Safety and Efficacy of Renuvion Helium Plasma to Improve the Appearance of Loose Skin in the Neck and Submental Region.

BACKGROUND: Minimally invasive procedures that deliver thermal energy to subcutaneous tissue offer a solution when deciding between excisional and noninvasive options to address face and neck aging-related changes. A minimally invasive helium plasma device, Renuvion, was first utilized for subdermal tissue heating to reduce skin laxity under an FDA general clearance for cutting, coagulation, and ablation of soft tissue. OBJECTIVES: The purpose of this study was to demonstrate the safety and effectiveness of the helium plasma device for improving the appearance of loose skin in the neck and submental region. METHODS: Patients undergoing the procedure with the helium plasma device in the neck and submentum were studied. They were seen for 6 months following the procedure. The primary effectiveness endpoint for improvement in lax skin in the treatment area was determined by 2 of 3 blinded photographic reviewers. The primary safety endpoint was the level of pain after treatment. RESULTS: The primary effectiveness endpoint was met; 82.5% demonstrated improvement at Day 180. The primary safety endpoint was met; 96.9% of patients experienced no pain to moderate pain to Day 7. There were no serious adverse events reported related to the study device or procedure. CONCLUSIONS: The data demonstrate benefit to patients by improvement of the appearance of lax skin in the neck and submental region. Outcomes resulted in US Food and Drug Administration 510(k) clearance in July 2022, expanding indications for the device to include subcutaneous dermatological and aesthetic procedures to improve the appearance of loose skin in the neck and submental region.

The Effect of Obesity, Bariatric Surgery, and Operative Time on Abdominal Body Contouring Outcomes.

BACKGROUND: Abdominal body contouring procedures are associated with the highest rates of complications among all aesthetic procedures. Patient selection and optimization of surgical variables are crucial in reducing morbidity and complications. OBJECTIVES: The purpose of this single-institution study was to assess complication rates, and to evaluate BMI, operative time, and history of bariatric surgery as individual risk factors in abdominal body contouring surgery. METHODS: A retrospective chart review was performed of all patients who underwent abdominoplasty, circumferential lower body lift, fleur-de-lis panniculectomy (FDL), and circumferential FDL between August 2014 and February 2020. Endpoints were the incidence of venous thromboembolism, bleeding events, seroma, infection, wound complications, and reoperations. Univariate statistical analysis and multivariate logistic regressions were performed. Covariates in the multivariate logistic regression were BMI, procedure time, and history of bariatric surgery. RESULTS: A total of 632 patients were included in the study. Univariate analysis revealed that longer procedure time was associated with infection (P = 0.0008), seroma (P = 0.002), necrosis/dehiscence (P = 0.01), and reoperation (P = 0.002). These associations persisted following multivariate analyses. There was a trend toward history of bariatric surgery being associated with minor reoperation (P = 0.054). No significant increase in the incidence of major reoperation was found in association with overweight or obese patient habitus, history of bariatric surgery, or prolonged procedure time. BMI was not found to be an individual risk factor for morbidity in this patient population. CONCLUSIONS: In abdominal body contouring surgery, surgery lasting longer than 6 hours is associated with higher incidence of seroma and infectious complications, as well as higher rates of minor reoperation.

Safety of Rivaroxaban for Postoperative Venous Thromboembolism Prophylaxis Following Abdominal Body Contouring Surgery: 600 Patients.

BACKGROUND: Reducing the incidence of venous thromboembolism (VTE) following abdominal body contouring surgery remains a top priority for patient safety. There is a lack of consensus regarding the optimal chemoprophylactic agent for postoperative VTE prophylaxis, and the role of oral anticoagulants warrants further investigation. OBJECTIVES: The aim of this multisurgeon, single-institution study was to determine the safety and efficacy of a 7-day postoperative rivaroxaban regimen for VTE prophylaxis in abdominal body contouring surgery. METHODS: A retrospective chart review was performed of all patients who underwent abdominoplasty, circumferential body lift, fleur-de-lis panniculectomy, or circumferential fleur-de-lis panniculectomy at our surgical center from August 2014 to November 2019. A 7-day postoperative course of once-daily 10 mg rivaroxaban, starting on postoperative day 1, was administered to every patient unless there was a contraindication. The 2 primary endpoints were the incidence of VTE and bleeding events. RESULTS: A total of 600 patients were included in the study. There were no deaths. There were 4 (0.7%) incidents of VTE events: 2 (0.3%) patients suffered pulmonary embolus and 2 (0.3%) patients suffered a lower-extremity deep venous thrombosis. A total of 13 (2.2%) patients suffered complications related to bleeding. Of these, operative intervention for control and evacuation was required in 7 (1.2%) patients. CONCLUSIONS: A 7-day postoperative course of once-daily rivaroxaban for VTE risk reduction in abdominal body contouring surgery is associated with a low incidence of VTE events and a low risk of bleeding complications.

