for primary BA; 4860 implants); 670 patients completed and returned the BQ, from which postoperative satisfaction was evaluated. RESULTS: BQ responses demonstrated a high rate of patient satisfaction, with outcomes comparable to those of other studies. The differences between the median BQ-assessed breast satisfaction and outcome satisfaction scores in the axillary and nonaxillary surgical groups were statistically significant, favoring axillary over nonaxillary. The difference in mean satisfaction scores was marginally significant between the 2 types of implants, favoring silicone gel. The incidence of surgical revision was 7.5% for the entire BA study population and 6.8% for the patients who underwent TAM. CONCLUSIONS: TAM produces long-term patient satisfaction as measured by the BQ. Complication rates are similar to those of other studies. In the present study, patients who underwent TAM and thus had hidden incisions were more satisfied than patients whose incisions were visible. LEVEL OF EVIDENCE: 3.

Successful Treatment of a Recalcitrant Mondor's Cord Following Breast Augmentation.

Mondor's disease, a superficial thrombophlebitis, is a common complication of thoracoabdominal wall surgeries. While most patients experience disease resolution with expectant management, occasionally the disease may persist. The authors present a case of a 49-year-old woman who had persistent, symptomatic Mondor's disease 15 months status post-breast augmentation. The patient responded rapidly to intralesional triamcinolone injections resulting in complete disease resolution. To the authors' knowledge, this is the first report of intralesional corticosteroids being used to treat this common surgical complication.

Current clinical practices of the Rhinoplasty Society members.

INTRODUCTION: As rhinoplasty remains among the most challenging and controversial operations in plastic surgery, we sought to elucidate present-day practice characteristics. Members of The Rhinoplasty Society were polled in preparation for the national meeting held in Boston, Mass, on May 2011. The goal was to provide information regarding surgical approaches used as well as technique and practice patterns used. METHODS: Two electronic surveys were distributed to members of The Rhinoplasty Society in preparation for the annual meeting. All 76 members received the surveys as well as instructions for completion. The initial survey included 10 questions discussing the preferred approach for rhinoplasty and practice details. The second survey dealt with specific techniques used during rhinoplasty. Data were collected and reviewed. RESULTS: The primary survey yielded a 61.8% response rate, whereas the secondary survey 48.7%. Of all surgeons, 72% reported doing the open approach for primary rhinoplasty more than 50% of the time, whereas the remaining 28% use the closed approach. For secondary rhinoplasty, 76% reported using the open approach in more than half of cases for which they were not the primary surgeons. In contrast, 53% used the closed approach in more than half the cases of secondary surgery if they were the initial surgeons. Revision rates for primary and secondary rhinoplasties were 9.1% and 7.8%, respectively. The difference was not statistically significant. On average, members performed 101 nasal surgeries per year. Previous patient recommendation was the most common reason for referral. Of the members, 54% reported using spreader grafts in more than half of the cases of aesthetic rhinoplasty and 75.7% when pertaining to functional rhinoplasty. Finally, 37.8% of responding members reported using tip grafts more than half the time when performing aesthetic rhinoplasty. CONCLUSIONS: Of the responding members of The Rhinoplasty Society, the open approach is the preferred choice for both primary and other surgeons' revision rhinoplasties. Spreader grafts are commonplace in both functional and aesthetic rhinoplasties.

Dual-plane breast augmentation for minimal ptosis pseudoptosis (the "in-between" patient).

BACKGROUND: Dual-plane breast augmentation (DPBA) can be an effective technique for treating patients with ptotic breasts who fall somewhere in between the traditional requirements for breast augmentation versus a more extensive augmentation-mastopexy. OBJECTIVES: The author outlines indications for DPBA, describes the technique, and presents outcomes data from patients receiving gel or saline implants in an effort to clarify the advantages of DPBA compared with breast augmentation with or without mastopexy. METHODS: This 8-year retrospective comparative study reviewed the results of saline implants placed with a DPBA technique in a single surgeon's practice during the final 4 years of the FDA moratorium (phase 1) compared with both gel and saline implants placed during the 4 years after the moratorium was lifted (phase 2). Patients were consecutive. The entire patient cohort (n = 1999 for primary BA; 3998 implants) was assessed for outcomes. RESULTS: Of the entire cohort, 24.2% were followed for over 1 year; 23.5% of the 256 DPBA patients were followed for over 1 year. Mean (SD) age was 33.6 (8.7) years. The difference in revision rates between BA versus DPBA was 4.6% (95% confidence interval [CI], 0.7-8.5). CONCLUSION: The DPBA approach is most likely suited for patients with minimal ptosis who fall into a "gray area" between normal anatomy (treated with a traditional BA) and frank ptosis (which would require mastopexy). Knowledge of this approach will allow surgeons to more effectively treat patients who present with unique "in-between" anatomy not addressed by ordinary BA and avoid more extensive mastopexy scars. LEVEL OF EVIDENCE: 3.

