Incorporating barbed sutures in abdominoplasty.

Barbed sutures can be used in body contouring procedures to close long incisions better than conventional sutures. The results of a literature review focusing on the use of barbed sutures in abdominal contouring procedures suggest that they are safe and effective in wound closure with complication rates similar to conventional sutures but with possibly faster incision-closure times. An update on one author's (K.A.G.) personal experience with barbed progressive tension sutures in abdominoplasty procedures is presented, along with practical technique recommendations for barbed suture use.

International interdisciplinary rhytidectomy survey.

Facial rhytidectomy is a complex and multi-faceted operation performed by different methodologies between practitioners. This study elucidates current international trends in facelift surgery, including patient selection, operative technique, and postoperative care. A 43-item questionnaire was sent electronically to 7247 members of the following societies: ASPS, ISAPS, CSPS, IFFPS, and the AAFPRS. The survey focused on 3 main areas: (a) background information, (b) intraoperative technique, and (c) postoperative care. The response rate was 11.4%. The majority of our population was from the United States (US) (73%). Most (85%) of the respondents have practices where over 50% of their procedures are considered aesthetic surgery. Statistical differences between the uses of minimally invasive adjuvant treatments (thread lifts, endotine mid-face devices, superficial and deep skin resurfacing procedures) were found between plastic surgeons (PS) and facial plastic surgeons (FPS), as well as between US, Canadian, and international surgeons. Suture imbrication (42%) was the most common way of handling the submuscular aponeurotic system. International surgeons were more likely (49.6% vs. 37.7%, P < 0.05) to use this technique than US or Canadian surgeons. Difference in handling patients who smoke and postoperative management differences were also found between the groups queried. No differences were found between FPS and PS in the handling of the submuscular aponeurotic system, treatment of platysmal bands, treatment of ptotic submandibular glands, or treatment of submental fat deposits (P > 0.05). Differences exist between FPS and PS, and between US, Canadian, and international surgeons with regard to facelift techniques and perioperative management. These differences need to be addressed in order to measure outcomes across specialties and between techniques. This data will additionally be helpful for less experienced and younger surgeons who wish to define best practice patterns.

Abdominoplasty with progressive tension closure using a barbed suture technique.

BACKGROUND: Seroma and skin necrosis are potential complications following abdominoplasty. Many methods have been employed to prevent these complications, including the progressive tension suture technique. OBJECTIVE: The authors evaluate a progressive tension suture technique modification using the Quill barbed suture (Angiotech Pharmaceuticals, Inc., Vancouver, British Columbia, Canada) to determine whether the original benefits of this classic technique can be obtained in a shorter operative period. METHODS: The modified progressive tension closure technique with Quill sutures uses barbed sutures to plicate the abdominoplasty flap to the underlying abdominal wall. The placement of the suture is performed with a running suture technique and provides progressive tension, resulting in minimal tension along the incision line. Data from 58 patients undergoing abdominoplasty using this technique are examined, including time to insert the sutures and complications such as seroma, hematoma, and skin necrosis. RESULTS: There was a marked reduction in the time necessary to perform the modified progressive tension suture technique using barbed sutures compared to previously published data. The authors' average time was nine minutes to complete plication of the entire abdominal flap. One seroma is reported, which was resolved with one aspiration. No hematomas or skin necrosis complications are reported. CONCLUSIONS: Using barbed sutures to perform progressive tension suture closure in abdominoplasty is a safe and effective way to considerably reduce operative time and retain all of the benefits of the original progressive tension suture technique.

Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty.