Avulsion Fat Graft Gluteoplasty: Technique Overview.

BACKGROUND: The popularity of gluteoplasty has grown significantly in recent years, and there are a variety of techniques described to address gluteal aesthetic deformities. The aim of this study was to describe the avulsion fat graft gluteoplasty technique. METHODS: A review of all consecutive patients undergone avulsion fat graft gluteoplasty from February 2018 to March 2019 was performed. Data included demographics, operative details, and clinical outcomes. RESULTS: A total of 7 patients with a minimum of 6 months follow-up were analyzed and included in the study. The avulsion fat graft gluteoplasty technique is described in a step-by-step fashion and illustrated by preoperative, postoperative, and intraoperative photographs, as well as video. The average total weight of the avulsed specimen was 372 g (range, 176-596 g) per patient. The average total volume of fat grafting was 593 mL (range, 344-900 mL) per patient. CONCLUSIONS: The avulsion fat graft gluteoplasty is a powerful technique with consistent results and low-risk profile. It provides durable lift and augmentation and produces a predictable and aesthetic scar.

Four-Position Four-Entry Site Circumferential Arm Liposuction: Technique Overview and Experience.

BACKGROUND: In attempting to overcome the challenges associated with arm contouring, arm liposuction has been an area of focus in recent years. In appropriately selected patients, circumferential liposuction is the procedure of choice. The objective of this study is to describe our experience with the four-position four-entry site circumferential arm liposuction technique. METHODS: All consecutive circumferential liposuction procedures that took place at our ambulatory surgical facility from January 2015 to November 2019 were retrospectively reviewed. The four-position four-entry site circumferential arm liposuction technique is described, and photographs as well as videos are presented. RESULTS: A total of 35 patients underwent circumferential bilateral arm liposuction via the four-position four-entry site technique. All patients were female, and their average age was 43 years. The average BMI was 28.4 kg/m2, and the average follow-up was 481 days. The average volume of lipoaspirate was 1,514 ml per patient, and the average volume of aspirated fat was 1,052 ml per patient. There was no incident of infection, seroma, bleeding event or venous thromboembolism. CONCLUSIONS: For the right candidate, the four-entry site four-position circumferential arm liposuction is an efficient and reproducible technique, which produces predictable and pleasing results. 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 .

A Multicenter, Prospective, Randomized, Contralateral Study of Tissue Liquefaction Liposuction vs Suction-Assisted Liposuction.

BACKGROUND: Tissue liquefaction liposuction (TLL) deploys a novel energy source utilizing a stream of warmed, low-pressurized, and pulsed saline to extract fat tissue. OBJECTIVES: Compare TLL to suction-assisted liposuction (SAL) to determine which device is more efficient for surgeons and provides better recovery for patients. METHODS: Thirty-one adult female patients were followed prospectively in a contralateral study design comparing differences in bruising, swelling, tenderness, and incision appearance ratings between TLL and SAL procedures. Surgical efficiency and appearance of the lipoaspirate were also compared. RESULTS: All 31 patients successfully completed the study. For TLL and SAL procedures, the average volumes of infusion (1.242 vs 1.276 L) and aspirated supernatant fat (704 vs 649 mL) were statistically similar. TLL median fat extraction rate was faster than SAL (35.6 vs 25 mL/min; P < 0.0001), and stroke rate was reduced in TLL vs SAL procedures (48 vs 120 strokes/min; P < 0.0001), and both were statistically significant. The mean total scores for bruising, swelling, treatment site tenderness, and incision appearance were lower, indicating improved patient recovery on the TLL side. CONCLUSIONS: TLL and SAL techniques produced comparable volume of fat aspirate. TLL demonstrated a 42% faster fat extraction rate and a 68% reduction in arm movements needed to complete the procedure compared to SAL, both of these differences are statistically significant. The TLL side was noted to have reduced bruising and swelling and improved incision site appearance with less tenderness compared to the SAL side.

Long-Term Outcomes of Pediatric Cranial Reconstruction Using Resorbable Plating Systems for the Treatment of Craniosynostosis.