Orlando 2006: plastic surgeons rate the "Hot Topics".

During the "Hot Topics" seminar at The Aesthetic Meeting 2006, authors polled participants to gain insight into how plastic surgeons evaluate current hot topics. Here are the results as well as the authors' notes on additional presentations.

Waste not, want not: the use of AlloDerm in secondary rhinoplasty.

BACKGROUND: This article describes the author's successful experience with AlloDerm onlay grafts for the correction of nasal contour deformities in secondary rhinoplasty. AlloDerm is a cadaver dermal filler graft, an off-the-shelf product that is readily available, pliable, and affordable. It is particularly suited for secondary rhinoplasty patients who are graft-depleted. The maximum dorsal augmentation is less than or equal to 3 mm; it is not a support graft. The major indication in this study was dorsal augmentation in the overresected secondary rhinoplasty patient to create a soft, smooth bridge and pleasing dorsal aesthetic lines. METHODS: Twenty-five secondary rhinoplasty patients underwent multiple nasal corrections and were followed for 2 to 8 years. RESULTS: Analysis demonstrated no contour changes between year 1 and year 2, showing the dermal grafts to be stable after 1 year. Long-term follow-up for 2 years or longer showed good results, although partial graft resorption (defined to be < or = 50 percent) occurred in 45 percent of patients. Resorption was most common over the bony dorsum, with approximately 20 to 30 percent of the graft absorbing; over the tip, approximately 10 to 15 percent of the graft absorbed. CONCLUSION: Absorption did not seem to relate to the number of layers used. AlloDerm does not shift. Overall, the experience for nasal augmentation in secondary rhinoplasty was encouraging. Partial absorption, especially over the bony dorsum in a thin-skinned patient, is a definite disadvantage. Complete absorption was not seen in this study. The author has discovered that it is imperative to overcorrect the defect intraoperatively. Regrafting is possible and sometimes necessary.

Visible scars from percutaneous osteotomies.

BACKGROUND: One of the criticisms of the percutaneous lateral nasal osteotomy technique is the potential for unfavorable, visible scarring. No clinical study has compared the external percutaneous approach with an internal approach to evaluate scarring in the same patient. This prospective, randomized, blinded study was designed to test the hypothesis that percutaneous perforating osteotomies cause perceptible scars when compared with the transnasal internal lateral osteotomy methods. METHODS: Fifty consecutive rhinoplasty patients requiring bilateral osteotomies (100 total lateral osteotomies) were prospectively randomized (institutional review board no. 1341-1M) so that each patient received an external skin puncture perforating osteotomy on one side and an internal lateral osteotomy on the control side. The percutaneous skin puncture was made with the flat edge of the sharpened 2-mm unguarded osteotome. The puncture site was approximated with Steri-Strips as part of the postoperative nasal splint. All patients were evaluated for scarring on the left versus the right side of the face at 1, 3, and 6 weeks; 6 months; 1 year; and when possible up to 2 years after the operation. The median follow-up in this series is over 1 year. RESULTS: The external percutaneous approach caused a visible scar in three patients (6 percent) as noted by three blinded examiners. One of these patients (2 percent) required a scar revision. Care must be taken to cleanse the chisel before percutaneous entry. This practice should avoid a traumatic tattoo. CONCLUSION: Percutaneous osteotomies generally produce an imperceptible scar (94 percent) but may cause a visible scar in a small percentage of patients.

Decision and management algorithms to address patient and food and drug administration concerns regarding breast augmentation and implants.

During the U.S. Food and Drug Administration's advisory panel hearings to evaluate the premarket approval for conventional silicone gel implants on October 14 and 15, 2003, panel members and patient advocate representatives focused on four specific areas of concern: reoperation rates in primary breast augmentation; levels, depth, and methods of patient education and informed consent; modes, frequency, and management of silicone gel implant device failures, including management of "silent" ruptures; and methods of monitoring and managing symptoms or symptom complexes that may or may not be associated with connective tissue disease or other undefined symptom complexes. These concerns, with a reported 20 percent reoperation rate for primary augmentation within just 3 years, and a lack of concise, definitive management protocols addressing these areas of concern may have contributed to the Food and Drug Administration's rejection of the premarket approval, despite the panel's recommendation for approval. This article presents decision and management algorithms that have been used successfully for 7 years in a busy breast augmentation practice (Tebbetts and Tebbetts). The algorithms have been further expanded and refined by a group of surgeons with diverse experiences and expertise to address the following clinical situations that coincide with concerns expressed by patients and the Food and Drug Administration: implant size exchange, grade III to IV capsular contracture, infection, stretch deformities (implant bottoming or displacement), silent rupture of gel implants, and undefined symptom complexes (connective tissue disease or other). In one practice (Tebbetts and Tebbetts) that uses the TEPID system (tissue characteristics of the envelope, parenchyma, and implant and the dimensions and fill distribution dynamics of the implant), implant selection is based on quantified patient tissue characteristics, pocket selection is based on quantified soft-tissue coverage, and anatomic saline implants have fill volumes that are designed to minimize shell collapse and fold fatigue; in this practice, the algorithms contributed to a 3 percent overall reoperation rate in 1662 reported cases with up to 7 years of follow-up, compared with a 20 percent reoperation rate at 3 years in the 2003 premarket approval study.

