High-Definition Liposculpture: What are the Complications and How to Manage Them?

BACKGROUND: High-definition liposculpture is a novel surgical technique widely accepted among plastic surgeons. The aim of this article is to describe surgical outcomes with a special emphasis on complications in high-definition liposculpture patients. METHODS: An historical cohort of patients who underwent high-definition liposculpture from two senior surgeons was reviewed. Technique, patient selection criteria, preoperative marks and surgical outcomes are described. Postoperative complications are discussed. RESULTS: A total of 417 patients underwent high-definition liposculpture between 2015 and 2018. Primary liposuction and secondary liposuction were performed in 308 (74%) and 109 (26%), respectively. Combined surgeries were performed in 121 cases (29%). There were no systemic complications. Local complications included hyperpigmentation (n = 276), seroma (n = 125), nodular fibrosis (n = 83), unsatisfactory definition in superficial liposuction areas (n = 16), unnatural appearance of body contour (n = 17), VASER-related burns (n = 3) and Mondor's syndrome (n = 2). Most patients (94%) were satisfied with the results. CONCLUSION: High-definition liposculpture is a body contouring technique that has shown excellent results. Despite non-serious complications were frequent, most complications were local and safely treated without affecting surgical outcome. To know these complications will help to recognize them earlier and to adjust patient expectation about the postoperative period. 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.

Is Banning Texturized Implants to Prevent Breast Implant-Associated Anaplastic Large Cell Lymphoma a Rational Decision? A Meta-Analysis and Cost-Effectiveness Study.

BACKGROUND: Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is an emergent disease that threatens patients with texturized breast implants. Major concerns about the safety of these implants are leading to global changes to restrict the utilization of this product. The principal alternative is to perform breast augmentation utilizing smooth implants, given the lack of association with BIA-ALCL. The implications and costs of this intervention are unknown. OBJECTIVES: The authors of this study determined the cost-effectiveness of smooth implants compared with texturized implants for breast augmentation surgery. METHODS: A tree decision model was utilized to analyze the cost-effectiveness. Model input parameters were derived from published sources. The capsular contracture (CC) rate was calculated from a meta-analysis. Effectiveness measures were life years, avoided BIA-ALCL, avoided deaths, and avoided reoperations. A sensitivity analysis was performed to test the robustness of the model. RESULTS: For avoided BIA-ALCL, the incremental cost was $18,562,003 for smooth implants over texturized implants. The incremental cost-effectiveness ratio was negative for life years, and avoided death and avoided reoperations were negative. The sensitivity analysis revealed that to avoid 1 case of BIA-ALCL, the utilization of smooth implants would be cost-effective for a risk of developing BIA-ALCL equal to or greater than 1:196, and there is a probability of CC with smooth implants equal to or less than 0.096. CONCLUSIONS: The utilization of smooth implants to prevent BIA-ALCL is not cost-effective. Banning texturized implants to prevent BIA-ALCL may involve additional consequences, which should be considered in light of higher CC rates and more reoperations associated with smooth implants than with texturized implants.

Winged Ribs: An Underestimated Problem That May Compromise Breast Augmentation Outcomes.

Chest wall shape is an important aspect to consider when planning a breast augmentation. Minor chest wall deformities are usually underestimated by the patient and surgeon and may compromise postoperative outcomes. Lower costal cartilage dysmorphia or winged rib is one of these minor underestimated chest wall deformities characterized by a visible and palpable cartilaginous prominence under the inframammary fold and causes discomfort in patients decreasing the satisfaction with the breast augmentation surgery. For these patients, the author utilized an innovative surgical technique that allows resection of the protruding cartilages and placement of breast implants through the same surgical incision. Six patients with winged ribs underwent breast augmentation and costal cartilage resection via this method and there were no intraoperative or early postoperative complications, and all patients were satisfied with the aesthetical result after 6 months of follow-up. The presented surgical technique has a short learning curve with excellent postoperative results. Cases are presented to demonstrate the improved postoperative chest wall contour combined with breast augmentation outcome.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 .