BACKGROUND: Resorbable plating in cranial reconstruction for craniosynostosis has fewer reported complications than rigid hardware. Few long-term outcome studies exist for pediatric patients treated with this technology for cranial vault reconstruction. METHODS: A retrospective review was performed on pediatric patients undergoing cranial vault reconstruction for craniosynostosis by 3 surgeons over a 15-year period. MacroPore (Cytori Therapeutics, San Diego, CA) or Lactosorb (Walter Lorenz Surgical Inc, Jacksonville, FL), composed of polyglycolic and polylactic acids, was used for resorbable plate fixation. RESULTS: A total of 203 patients underwent resorbable plate fixation with a mean age of 15.8 months at surgery. Mean length of follow-up was 6.4 years. Lactosorb plating system was used in the majority of patients (74%) compared with MacroPore plating system (26%). Overall, unplanned reoperations were required in 5.4% of patients. Palpable hardware was noticed in 10.3% of patients. Only 3 patients (1.5%) developed exposure of the resorbable hardware requiring removal, all MacroPore plates. Four patients (2%) developed surgical site infection and 3 patients (1.5%) developed a seroma. There were 15.8% requiring later surgical revision with cranial vault expansion or cranioplasty with grafts for residual cranial defects. The majority of revisional reoperations (81%) occurred in the first half of the study before the addition of Allogenix. CONCLUSIONS: Resorbable plating systems, specifically Lactosorb, for cranial reconstruction are a safe, reproducible, inexpensive modality with very low complication rates. They have 3-dimensional stability, rigid fixation without causing growth restriction, and lower likelihood of need for removal.

Expansion of Renuvion Application to Areas Beyond the Submental Region: Review and Experience.

Background: Minimally invasive and consistent skin redraping following liposuction remains an elusive goal. With the application of Renuvion (Apyx Medical, Clearwater, FL), helium induced cold atmospheric plasma provides coagulation, collagen contraction, and subsequent skin tightening, making this elusive goal attainable. Objectives: The objective of this study is to evaluate energy settings, and the safety profile of Renuvion in an effort to achieve optimal cosmesis through the improvement of skin laxity. Methods: A retrospective review at a single site evaluated cases of Renuvion between March 2020 and May 2022. Energy settings, use of concomitant VASER (Solta Medical, Bothwell, WA) liposuction frequency, and adverse events were analyzed. Results: In total, 180 patients were evaluated, of whom 135 (75%) underwent concomitant VASER liposuction. Renuvion was used on the abdomen (47.8%), thighs (45.6%), arms (27.2%), submental region (25%), hip rolls (21.2%), and back (19.4%). Among the entire cohort, there were a total of 24 (13.3%) complications. The complications consisted of 3 (12.5%) hematomas, 1 (4.2%) burn, 6 (25%) persistent skin laxity with 2 returned operating room (OR) treatments, 4 (16.7%) seromas, 9 (37.5%) postoperative lymphedema that self-resolved, and 1 (4.2%) self-limited neuralgia. There were no complications that required an immediate return to the OR. Conclusions: Renuvion utilization with or without VASER has a relatively high complication rate-with minor complications as the most common-relatively safe barring proper patient selection, which can be mitigated with proper patient selection.

Factors affecting complications in radiated breast reconstruction.

INTRODUCTION: Breast irradiation in combination with breast reconstruction is associated with increased complications. Because of the diminishing threshold for radiotherapy, breast reconstruction irradiation is rising. Our aim was to evaluate factors affecting outcomes in irradiated breast reconstructions. METHODS: A review of consecutive patients who underwent mastectomy, radiation, and breast reconstruction was conducted. Patient demographics, operative procedure, breast irradiation timing, and postoperative complications were collected. RESULTS: One hundred fifty-four patients (157 breast reconstructions) were included with a mean follow-up of 6 years. Average age at reconstruction was 50 years. One hundred nine cases were immediate and 48 cases were delayed. Sixty-eight cases were autologous reconstructions and 89 cases were implant-based. Thirty-seven cases used acellular dermal matrices (ADMs); 60% of cases were radiated before reconstruction and 40% were radiated afterward. Major complications occurred in 43% of patients and minor complications occurred in 17%. The presence of ADM led to an increase in complication rate with a 2.3-fold greater chance of requiring reoperation (P = 0.03). No significant difference in complication rates was associated with presence of hypertension, diabetes, smoking, elevated body mass index, autologous versus implant-based reconstructions, delayed versus immediate reconstructions, and time between radiation and reconstruction. CONCLUSIONS: Radiation after prosthetic reconstruction may produce an increase in failure rates. The use of ADMs in the face of breast irradiation increases the likelihood of a complication requiring reoperation.