Objective Rhinoplasty, a surgical procedure that alters the shape or appearance of the nose while preserving or enhancing the nasal airway, ranks among the most commonly performed cosmetic procedures in the United States, with >200,000 procedures reported in 2014. While it is difficult to calculate the exact economic burden incurred by rhinoplasty patients following surgery with or without complications, the average rhinoplasty procedure typically exceeds $4000. The costs incurred due to complications, infections, or revision surgery may include the cost of long-term antibiotics, hospitalization, or lost revenue from hours/days of missed work. The resultant psychological impact of rhinoplasty can also be significant. Furthermore, the health care burden from psychological pressures of nasal deformities/aesthetic shortcomings, surgical infections, surgical pain, side effects from antibiotics, and nasal packing materials must also be considered for these patients. Prior to this guideline, limited literature existed on standard care considerations for pre- and postsurgical management and for standard surgical practice to ensure optimal outcomes for patients undergoing rhinoplasty. The impetus for this guideline is to utilize current evidence-based medicine practices and data to build unanimity regarding the peri- and postoperative strategies to maximize patient safety and to optimize surgical results for patients. Purpose The primary purpose of this guideline is to provide evidence-based recommendations for clinicians who either perform rhinoplasty or are involved in the care of a rhinoplasty candidate, as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The target audience is any clinician or individual, in any setting, involved in the management of these patients. The target patient population is all patients aged ≥15 years. The guideline is intended to focus on knowledge gaps, practice variations, and clinical concerns associated with this surgical procedure; it is not intended to be a comprehensive reference for improving nasal form and function after rhinoplasty. Recommendations in this guideline concerning education and counseling to the patient are also intended to include the caregiver if the patient is <18 years of age. Action Statements The Guideline Development Group made the following recommendations: (1) Clinicians should ask all patients seeking rhinoplasty about their motivations for surgery and their expectations for outcomes, should provide feedback on whether those expectations are a realistic goal of surgery, and should document this discussion in the medical record. (2) Clinicians should assess rhinoplasty candidates for comorbid conditions that could modify or contraindicate surgery, including obstructive sleep apnea, body dysmorphic disorder, bleeding disorders, or chronic use of topical vasoconstrictive intranasal drugs. (3) The surgeon, or the surgeon's designee, should evaluate the rhinoplasty candidate for nasal airway obstruction during the preoperative assessment. (4) The surgeon, or the surgeon's designee, should educate rhinoplasty candidates regarding what to expect after surgery, how surgery might affect the ability to breathe through the nose, potential complications of surgery, and the possible need for future nasal surgery. (5) The clinician, or the clinician's designee, should counsel rhinoplasty candidates with documented obstructive sleep apnea about the impact of surgery on nasal airway obstruction and how obstructive sleep apnea might affect perioperative management. (6) The surgeon, or the surgeon's designee, should educate rhinoplasty patients before surgery about strategies to manage discomfort after surgery. (7) Clinicians should document patients' satisfaction with their nasal appearance and with their nasal function at a minimum of 12 months after rhinoplasty. The Guideline Development Group made recommendations against certain actions: (1) When a surgeon, or the surgeon's designee, chooses to administer perioperative antibiotics for rhinoplasty, he or she should not routinely prescribe antibiotic therapy for a duration >24 hours after surgery. (2) Surgeons should not routinely place packing in the nasal cavity of rhinoplasty patients (with or without septoplasty) at the conclusion of surgery. The panel group made the following statement an option: (1) The surgeon, or the surgeon's designee, may administer perioperative systemic steroids to the rhinoplasty patient.

Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty Executive Summary.

