The Innovation Press: A Primer on the Anatomy of Digital Design in Plastic Surgery.

ABSTRACT: Three-dimensional (3D) printing continues to revolutionize the field of plastic surgery, allowing surgeons to adapt to the needs of individual patients and innovate, plan, or refine operative techniques. The utility of this manufacturing modality spans from surgical planning, medical education, and effective patient communication to tissue engineering and device prototyping and has valuable implications in every facet of plastic surgery. Three-dimensional printing is more accessible than ever to the surgical community, regardless of previous background in engineering or biotechnology. As such, the onus falls on the surgeon-innovator to have a functional understanding of the fundamental pipeline and processes in actualizing such innovation. We review the broad range of reported uses for 3D printing in plastic surgery, the process from conceptualization to production, and the considerations a physician must make when using 3D printing for clinical applications. We additionally discuss the role of computer-assisted design and manufacturing and virtual and augmented reality, as well as the ability to digitally modify devices using this software. Finally, a discussion of 3D printing logistics, printer types, and materials is included. With innovation and problem solving comprising key tenets of plastic surgery, 3D printing can be a vital tool in the surgeon's intellectual and digital arsenal to span the gap between concept and reality.

Maximizing the Virtual Surgical Planning Session for Orthognathic Surgery.

Virtual surgical planning (VSP) and computer-aided design/computer-aided manufacturing have become essential tools for planning orthognathic surgery. Despite widespread use, empirical gaps still exist in the literature regarding the logistics of the orthognathic planning session itself. More precisely, there is a need to explicate the VSP workflow on which specific parameters are needed for a translation into 3D software. Although each surgeon has his/her theoretical framework, none have been elucidated to properly communicate the necessary pieces of information needed to plan the correction of a variety of dentofacial deformities. The authors provide an outline for conducting a successful VSP planning session for orthognathic surgery.

A Novel Approach to Preventing Temporal Hollowing Using Virtual Surgical Planning and Suture Suspension of the Temporalis Muscle.

Cranioplasty is a well-described technique used to restore the contour and function of calvarial defects using various alloplastic implants and autologous bone grafts. However, unsatisfactory esthetic outcomes after cranioplasty are frequently reported, specifically postoperative temporal hollowing. Temporal hollowing arises when the temporalis is inadequately resuspended after cranioplasty. Several methods to prevent this complication have been described with variable degrees of esthetic improvement, but no single method has proven superior. Herein the authors present a case report demonstrating a novel approach to resuspending the temporalis that incorporates holes in the custom cranial implant to allow for resuspension of the temporalis through suture fixation to the implant.

Trends in Craniofacial Fellowship Career Outcomes: A Call for Expanding Professional Opportunities in Craniofacial Surgery.

PURPOSE: Limited available pediatric plastic surgery positions fail to accommodate the increasing number of craniofacial fellows trained annually. However, many adult indications have increased the demand for craniofacial expertise. Given new opportunities available to craniofacial surgeons, the authors aim to evaluate career prospects for recent craniofacial graduates and explore additional career opportunities. METHODS: Upon approval from the American Society of Craniofacial Surgeons (ASCFS), an anonymous online survey invitation was sent to craniofacial fellows who graduated from 2016 to 2021. Respondents were queried regarding their craniofacial fellowship and subsequent career prospects. RESULTS: A total of 124 eligible participants were identified, of which 30 (24.2%) responded. Craniomaxillofacial case distribution at respondents' current practices varied, with 42.3% reporting a 50% to 75% craniofacial caseload and 38.5% reporting less than 25%. Craniofacial trauma reconstruction was performed most at current positions (92.3%), followed by general reconstruction (92.3%) and breast surgery (69.2%); the least commonly performed was facial feminization (23.1%). Most respondents desired an increased craniomaxillofacial caseload (65.4%). However, 26.9% were unable to secure their current position before fellowship completion, and 80.0% cited limited craniofacial job availability. Recommendations to improve fellowship comprehensiveness and increase candidate competitiveness included increased facial feminization, facial esthetic, and microsurgical experience. CONCLUSION: To adapt to trends in craniomaxillofacial surgery, ASCFS should encourage developing fellowships that increase exposure to gender-affirming, adult craniofacial reconstruction, orthognathic, and skeletal facial esthetic surgery. Expanding training beyond congenital deformities can provide additional employment opportunities while maintaining excellence and innovation in facial plastic surgery.