Long-Term Quality-of-Life Outcomes After Body Contouring Surgery: Phase IV Results for the Body-QoL® Cohort.

BACKGROUND: Body contouring surgery (BCS) is becoming increasing popular for aesthetic and reconstructive purposes, particularly among patients with massive weight loss (MWL). However, data on quality of life (QoL) following the surgery are limited, especially long-term QoL. OBJECTIVES: The authors evaluated the effect of BCS on QoL and the durability of this effect over time. METHODS: QoL was measured with the Body-QoL® instrument at 3 time points among consecutively treated patients: the day before BCS, 1 to 9 months postoperatively (short term), and 1 to 2.7 years postoperatively (long term). Total Body-QoL scores were compiled, as were scores for the instrument's main domains: body satisfaction, sex life, self-esteem and social performance, and physical symptoms. Scores were examined for the entire study population and separately for the cosmetic and MWL cohorts. RESULTS: Fifty-seven of the 112 patients participated in the short-term assessment and 84 in the long-term assessment. Total Body-QoL scores increased significantly (P < 0.0001), from 44.0 ± 14.1 preoperatively to 85.5 ± 17.5 short-term postoperatively and to 84.4 ± 12.7 long-term postoperatively. Scores for the 2 postoperative assessments did not differ significantly. Similar results were observed for scores on each separate domain. Although preoperative scores were lower for the MWL cohort than the cosmetic cohort (33.9 ± 15.6 vs 46.1 ± 12.8; P = 0.0002), they improved substantially after BCS, approaching scores for the cosmetic cohort. CONCLUSIONS: QoL increases significantly after BCS. This favorable outcome remained stable throughout long-term follow-up and was true for the cosmetic and MWL cohorts.

Reliability of Nasofacial Analysis Using Rhinobase® Software.

OBJECTIVE: Rhinoplasty is a constant challenge for the surgeon, where the correct evaluation of facial aesthetic parameters allows harmonic changes appropriate for each patient. The aim of this study was to compare the preoperative and postoperative results of nasofacial analysis, performed by Rhinobase® software (indirect anthropometry) compared with direct anthropometry (caliper), in patients undergoing aesthetic rhinoplasty. METHODS: The authors assessed the reliability of using Rhinobase® software for measuring nasofacial characteristics in 20 individuals (18 F, 2 M). In each patient, the nasofacial analysis was performed before and after surgery. Two raters performed indirect anthropometry on each image on two separate occasions. RESULTS: Intrarater and interrater reliability for most indirect anthropometric measurements had intraclass correlation coefficients greater than 0.8. Regarding intermethod reliability, Pearson correlation coefficients ranged from 0.6 to 0.9 for most measurements. The highest correlation was found in interalar width, chin vertical, and lower facial height. The Cronbach's α coefficient calculated for all measurements was 0.8. CONCLUSIONS: The Rhinobase® software is an easy and safe method for facial analysis. This study provides evidence of high reliability for several nasofacial measurements. The nasofacial analysis allows an accurate preoperative evaluation, surgical planning, and analysis of outcomes in rhinoplasty and may be a useful tool for both novice and experienced surgeons. 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.

Introducing the Body-QoL®: A New Patient-Reported Outcome Instrument for Measuring Body Satisfaction-Related Quality of Life in Aesthetic and Post-bariatric Body Contouring Patients.