Nasal osteotomies: a clinical comparison of the perforating methods versus the continuous technique.

Do perforating lateral osteotomies cause less ecchymosis and edema compared with the popular continuous method? Many studies have demonstrated that perforated osteotomies cause less trauma and periosteal disruption. Numerous investigators have subjectively perceived less postoperative ecchymosis and edema, but no clinical study has compared the perforated methods versus the continuous technique in the same patient. This prospective, randomized, partially blinded study was designed to test the hypothesis that the perforating method causes less postoperative ecchymosis and edema compared with the continuous lateral osteotomy technique. The questions remain: does the type of perforating osteotomy affect the results? Does a percutaneous approach cause more ecchymosis and edema by the access maneuver of piercing the skin? The two perforating lateral nasal osteotomy techniques require the same 2-mm straight osteotome, so any genuine difference in postoperative ecchymosis or edema could only be attributed to the differing surgical approaches. Accordingly, this study also tests whether the external percutaneous perforating osteotomy causes more ecchymosis and edema than the internal transnasal perforating method. Twenty-five consecutive rhinoplasty patients (group A) requiring bilateral osteotomies (50 total lateral osteotomies) were randomized so that each patient received an internal/transnasal perforating lateral osteotomy (2-mm straight chisel) on one side and an internal/transnasal continuous osteotomy (4-mm curved, guarded osteotome) on the other. The next 25 patients studied (group B) received an external/percutaneous perforating lateral osteotomy (same 2-mm straight chisel as used in group A) on one side and the same internal/transnasal continuous osteotomy on the other. The final 25 consecutive rhinoplasty patients (group C) received an external percutaneous perforating lateral osteotomy on one side and an internal transnasal perforating lateral osteotomy on the other. The entry sites for the perforating osteotomies were either external (groups B and C) with a percutaneous skin puncture or intranasal (groups A and C) at the pyriform aperture. All 75 patients (150 total lateral osteotomies) initialed the surgical plan on the Gunter rhinoplasty worksheet, which has been approved by the Institutional Review Board of Abbott-Northwestern Hospital, Minneapolis, Minnesota (study no. 1341-1 M). All patients were evaluated for ecchymosis and edema on the left versus the right side of the face at 2 to 3, 7, and 21 days after the operation. The clinical evaluation was performed by two blinded examiners (clinic registered nurse and the patient with his or her family) and a partially blinded examiner (the surgeon, who did not refresh his memory about the randomization). To compare the two methods in each study (groups A, B, and C) for the six outcomes (edema and ecchymosis at 2 to 3, 7, and 21 days), the authors used an exact binomial test of the null hypothesis that the treatments do not differ. To compare the two methods in each study (groups A, B, and C) using all six outcomes simultaneously, the authors used a permutation test. By both testing methods, the perforating internal method was superior to the continuous technique (group A; p < 0.01 in both tests). Although the perforating external method gave better results than the continuous technique (group B) and the perforating internal method gave better results than the perforating external method (group C), neither of these differences was significant by either testing method. A lateral osteotomy technique should be precise, reproducible, and safe, and it should minimize ecchymosis and edema. Since edema and ecchymosis are comparable regardless of osteotome size, this prospective randomized study confirms the subjective clinical impression that perforating lateral osteotomies with a 2-mm straight osteotome reduce postoperative ecchymosis and edema in rhinoplasty patients compared with the continuous osteotomy (4-mm curved, guarded osteotome). These findings should encourage te the use of perforating osteotomies rather than continuous osteotomies.

Submental suction-assisted lipectomy without platysmaplasty: pushing the (skin) envelope to avoid a face lift for unsuitable candidates.