Objective Rhinoplasty, a surgical procedure that alters the shape or appearance of the nose while preserving or enhancing the nasal airway, ranks among the most commonly performed cosmetic procedures in the United States, with >200,000 procedures reported in 2014. While it is difficult to calculate the exact economic burden incurred by rhinoplasty patients following surgery with or without complications, the average rhinoplasty procedure typically exceeds $4000. The costs incurred due to complications, infections, or revision surgery may include the cost of long-term antibiotics, hospitalization, or lost revenue from hours/days of missed work. The resultant psychological impact of rhinoplasty can also be significant. Furthermore, the health care burden from psychological pressures of nasal deformities/aesthetic shortcomings, surgical infections, surgical pain, side effects from antibiotics, and nasal packing materials must also be considered for these patients. Prior to this guideline, limited literature existed on standard care considerations for pre- and postsurgical management and for standard surgical practice to ensure optimal outcomes for patients undergoing rhinoplasty. The impetus for this guideline is to utilize current evidence-based medicine practices and data to build unanimity regarding the peri- and postoperative strategies to maximize patient safety and to optimize surgical results for patients. Purpose The primary purpose of this guideline executive summary is to provide evidence-based recommendations for clinicians who either perform rhinoplasty or are involved in the care of a rhinoplasty candidate, as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The target audience is any clinician or individual, in any setting, involved in the management of these patients. The target patient population is all patients aged ≥15 years. The guideline is intended to focus on knowledge gaps, practice variations, and clinical concerns associated with this surgical procedure; it is not intended to be a comprehensive reference for improving nasal form and function after rhinoplasty. Recommendations in this guideline concerning education and counseling to the patient are intended to include the caregiver if the patient is <18 years of age. Action Statements The Guideline Development Group made the following recommendations: (1) Clinicians should ask all patients seeking rhinoplasty about their motivations for surgery and their expectations for outcomes, should provide feedback on whether those expectations are a realistic goal of surgery, and should document this discussion in the medical record. (2) Clinicians should assess rhinoplasty candidates for comorbid conditions that could modify or contraindicate surgery, including obstructive sleep apnea, body dysmorphic disorder, bleeding disorders, or chronic use of topical vasoconstrictive intranasal drugs. (3) The surgeon, or the surgeon's designee, should evaluate the rhinoplasty candidate for nasal airway obstruction during the preoperative assessment. (4) The surgeon, or the surgeon's designee, should educate rhinoplasty candidates regarding what to expect after surgery, how surgery might affect the ability to breathe through the nose, potential complications of surgery, and the possible need for future nasal surgery. (5) The clinician, or the clinician's designee, should counsel rhinoplasty candidates with documented obstructive sleep apnea about the impact of surgery on nasal airway obstruction and how obstructive sleep apnea might affect perioperative management. (6) The surgeon, or the surgeon's designee, should educate rhinoplasty patients before surgery about strategies to manage discomfort after surgery. (7) Clinicians should document patient satisfaction with their nasal appearance and with their nasal function at a minimum of 12 months after rhinoplasty. The guideline development group made recommendations against certain actions: (1) When a surgeon, or the surgeon's designee, chooses to administer perioperative antibiotics for rhinoplasty, he or she should not routinely prescribe antibiotic therapy for a duration >24 hours after surgery. (2) Surgeons should not routinely place packing in the nasal cavity of rhinoplasty patients (with or without septoplasty) at the conclusion of surgery. The panel group made the following statement an option: (1) The surgeon, or the surgeon's designee, may administer perioperative systemic steroids to the rhinoplasty patient.

Perceived age change after aesthetic facial surgical procedures quantifying outcomes of aging face surgery.

OBJECTIVE: To quantify the degree of perceived age change after aesthetic facial surgical procedures to provide an objective measure of surgical success. METHODS: Sixty patients undergoing various aging face surgical procedures were randomly chosen for analysis. Preoperative and postoperative photographs were evaluated. Raters were presented with photographs in a random assortment and were asked to estimate the age of the patient. Perceived age difference was defined as the difference between the chronological age and the estimated age, and the change in this value after surgery was the chief outcome of interest. Statistical models were designed to account for any effects of interrater differences, preoperative chronological age, rater group, photograph order, or surgical procedure performed. RESULTS: Our patient population was divided into the following 3 groups based on the surgical procedure performed: group 1 (face- and neck-lift [22 patients]), group 2 (face- and neck-lift and upper and lower blepharoplasty [17 patients]), and group 3 (face- and neck-lift, upper and lower blepharoplasty, and forehead-lift [21 patients]). Adjusted means demonstrated that patient ages were estimated to be 1.7 years younger than their chronological age before surgery and 8.9 years younger than their chronological age after surgery. The effect was less substantial for group 1 patients and was most dramatic for group 3 patients, who had undergone all 3 aging face surgical procedures. CONCLUSIONS: Our study is novel in that it quantifies the degree of perceived age change after aging face surgical procedures and demonstrates a significant and consistent reduction in perceived age after aesthetic facial surgery. This effect is more substantial when the number of surgical procedures is increased, an effect unrelated to the preoperative age of a patient and unaffected by other variables that we investigated. The ability to perceive age correctly is accurate and consistent.

Have we expanded the equitable delivery of postmastectomy breast reconstruction in the new millennium? Evidence from the national cancer data base.