OBJECTIVE: To develop a new patient-reported outcome instrument (PRO) to measure body-related satisfaction quality of life (QoL). METHODS: Standard 3-phase PRO design was followed; in the first phase, a qualitative design was used in 45 patients to develop a conceptual framework and to create preliminary scale domains and items. In phase 2, large-scale population testing on 1340 subjects was performed to reduce items and domains. In phase 3, final testing of the developed instrument on 34 patients was performed. Statistics used include Factor, RASCH, and multivariate regression analysis. Psychometric properties measured were internal reliability, item-rest, item-test, and test-retest correlations. RESULTS: The PRO-developed instrument is composed of four domains (satisfaction with the abdomen, sex life, self-esteem and social life, and physical symptoms) and 20 items in total. The score can range from 20 (worst) to 100 (best). Responsiveness was 100 %, internal reliability 93.3 %, and test-retest concordance 97.7 %. Body image-related QoL was superior in men than women (p < 0.001) and decreased with increasing age (p = 0.004) and BMI (p < 0.001). Post-bariatric body contouring patients score lower than cosmetic patients in all domains of the Body-QoL instrument (p < 0.001). After surgery, the score improves by on average 21.9 ± 16.9 (effect size 1.8, p < 0.001). CONCLUSIONS: Body satisfaction-related QoL can be measured reliably with the Body-QoL instrument. It can be used to quantify the improvement in cosmetic and post-bariatric patients including non- or minimally invasive procedures, suction assisted lipectomy, abdominoplasty, lipoabdominoplasty, and lower body lift and to give an evidence-based approach to standard practice. LEVEL OF EVIDENCE I: 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.

The Body-QoL(®): patient reported outcomes in body contouring surgery patients [corrected].

BACKGROUND: This study aimed to design a new patient-reported outcome (PRO) instrument to measure patient satisfaction after body-contouring procedures such as liposculpture, abdominoplasty, body-lift, thigh-lift, and arm-lift. METHODS: Phase 1a involved an extensive literature review, 16 in-depth patient interviews, and expert focus groups with 5 plastic surgeons to develop a conceptual framework for the outcomes deemed important for body image and preliminary PRO instruments. In phase 1b, the preliminary instrument was tested with a second independent sample of 29 patients with whom simple interviews were additionally performed. In the second sample, scale reliability was calculated. RESULTS: In phase 1a, the domains identified for the conceptual framework included clothing and body image, sexual and affective life, self-image and self-esteem, social relationships, and physical symptoms. In phase 1b, the scale internal consistency was 91.5 %. CONCLUSIONS: When psychometric evaluation is completed, the Body-Shape-Related Quality of Life instrument and its subscales will provide a reliable tool for plastic surgeons, researchers, and patients to use in measuring the impact and effectiveness of body-contouring procedures from the patient's perspective. 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 . This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-B.

Intraoperative Fluoroscopy Reduces Complication and Reoperation Rate in Facial Fractures.

Purpose: The purpose of this study is to evaluate surgical outcomes of facial fractures after the introduction of intraoperative radiology. Methods: An historic cohort of patients without intraoperative fluoroscopy (IOF) was compared with a prospective cohort of patients with IOF. Main outcomes were postoperative complications and reoperation rate. Results: There were 51 in the non-IOF group and 49 in the IOF group. In the group with IOF 10 patients required intraoperative revisions (20.46%). Overall postoperative complication rate was higher in the non-IOF group (25.49% vs. 6.12%) due to the significantly higher bone-related complication rate (15.69% vs. 2.04%). Reoperation rate was also higher in the non-IOF group (11.76% vs. 0%). Conclusion: This study demonstrates that IOF reduces bone-related complication and reoperation rate by allowing correction of surgical errors immediately during surgery.

[Acute compartment syndrome as a complication of cutaneous loxoscelism mainly edematous]. / Síndrome compartimental agudo como complicación de un loxoscelismo cutáneo edematoso.

Acute compartment syndrome (ACS) is the increase of pressure in a closed osteofascial space. This reduces capillary perfusion below the level necessary for tissue viability. Injury could be irreversible if proper treatment is not performed. Hand ACS secondary to cutaneous loxoscelism with edematous predominance is extremely infrequent. We present a clinical case of a 22-year-old patient who started a hand compartment syndrome secondary to cutaneous loxoscelism (CL), requiring emergency surgical treatment with dorsal and palmar fasciotomy.

Degrees of tolerance in post-traumatic orbital volume correction: the role of prefabricated mesh.

