Expanding horizons of reconstructive microsurgery in Lebanon: Reconstruction of complex traumatic wounds with anterolateral thigh perforator flaps in paediatrics patients less than 10 years of age.

Paediatric complex wounds pose a challenge to the reconstructive surgeon due to the intricacy of reconstructive options required. Developments in microsurgery and microsurgical technique have brought free tissue transfer ever closer to the comfort zone of the reconstructive surgeon for reconstruction of paediatric traumatic complex wounds. We present our experience of microsurgical reconstruction in Lebanon for complex traumatic wounds in paediatric patients under the age of 10 years using the free anterolateral thigh (ALT) flap. The ALT flap has proven its value as a safe, adaptable, and aesthetically acceptable reconstructive option in paediatric complex trauma.

Outcome Measurement of Beauty and Attractiveness of Facial Aesthetic Rejuvenation Surgery.

ABSTRACT: Aesthetic plastic surgery is a most unusual and unique subspecialty. Unlike other medical and surgical specialties driven primarily by objective medical diagnosis and outcome, aesthetic surgery is patient driven; it represents a special exercise in professional competence by adapting objective medical standards to a mostly subjective field. Given the subjectivity of facial beauty and of the projected aesthetic intervention outcome, in addition to be able to determine beauty of the final result as precisely and objectively as possible, it is also essential to be able to assess patient's satisfaction. However, lack of standardized facial measurements and clear definition of aesthetic outcome and beauty are still major obstacles preventing real change in the consultation dynamics to help better serve patients' expectations. Because of the tremendous increase in demand for all types of facial aesthetic procedures, an objective understanding of aesthetics and beauty is becoming of utmost importance. Recognition of the importance of science and evidence-based medicine is long overdue in our specialty. This study aims at identifying the most recently available evidence-based measures to quantitatively assess beauty and measure outcome of rhytidoplasty that can be useful in everyday aesthetic practice.

An Update on Facial Skin Rejuvenation Effectiveness of Mesotherapy EBM V.

ABSTRACT: Although it appears to be a simple, easy, and financially attractive therapeutic modality, skin rejuvenation mesotherapy is a controversial cosmetic procedure and proof of its efficacy is still lacking. The authors have published a review about this therapeutic modality more than a decade ago. Few clinical studies evaluating its efficacy and safety were available then without any conclusive scientific evidence about its efficacy; nevertheless, mesotherapy has continued to be performed at a relatively high financial cost to patients by many nonmedical and medical professionals for antiaging purposes. The authors have published a review about this therapeutic modality more than a decade ago. The current review is an update aimed at identifying any evidence about the scientific validity and efficacy of this approach that has emerged since then. No clinical valuable new data and new information has been identified. As by American Society of Plastic Surgeons (ASPS) policy statement updated and approved in 2019, mesotherapy for skin rejuvenation is currently not Food and Drug Administration approved. Until more conclusive data is available, skin rejuvenation mesotherapy cannot be recommended for routine skin rejuvenation clinical application.

Evidence-Based Efficacy of High-Intensity Focused Ultrasound (HIFU) in Aesthetic Body Contouring.

Being profitable procedures with little disposable costs, a number of noninvasive technologies have gained much popularity in recent years and are permeating the aesthetic marketplace. High-intensity focused ultrasound (HIFU) when focused at a targeted depth of 1.1 to 1.6 cm within subcutaneous tissue raises local tissue temperature at the focal point resulting in almost immediate cell death without damage to the surrounding tissues. Despite having gained popularity, little information is available regarding HIFU use for the treatment of localized fat and aesthetic body sculpturing. The current literature review is intended to investigate evidence-based efficacy of HIFU in aesthetic body contouring. LEVEL OF EVIDENCE IV: 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 .

Microneedling: Percutaneous Collagen Induction (PCI) Therapy for Management of Scars and Photoaged Skin-Scientific Evidence and Review of the Literature.

Demand for safe, less aggressive and cost-efficient treatment modality to improve skin quality and appearance following scarring or photoaging is increasing steadily. A treatment modality that preserves the epidermis while promoting regeneration rather than cicatrization would be ideal. Percutaneous collagen induction (PCI) therapy or microneedling is claimed to approach this ideal objective. The current comprehensive literature review is intended to analyze the scientific basis supporting this therapeutic modality and to evaluate the efficacy of PCI microneedling therapy versus no treatment of patients with photoaged skin and scars of various etiologies on aesthetic skin rejuvenation, skin tightening and scar quality in prospective, retrospective and experimental studies. Twenty-five published studies were identified and included in this review. Four publications are experimental animal studies; most clinical reports are case series or small cohort non-randomized studies or trials lacking methodological unity with a heterogenous mix of scars, wrinkles and skin laxity being treated. The majority are studies about management of scars of various etiologies while only 4 specifically investigated the effect of PCI on wrinkles and aging skin. One study compared burn scar erythema in the treated area to the untreated area, and 5 studies included histologic evaluation of biopsies. Despite PCI promising therapeutic benefits and its increasing cosmetic applications, the current literature review unfortunately revealed a limited number of high-quality studies mostly experimental. Data and conclusions of clinical studies must be carefully interpreted before translating the evidence presented into clinical recommendations. LEVEL OF EVIDENCE IV: 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 .

Social Media and Plastic Surgery Practice Building: A Thin Line Between Efficient Marketing, Professionalism, and Ethics.