Minimizing donor-site morbidity following bilateral pedicled TRAM breast reconstruction with the double mesh fold over technique.

INTRODUCTION: Transverse rectus abdominus muscle flaps (TRAM) can result in significant abdominal wall donor-site morbidity. We present our experience with bilateral pedicle TRAM breast reconstruction using a double-layered polypropylene mesh fold over technique to repair the rectus fascia. METHODS: A retrospective study was performed that included patients with bilateral pedicle TRAM breast reconstruction and abdominal reconstruction using a double-layered polypropylene mesh fold over technique. RESULTS: Thirty-five patients met the study criteria with a mean age of 49 years old and mean follow-up of 7.4 years. There were no instances of abdominal hernia and only 2 cases (5.7%) of abdominal bulge. Other abdominal complications included partial umbilical necrosis (14.3%), seroma (11.4%), partial wound dehiscence (8.6%), abdominal weakness (5.7%), abdominal laxity (2.9%), and hematoma (2.9%). CONCLUSIONS: The TRAM flap is a reliable option for bilateral autologous breast reconstruction. Using the double mesh repair of the abdominal wall can reduce instances of an abdominal bulge and hernia.

Outcome analysis of 541 women undergoing breast conservation therapy.

Breast conservation therapy (BCT) has evolved as a favorable approach to the management of early-stage breast cancer. Shortcomings of BCT include the potential need for re-excision in the event of positive tumor margins as well as the untoward sequelae of radiation therapy. Both of those factors have led to a substantial proportion of patients undergoing BCT who ultimately report suboptimal aesthetic outcomes. Application of plastic surgery principles to the management of this patient subset has been shown to be beneficial from both an oncologic and cosmetic perspective.The aim of this study was to identify factors that may predict which patients would benefit most from involvement of a plastic surgeon before BCT. A retrospective analysis was performed on 762 patients undergoing lumpectomy during a 10-year study period at a single institution. Younger women and patients with tumor size approaching 2 cm were noted to have a significantly higher likelihood of oncologic outcomes that ultimately required breast reconstruction. Integration of oncoplastic techniques in the surgical management of patients undergoing BCT would likely contribute to improvement in aesthetic outcomes and overall patient satisfaction.

Combination non-invasive radiofrequency and electrical muscle stimulation: A synergistic combination for body contouring.

INTRODUCTION: Patients desiring noninvasive body contouring increasing require a more comprehensive approach to soft tissue laxity, muscle, and adipose hypertrophy. Previous devices have typically focused on only adipose reduction, without impact on muscle or skin laxity. This study describes the first use of noninvasive bipolar radiofrequency in combination with electromagnetic muscle stimulation. METHODS: This study was an IRB-approved study conducted at four sites (TN, TX, PA, NC). In all, 38 patients completed the three-treatment regimen of combined non-invasive bipolar RF and EMS. Efficacy of the Transform (InMode, Lake Forest, CA) treatment was assessed by numerous outcomes including sequential caliper measurements, circumference measurements, comfort during treatment, subject satisfaction, ultrasound measurements, blinded pictures evaluation, and histology. RESULTS: The combination of non-invasive bipolar RF with EMS was found to be safe and efficacious. The three-treatment regimen was statistically efficacious as it related to (1) subject satisfaction, (2) 1 mm ultrasound, (3) 2 mm ultrasound, (4) average of 1 and 2 mm ultrasound, (5) caliper 1 measurements, (6) caliper 2 measurements, (7) average of caliper 1 and 2 measurements, (8) subject comfort, (9) widest circumference measure, (10) 2-inches above circumference measure, (11) 2-inches below circumference measure, (12) average circumference measure, and finally, (13) blinded evaluator photograph agreement. CONCLUSION: The combination of noninvasive bipolar radiofrequency and electrical muscle stimulation is a safe and effective method for treatment of skin laxity, adipose hypertrophy, and muscle.

Roundtable Discussion: Making Sense of Current Liposuction Technologies.