PURPOSE: To identify factors influencing the volumetric correction of orbital fractures, and evaluate the use of prefabricated titanium mesh in their repair. MATERIALS AND METHODS: We included patients with unilateral orbital fractures and floor or medial-wall defects, subsequently reconstructed with titanium mesh, and subject to adequate follow-up with multislice, digitalized computed tomography (CT) images. Medical records were reviewed, and demographics, operative details, and postoperative course were recorded as prognostic variables. Moreover, orbital volume, apex-to-globe distance, and orbital rim area were measured using postoperative CT. Univariate analysis and a multiple-regression model were used to identify associated factors. RESULTS: A total of 32 patients fulfilled the inclusion criteria. Postoperative clinical evaluation and CT images were obtained in a mean +/- SD of 12.3 +/- 7.2 months after surgery. Clinically, 20 patients were considered normal (63%), and 12 manifested some ocular dystopia (37%). On postoperative CT, the mesh was in good position in 44% of cases, and in an insufficient position in 56% of cases. There was a significant difference between fractured and normal orbits in relation to orbital volume and apex-globe distance. Clinical evaluation significantly correlated with CT mesh placement, but there was no correlation between clinical evaluation and any of the variables measured on CT. The most important factors influencing postoperative orbital volume correction were type of fracture, affected walls, and use of prefabricated mesh. CONCLUSION: Volumetric and lineal symmetry between fractured and normal orbits are very difficult to achieve. In this study, postoperative CT measurements did not correlate with subjective clinical assessment. The clinical-radiological disagreement may be explained by measurement accuracy problems, clinical bias, or normal differences between orbits. The most important identified modifiable factor was the use of prefabricated mesh.

Indications and outcomes of double free flaps in head and neck reconstruction.

OBJECTIVE: This study describes the clinical setting and operative outcomes for simultaneous double free flap treatment of extensive composite head and neck cancers. METHODS: A retrospective review at two tertiary referral centers was performed. Patient demographics, cancer characteristics, reconstruction methods, and postoperative course were recorded. All patients were assessed for diet, speech, esthetics, socialization, and satisfaction using specific evaluation scales. RESULTS: A total of 30 patients underwent double free flap reconstruction between 2001 and 2007. There were 19 men and 11 women, mean age of 62 years (range, 42-79). Comorbidities were present in 67% of the cases and 70% smoked. Most frequently the cancer was a squamous cell carcinoma (90%), in advanced stage (87%), and recurrent (67%), affecting the oral cavity (43%), larynx (23%) or pharynx (20%). The fibula osteoseptocutaneous/radial forearm fasciocutaneous flap combination was most commonly used (n = 13), followed by the jejunum-radial forearm flap (n = 10). Three flaps required early anastomosis revision and only two partial flap losses were observed. In 11 cases, there was a severe recipient site complication: wound dehiscence (n = 3), oral incompetence (n = 4), fistula (n = 2), and stenosis (n = 2). Two patients died in the postoperative period due to medical problems (7%). The mean follow up was 15.3 months. Patient satisfaction was poor to moderate and the overall functional evaluation score was low. CONCLUSIONS: Double free flaps for one-stage reconstruction of extensive head and neck defects should be used in selected cases. Although a reliable procedure, immediate postoperative morbidity and mortality is high, and the long-term functional and esthetic results are modest. Realistic outcomes should be discussed with patients during planning and consent.

Safety profile of wire osteosynthesis in craniosynostosis surgery.

With the advent of resorbable systems, most surgeons have stopped using wires for craniofacial fixation. Although numerous large retrospective reports regarding craniofacial surgery have been published, no documentation exists regarding the disadvantages or complications associated with wires. We review our experience with 47 consecutive patients with bicoronal and unicoronal craniosynostosis where wire osteosynthesis alone was used. Nine patients (19.1%) developed wire-related complications, but only 5 patients (10.6%) required reoperations. No other complications were observed including growth restrictions, implant migration, or interference with radiographic imaging. These results are comparable to those reported in the literature for other fixation systems and demonstrate that wires are a safe means of fixation of the cranial vault in infancy.