BACKGROUND: Studies examining patterns of cancer care before 2000 have shown underuse of postmastectomy breast reconstruction as well as racial and socioeconomic disparities in its delivery. These findings prompted legislation designed to broaden use at the turn of the millennium. However, little is known about trends in these findings over the past decade. STUDY DESIGN: Patients who underwent mastectomy for stage 0 to III breast cancer between 1998 and 2007 (n = 452,903) were studied using the National Cancer Data Base to evaluate trends in the receipt of immediate and early delayed breast reconstruction. Those who underwent mastectomy between 1998 and 2000 (n = 150,177) and between 2005 and 2007 (n = 123,518) were compared using logistic regression to identify factors influencing the use of breast reconstruction and how they changed over time. RESULTS: The use of postmastectomy breast reconstruction increased from 13% to 26% from 1998 to 2007. This increase was statistically significant in almost all patient subsets. Independent factors associated with breast reconstruction included age less than 50 years old; higher census-derived household income; private or managed care insurance; non-African American race; and treatment in an academic hospital setting. Treatment in an academic hospital and higher income became stronger predictors of breast reconstruction over the study period, while age became less of a predictor. CONCLUSIONS: Although the use of breast reconstruction has increased from 1998 to 2007, it is still underused among many patient populations. Furthermore, racial and socioeconomic disparities in its delivery have persisted or widened. Additional effort is necessary to broaden the use of breast reconstruction and to ensure equitable access to it.

Alar soft-tissue techniques in rhinoplasty: algorithmic approach, quantifiable guidelines, and scar outcomes from a single surgeon experience.

OBJECTIVES: To describe various techniques, including alar base reduction, alar flaring reduction, and alar hooding reduction and present a decision-making treatment algorithm and quantifiable guidelines for soft-tissue excision, along with scar outcomes from a single-surgeon practice. The soft tissue of the nasal tip, ala, and nostrils is important in overall nasal tip dynamics. Excisional alar contouring is an essential part of many successful cosmetic rhinoplasty outcomes. METHODS: The various soft-tissue excision techniques are described in detail and an algorithm is provided. Quantitative analysis of excision parameters was performed using statistical analysis. Finally, qualitative scar analysis was performed and scar outcomes were statistically derived. RESULTS: Seventy-four patients were female and 26 were male. Of the procedures reviewed, 47% involved alar soft-tissue excision. Alar base reduction was performed in 46 patients (46%). Alar flare reduction was performed in 16 patients (16%). Alar hooding reduction was performed in 2 patients (2%). Mean scar outcome scores ranged from 0.55 to 0.69. CONCLUSIONS: Alar soft-tissue techniques are often necessary to achieve a balanced outcome and superior results when performing rhinoplasty surgery. Therefore, they should be an integral part of every rhinoplasty evaluation and surgical plan as indicated.

National bariatric surgery and massive weight loss body contouring survey.

BACKGROUND: As bariatric surgery has become more popular, plastic surgeons have seen increases in post-bariatric surgery body contouring procedures. The aim of the authors' survey was to better understand perspectives of bariatric surgeons toward body contouring procedures and referral patterns to plastic surgeons. METHODS: A questionnaire was sent to 500 surgeon members of the American Society for Metabolic and Bariatric Surgery. Questions focused on bariatric surgery practices, perspectives toward massive weight loss body contouring, and referral patterns. One hundred eighty-eight surveys were analyzed. RESULTS: Sixty-four percent of surgeons surveyed reported that patients ask about body contouring procedures before bariatric procedures. Only 54 percent reported routine counseling on the potential functional and aesthetic consequences of bariatric surgery. Ninety-six percent of bariatric surgeons have access to plastic surgeons, but only 7 percent of bariatric surgeons always refer their patients to a plastic surgeon and 33 percent rarely refer to a plastic surgeon. Fifty-one percent of surgeons report that patients who have undergone body contouring procedures are overall more satisfied with their decision to undergo bariatric surgery versus bariatric patients who have not had body contouring. Seventy-five percent of surgeons reported that patients rarely express any concern regarding their decision to undergo plastic surgery. CONCLUSIONS: Bariatric surgery requires multispecialty care from bariatric and plastic surgeons. Results and outcomes can be improved with body contouring procedures, especially with regard to better self-image, self-confidence, and satisfaction. However, there are deficiencies in pre-bariatric surgery counseling regarding outcomes and discussions of body contouring procedures. Therefore, better methods of referrals to plastic surgeons need to be identified.

Surgical improvement of the aging forehead and eyelids.

Periocular reconstruction is limited to the upper lid, lower lid, and brow. Although many of the same principles apply as in other facial rejuvenation procedures, special techniques are involved frequently using microsurgical procedures. Although the majority of oculoplastic procedures are done for cosmetic purposes, occasionally patients with extreme distortion in periorbital anatomy may benefit from this procedure. These include patients with profound ptosis and severe cases of lower lid distortion who have visual compromise.