Social media sites and platforms have grown in numbers with an enormous potential to reach and disseminate information in real time. They are impacting tremendously for better or for worse on the current practice of plastic surgery. As the demand for elective plastic surgery, in particular for aesthetic procedures, continues to rise, there is a need to determine the influence of social media advertisements and how it motivates the public to undergo cosmetic procedures. Most importantly, there is an urgent need to determine how the social media are impacting plastic surgery practice building and what is proper and efficient marketing while upholding ethics of the medical profession? A thorough PICO tool-based comprehensive literature search was conducted. Fifty-one peer-reviewed publications, 15 patient-centered, 33 provider-centered, and three combined patient/provider were identified to be relevant to the use of social media in plastic surgery and were selected for this review. Evidence on how social media influences the medical practice and helps in practice building remains scarce; nevertheless, reliance of plastic surgeons on social media to improve their practice has been increasing steadily. Social media may be a powerful tool to promote one's career. It presents, however, serious professional, legal, and ethical challenges including maintenance of professionalism and protecting patient confidentiality. If misused, it may be a quick way to end a plastic surgery practice.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 .

Percutaneous Thread Lift Facial Rejuvenation: Literature Review and Evidence-Based Analysis.

PURPOSE: Interest in noninvasive facial rejuvenation procedures continues to grow. With the advent of the so-called lunch-time face-lift, suture suspension facial rejuvenation has gained prominence and much popularity largely patient driven rather than data driven. We have published a decade ago a review about this rejuvenation technique. Despite its popularity at that time, serious long-term studies and peer-reviewed data about longevity and patient satisfaction were lacking to our surprise. As 10 years have passed, we have conducted a new systematic PubMed database search limited to the last 10 years interval. METHODS: The search identified 192 publications. After screening the titles and abstracts, 20 clinical and 2 experimental studies met the inclusion criteria and were selected for this review. RESULTS: Though thread lift facial rejuvenation is considered to be a promising modality, no new evidence has been added to the literature to support its use. CONCLUSION: Until evidence-based efficacy and robust data are objectively documented, patients requesting percutaneous facial rejuvenation must be well informed about adverse events, longevity of effect, and limited available data on efficacy. 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 .

Nonsurgical Management of Hypertrophic Scars: Evidence-Based Therapies, Standard Practices, and Emerging Methods.

Hypertrophic scars, resulting from alterations in the normal processes of cutaneous wound healing, are characterized by proliferation of dermal tissue with excessive deposition of fibroblast-derived extracellular matrix proteins, especially collagen, over long periods, and by persistent inflammation and fibrosis. Hypertrophic scars are among the most common and frustrating problems after injury. As current aesthetic surgical techniques become more standardized and results more predictable, a fine scar may be the demarcating line between acceptable and unacceptable aesthetic results. However, hypertrophic scars remain notoriously difficult to eradicate because of the high recurrence rates and the incidence of side effects associated with available treatment methods. This review explores the various treatment methods for hypertrophic scarring described in the literature including evidence-based therapies, standard practices, and emerging methods, attempting to distinguish those with clearly proven efficiency from anecdotal reports about therapies of doubtful benefits while trying to differentiate between prophylactic measures and actual treatment methods. Unfortunately, the distinction between hypertrophic scar treatments and keloid treatments is not obvious in most reports, making it difficult to assess the efficacy of hypertrophic scar treatment.

Cryolipolysis (CLL) for Reduction of Localized Subcutaneous Fat: Review of the Literature and an Evidence-Based Analysis.

INTRODUCTION: In recent years, cryolipolysis (CLL), a noninvasive approach based upon the inherent sensitivity of adipocytes to cold injury, has emerged. However, it is not clear whether available evidence to date about its efficacy justifies aggressive marketing and extensive widespread application by many practitioners without well-defined indications or objectives of treatment. The current review is intended to evaluate available evidence regarding CLL mechanisms of action and its efficacy not only in fat reducing but also in its ability to result in an aesthetically optimal outcome. MATERIALS AND METHODS: A systematic search of PubMed and Scopus computerized medical bibliographic database was conducted with the search terms "cryolipolysis," "lipocryolysis," and "cool sculpting." Selection criteria included all matched reports with the search terms in their titles. RESULTS: Thirty-two reports matched the inclusion criteria of this review. Five experimental studies were identified and included to further supplement the discussion. CONCLUSION: Most reports about CLL included in this review lacked rigorous scientific methodology in study design or in outcome measurement. Serious concerns about integrity of many of these reports, particularly with respect to validity of photographic outcome documentation in addition to objectivity, conflict of interest issues, and commercial bias, have been expressed. Further research should be encouraged to prove with methodological rigor positive effects of this treatment modality and to determine categories of patients in whom most favorable outcomes might be expected. 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 .

Aesthetic/Cosmetic Surgery and Ethical Challenges.

Is aesthetic surgery a business guided by market structures aimed primarily at material gain and profit or a surgical intervention intended to benefit patients and an integral part of the health-care system? Is it a frivolous subspecialty or does it provide a real and much needed service to a wide range of patients? At present, cosmetic surgery is passing through an identity crisis as well as an acute ethical dilemma. A closer look from an ethical viewpoint makes clear that the doctor who offers aesthetic interventions faces many serious ethical problems which have to do with the identity of the surgeon as a healer. Aesthetic surgery that works only according to market categories runs the risk of losing the view for the real need of patients and will be nothing else than a part of a beauty industry which has the only aim to sell something, not to help people. Such an aesthetic surgery is losing sight of real values and makes profit from the ideology of a society that serves only vanity, youthfulness, and personal success. Unfortunately, some colleagues brag that they chose the plastic surgery specialty just to become rich aesthetic surgeons, using marketing tactics to promote their practice. This is, at present, the image we project. As rightly proposed, going back a little to Hippocrates, to the basics of being a physician, is urgently warranted! Being a physician is all that a ''cosmetic'' surgeon should be. In the long run, how one skillfully and ethically practices the art of plastic surgery will always speak louder than any words.