A Five-Year Retrospective Cohort Study Analyzing Factors Influencing Complications after Nasal Trauma.

The purpose of this study was to assess the outcomes of patients with nasal trauma during a long period of time and determine factors predisposing to complications after nasal trauma treatment. A retrospective cohort study was conducted that included all patients who were attended for a nasal trauma between January and December 2010. In 2015, the charts were retrospectively reviewed and the patients were prospectively followed up looking for outcomes after treatment of nasal trauma. A univariate analysis between complications and risk factors was performed and a logistic regression model was used to explore the prognostic role of the variables considered to have clinical relevance and to estimate the odds ratio for the occurrence of postoperative complications. A total of 220 consecutive patients with nasal trauma were included in the study. The mean follow-up was 44.3 ± 10.3 months (3-67) with 10% of lost patients. The most important factors determining complications after nasal trauma treatment were male gender, acute septal injury, chronic septal deviation, displaced or comminuted fractures in the radiologic study, and late nasal reduction surgery. A decision-making algorithm is proposed based on the fact that nasal bone fracture is not a minor problem and that closed nasal bone reduction is not the treatment of choice for all patients with nasal trauma.

IL-10 and IL-4 in skin allograft survival induced by T-cell depletion plus deoxyspergualin.

The mechanisms mediating T-cell depletion plus 15-deoxyspergualin (DSG)-induced prolonged allograft survival or tolerance are uncertain. The purpose of this study is to evaluate the role of IL-4 and IL-10 in prolonged allograft survival induced by T-cell depletion plus DSG. MHC mismatched skin allograft transplantation was performed, using wild-type and three separate knockout (i.e., IL-4-/-, Stat6-/-, or IL-1-/ -) mice as recipients. Induction therapy consisted of T-cell depletion and or brief course of DSG. The data demonstrate that monotherapy with T-cell-depleting mAbs or DSG prolonged skin allograft survival, compared to controls, in wild-type Balb/c recipients [median survival time (MST) = 25 and 21 vs. 10 days, p < 0.007]. T-cell depletion plus DSG further augmented skin allograft survival in wild-type animals relative to monotherapy (MST = 35 days vs. 25 and 21 days, p < 0.006 vs. mAbs or DSG only), and was equally effective in IL-4-/- and Stat6-/- recipients. In contrast, combined therapy was no better than monotherapy in IL-10-/- animals (p > 0.05). Furthermore, skin allograft survival after combined therapy was shorter in IL-10-/- versus wild-type recipients (MST 20 and 41 days, respectively, p < 0.001). IL-4-mediated signaling through Stat6 is dispensable for prolonged allograft survival induced by T-cell depletion plus DSG. In contrast, IL-10 appears to be important for prolonged allograft survival induced by combined therapy in this model.

Open repair of ventral incisional hernias.

Despite advances in many fields of surgery, incisional hernias still remain a significant problem. There is a lack of general consensus among surgeons regarding optimal treatment. A surgeon's approach is often based on tradition rather than clinical evidence. The surgeon's treatment plan should be comprehensive, with attention focused not merely on restoration of structural continuity. An understanding of the structural and functional anatomy of the abdominal wall and an appreciation of the importance of restoring dynamic function are necessary for the successful reconstruction of the abdominal wall.

Ischemic complications in pedicle, free, and muscle sparing transverse rectus abdominis myocutaneous flaps for breast reconstruction.