Patients with submental fullness may not be candidates for a full or short-scar face lift because of medical contraindications, uncontrolled hypertension, a refractory nicotine habit, or anticoagulant medications, or patients may disqualify themselves because of cost, unavailable recovery time, or emotional resistance. Submental suction-assisted lipectomy has traditionally been reserved for younger patients. For older patients, suction-assisted lipectomy is typically used as an adjunct for face/neck lifts. This report describes experiences with suction-assisted lipectomy for older patients who were not face lift candidates, for the aforementioned reasons. The study goals were to better delineate the indications for submental suction-assisted lipectomy, as opposed to a face lift, and to obtain improved results with a less-invasive procedure. A 6-year study involving 132 patients (21 to 73 years of age), of whom 4.5 percent were men, was performed. Eighty-eight patients (67 percent), the primary focus of this study, were more than 40 years of age. Of those 88 patients, 24 patients (18 percent of the 132 patients in this series) were in their forties, 45 (34 percent) were in their fifties, 16 (12 percent) were in their sixties, and three (2.3 percent) were at least 70 years of age. The median follow-up time in this series was more than 1 year. The results were assessed with the five criteria for facial rejuvenation described by Ellenbogen and Karlin. All patients demonstrated improvement, with three to five of the Ellenbogen-Karlin neck rejuvenation criteria being met for each patient. All patients demonstrated an improved submandibular border, a more visible anterior sternocleidomastoid muscle border, and an improved neck angle (as determined with angle measurements). For many patients, all five of the Ellenbogen-Karlin criteria were met. A visible subhyoid depression and a visible thyroid cartilage bulge were the two criteria most often not met. A retrospective evaluation using Baker's preoperative classification of patient types for short-scar face lifts was performed. Results for patients more than 64 years of age (11 patients) were less satisfactory, often with redundant or crepe paper-like skin. Submental suction-assisted lipectomy, as opposed to a face lift, was observed to be a reasonable alternative for older patients who were unable or unwilling to undergo a face lift. Localized fullness in the midline was observed to be the best predictor of a good outcome (even better than age or skin tone). A crepe paper appearance of the skin preoperatively was the best predictor of failure. The surgical anatomical features, technique, advantages, disadvantages, and principles are discussed. Complications and their treatment are addressed. It is concluded that submental suction-assisted lipectomy alone, without platysmaplasty, can be helpful for patients with submental fullness who are unsuitable candidates for a face lift and who accept the limitations of liposuction without platysmaplasty. Suction-assisted lipectomy can sufficiently contract and smooth the skin envelope for selected patients, with less consideration for age than previously proposed.

Investigation of accolate and singulair for treatment of capsular contracture yields safety concerns.

At The Aesthetic Meeting 2002 of the American Society for Aesthetic Plastic Surgery, the Aesthetic Surgery Education and Research Foundation/Plastic Surgery Educational Foundation (ASERF/PSEF) Emerging Trends Task Force and Innovative Procedures Committee requested an update on zafirlukast (Accolate; AstraZeneca Pharmaceuticals, Wilmington, DE) and montelukast (Singulair; Merck & Co, West Point, PA) - what they are and how they work. These two asthma medications were reported to possibly treat and prevent capsular contracture after breast augmentation. On further analysis of postmarketing complications associated with zafirlukast based on information obtained through the Freedom of Information Act, it was discovered that between November 1, 1997, and October 31, 2002, 66 cases of hepatitis or liver failure in asthma patients occurred after a normal dose (13 of these 66 patients were taking no other medication). Two patients required liver transplants. Twenty-three deaths were reported (8 of these 23 patients were taking no other medication); 12 of these deaths followed liver failure. It should be noted that the Adverse Event Reporting System contains a disclaimer saying, "The reports have not been scientifically or otherwise verified as to a cause-and-effect relationship and cannot be used to estimate the incidence of adverse drug reactions." Many physicians entered the specific code to indicate zafirlukast as the "primary suspect" in the adverse event. Merck & Co reported no postmarketing cases of hepatitis or liver failure associated with montelukast. This article summarizes the proposed logic behind using these two asthma medications for the prevention and treatment of breast implant capsular contracture. (Aesthetic Surg J 2003;23:98-102.).

"Zigzag" wavy-line periareolar incision.

There is almost no mention of improvement in the aesthetics of areolar incisions in the plastic and reconstructive surgery literature. The most visible area of the breast is the central mound; therefore, it behooves surgeons to make an areolar incision as inconspicuous as possible. Minimal incision breast operations and short-scar operations, such as mastopexy and vertical reduction mammaplasty, use a circumareolar incision. This circumareolar technique, which specifically avoids a purse-string support suture, is useful in all periareolar incisions. This method creates a scar that mimics the elusive, natural irregularity between the areola and periareolar skin. The goal is to have an irregular, random, wavy line that appears more natural. Between August of 1998 and August of 1999, 104 "zigzag" wavy-line procedures were performed. The complications seen in this series included delayed healing in four patients and hypertrophic scar in two patients. No scars were surgically revised. The results demonstrated a definite difference compared to a circular scar. The zigzag wavy-line technique complements the innovative methods that shorten scars while they create a more natural, lasting breast mound. For areolar incisions, good results are deceptively subtle, but unnatural results can be painfully obvious. The zigzag wavy-line incision subtly eludes the eye in diminishing the signs the patient has undergone an operation.