Suction-assisted lipectomy (or "liposuction") is a fundamental technique for all plastic surgeons, and like many procedures in aesthetic surgery, its applications are continuing to evolve. With the rapid introduction of new technologies, many plastic surgeons are left with questions about how these new devices work, what results to expect, and how to best apply these technologies in their practice. We recognized that there is a need for unbiased recommendations to guide surgeons on how to approach current liposuction devices (as well as their adjuncts) and how to use them effectively for their patients. Using available literature and personal experience, we answer the most common questions that we hear from our plastic surgery colleagues.

Incidence of vitreous loss and visual outcome following cataract surgery by surgeons with various levels of experience at a tertiary eye care center in North India.

Purpose: To determine the incidence of vitreous loss and visual outcome after a vitreous loss during cataract surgery performed by surgeons with various levels of experience in adults >40 years of age at a tertiary eye care center in North India. Methods: The study was conducted at a tertiary eye care center in North India. This was an observational, retrospective, cross-sectional study of patients who underwent cataract surgery from August 1, 2011 to July 31, 2014. All adult cataract cases who were operated on from August 1, 2011 to July 31, 2014 and who experienced vitreous loss during their surgery were included in the study. The visual outcomes of these patients who experienced vitreous loss during cataract surgery in uncomplicated cataract and were managed using standard automated vitrectomy techniques were assessed for different cataract surgical techniques (extracapsular, small-incision, and phacoemulsification) as well as at different levels of skill of the operative surgeon (consultant, short term fellow, and long-term fellow). Details of the postoperative period and best-corrected visual acuity (BCVA) were collected from patient records by the principal investigator on day 1, 1 week, 4 weeks, 6 weeks, and 3 months post cataract surgery. Results: Vitreous loss occurred in 374 out of 18,430 patients who underwent cataract surgery from August 1, 2011 to July 31, 2014. The overall incidence of vitreous loss in our study was found to be 2.03% with consultants having a rate of 1.66%, short-term fellows at 5.19%, and long-term fellows at 2.02%. Two hundred eighty-eight patients of the 374 cases followed up for 3 months at the hospital and 75.69% of these patients had a final visual acuity of ≥6/18. Conclusion: In an institute with a structured training program for residents/trainees, the vitreous loss rate is low during cataract surgery. Early intervention and proper management with the standard microsurgical technique by experienced hands can improve the final visual outcome in eyes with vitreous loss. Cystoid macular edema and corneal edema were the most common causes of poor postoperative vision.

Congenital pyriform aperture stenosis.

Neonates rely on the nasal airway for their source of air; thus, any compromise in the ability to inhale will dramatically alter their ability to breathe. Congenital nasal pyriform aperture stenosis is a rare yet serious form of airway obstruction due to overgrowth of the maxilla at the medial nasal process. Infants typically present with difficulty feeding and obvious difficulty breathing. Radiologic imaging aids in confirming the diagnosis and assists in operative planning to open the medial nasal process to reduce airway resistance. Further corrective surgery is often needed and is planned commensurate with facial growth. We present a novel case of a child diagnosed with congenital nasal pyriform aperture stenosis who has performed extraordinarily well intellectually and has achieved an excellent cosmetic and physiological reconstruction of the nose and airway.

Aplasia cutis congenita: clinical management of a rare congenital anomaly.

BACKGROUND: Aplasia cutis congenita (ACC) is a rare congenital disorder characterized by absence of skin and adjacent tissue that usually affects the scalp, but any part of the body may be affected. Although ACC is more often superficial and small, it can be large and involve the underlying structures such as skull and dura, thus increasing the risk of hemorrhage, infection, and mortality. Controversy exists regarding nonsurgical versus surgical intervention for this condition. This study reviews indications and modalities for treatment of this rare congenital anomaly. RESULTS: Management of this anomaly depends on size, location, and structures at risk. Small lesions with intact underlying structures and lesions affecting extremities are treated in a conservative fashion with dressings and ointments followed by delayed scar excision. Aplasia cutis congenita scar excision often requires complex tissue rearrangement, tissue expansion, or skin grafting. Larger ACC lesions or lesions with exposure of vital structures require early surgical intervention. Initially, exposed vital structures and bony ridges can be protected using conservative measures. Delayed definitive repair can then be performed using scalp flaps, split- and full-thickness skin grafts, cultured epithelial autografts, delayed split rib cranioplasty, tissue expansion, and composite cranioplasty. CONCLUSIONS: Aplasia cutis congenita should be individually evaluated based on size, depth, location, and tissues involved. Using conservative and surgical modalities, one can achieve complete closure of the defect, thus avoiding risks of infection, hemorrhage, and further trauma.