Muscle sparing and perforator flaps techniques for breast reconstruction have focused in reducing the donor site morbidity. Theoretically this may result in a less robust blood supply to the flap. The purpose of this study was to assess flap ischemic complications with the pedicle, free, and the different muscle sparing transverse rectus abdominis myocutaneous (TRAMs) flaps for breast reconstruction and determine the factors associated with these complications. A total of 301 consecutive patients that underwent 399 breast reconstructions were retrospectively reviewed. Patient, oncologic, and reconstruction data were recorded. A flap ischemic complication scale was design including: wound healing problems, skin flap necrosis, fat necrosis, partial flap loss, and total flap loss. Analysis of donor site complications, bilateral and unilateral reconstructions were also performed. There were 147 pedicle TRAM and 154 free TRAM with the following subgroup distribution: MS-0 = 102; MS-1 = 37; and MS-2 = 15 patients. The groups were comparable in relation to age, comorbidities, cancer stage, and treatment. The overall complication rate after reconstruction had no statistical differences between the groups. The variables related to flap ischemia were statistically lower in the free TRAM. Mild and severe fat necrosis were the indicators with a statistical difference. The MS-0 group had lower ischemic complications and fat necrosis than the pedicled group, but no differences were observed for the MS-1 and MS-2 groups. The same results were seen in the unilateral reconstructions but not in the bilateral ones. No differences in donor site bulging or hernia were observed between the groups. In our study, the free TRAM flap demonstrated lower ischemic complications than the pedicle TRAM. A trend for decreased flap blood supply when more muscle is preserved and less number of perforators are used with a constant tissue volume was observed.

Areola-nipple perception threshold to faradic electricity: a new measure of sensibility of the breasts.

BACKGROUND: We describe a new method to study the sensibility of the nipple-areola complex of the breast with faradic electricity delivered through an electromyographic device used to monitor peripheral nerve conduction. METHODS: The objective results of faradic pulses (2-50 mA per pulse) delivered to the nipple-areola complex of the breast through a Nihon-Kohden II machine (Evoked potential/Electromyographs, Nihon-Kohden Co., Japan) were evaluated in normal volunteers to get a basal measure that was defined by the patient as "a soft electric discharge." The measures were recorded and their output discharges averaged (at least 5 to each complex). RESULTS: Twenty-eight volunteers with normal breasts, 28 patients with breast hypertrophy before and after breast reduction, and 28 patients before and after breast augmentation were studied. The faradic pulses were perceived from 1.5 to 3.5 mA in the areola and from 3 to 5.5 mA in the nipple in the control group and from 4.5 to 7.0 mA in the areola and from 6.5 to 9.5 mA in the nipple in the breast hypertrophy group with no significant changes before and after surgery. In the breast augmentation group the faradic pulses were very similar to the volunteers that had normal breasts, but 13 months after breast augmentation with silicone gel prosthesis, a difference was found because all the patients had a higher threshold and three cases had lost sensibility of the nipple-areola complex. CONCLUSION: In normal breasts the areola had a lower threshold for faradic pulses compared to the nipple. Hypertrophic breasts had a higher threshold to the faradic stimulation than normal subjects in the pre- and postoperative period. Hypoplastic breasts before breast augmentation had a perception threshold similar to that of the normal volunteers but after breast augmentation this perception was much higher.

Characterization of the orbital volume in normal population.

INTRODUCTION: The aim of the study was to describe the normal orbital volume and its most important relationships with other clinical variables. METHODS: We designed a correlation study and consecutive normal CTs scans were included. Orbital volume and facial anthropometrics were measured and correlated between them. Two independent and blind observers made all the measurements. Uni and multivariate statistical analysis were performed in order to create a predicting model for orbital volume. RESULTS: A total of 199 consecutive patients were included in the study (398 orbits). The mean Orbital Volume (OV) was 24.5 ± 3.08 cc. Adequate intra and interobserver reliability was observed. There were no differences between the right and left orbit (p=0.73). The male average OV was 24.9 ± 3.03 cc, the female OV was 23.9 ± 3.08 cc. Age group analysis demonstrated a slow increase in OV beyond thirty years, but these differences were not significant (p=0.98). Only the age, total facial height, facial width and the interorbital distance were significant and were included in the predictive model of OV. CONCLUSION: We have characterized the normal orbital volume,variations and associations. In order to further advance in the understanding of the clinical implications the abnormal orbital volume must be fully studied.