Custom Plates in Orthognathic Surgery: A Single Surgeon's Experience and Learning Curve.

BACKGROUND: Virtual surgical planning (VSP) now allows for the fabrication of custom plates in orthognathic surgery. The senior author was an early adopter, using VSP and stereolithographic splints for over a decade, before transitioning to custom plates in 2019. The authors present our experience and learning curve with this new technology and compare results to a prior cohort of orthognathic patients. METHODS: A retrospective chart review identified patients undergoing orthognathic surgery with the senior author between 2016 and 2021. All underwent VSP and stereolithographic splint formation, and then either traditional or custom-plate fixation. Demographics, perioperative variables, and postoperative outcomes were analyzed. Traditional fixation consisted of craniomaxillofacial plates, bent intraoperatively by the surgeon to adapt to the facial skeleton. Custom plates were prefabricated and prebent to fit drill holes outlined by customized cutting guides. RESULTS: Forty-three patients underwent surgery in the study period, 25 (58.1%) with traditional fixation hardware and 18 (41.9%) with custom plates. The surgical technique evolved throughout the custom-plate cohort, with the most recent technique involving custom maxillary plate fixation and traditional mandibular plate fixation. When comparing this group of patients to the prior cohort of traditional fixation patients, operative time significantly decreased (mean 233 minutes versus 283 minutes, P = 0.044), without significant difference in complications. CONCLUSIONS: Patient-specific cutting guides and custom plates allow for precise spatial positioning of the osteotomized jaw in the orthognathic surgery. Unsurprisingly, obstacles must be overcome in adopting this new technology; here, we outline our experience and technical modifications that have resulted in increased surgical efficiency with comparable outcomes.

A Look Back: A Single Surgeon's Experience Using Virtual Surgical Planning in Adult Orthognathic Surgery.

The evolution of virtual surgical planning (VSP) in the last 2 decades has led to improved precision and efficiency for orthognathic surgery, both pre- and intraoperatively. This study evaluates a single surgeon's experience with this technology over the past 6 years. Patients undergoing orthognathic surgery using VSP with the senior author between 2015 and 2021 were retrospectively reviewed. Virtual surgical planning -specific data including incidence of midline/cant correction, occlusal equilibration, serial splints, segmental osteotomies, and custom plates were recorded and analyzed. Sixty patients undergoing orthognathic surgery using simulated VSP in the study period were retrospectively reviewed. Mean age at time of surgery was 23.5±7.9 years. Forty-nine patients (81.7%) underwent LeFort I osteotomy combined with at least 1 additional procedure (eg,unilateral or bilateral sagittal split osteotomy, condylectomy, genioplasty, etc.). Twenty-six (43.3%) of patients in the studied cohort underwent maxillary midline correction, 30.0% required occlusal equilibration, 36.7% underwent maxillary molar cant correction, 30.0% underwent mandibular cant correction, and 21.7% required both maxillary and mandibular cant correction. Three patients required serial splinting, and 15 patients (25.0%) required modification of splint design. Custom plates were utilized in 15 patients (25.0%). This study demonstrates the utility of VSP in accurately detecting occlusal cants, asymmetry, and occlusal interferences. Virtual surgical planning also allows for a dynamic preoperative planning process, offering the surgeon a high degree of versatility in splint design, and the ability to fabricate multiple customized splints for each case. This is particularly useful in patients with limited or unpredictable soft tissue elasticity.

A surgeon's perspective on the uncorrected skeletal deformity. Part I: Unintended consequences on facial structures and esthetic harmony.

It is not uncommon for orthodontists to encounter patients whose malocclusion results, at least in part, from an underlying skeletal discrepancy. In many patients, these discrepancies can be fully corrected with growth modification with or without dental compensation to achieve a Class I occlusal relationship. A subset of patients with moderate skeletal deformities in whom surgery is ideally indicated but who choose to defer surgical treatment may be at risk for long-term adverse consequences on facial esthetics. As a surgeon who performs both orthognathic and facial esthetic surgery, the senior author has had the opportunity to appreciate the contributions of underlying skeletal deformities to his patients' esthetic concerns. These patients often present years after orthodontic treatment with complaints of early facial soft tissue laxity, facial disproportion, and overall dissatisfaction with facial appearance. The authors hope to illustrate to the orthodontic community the clinical picture of adult patients who present to the offices of surgeons dissatisfied with their appearance secondary to the uncorrected skeletal deformity. This paper aims to increase orthodontists' awareness of the long-term effects of uncorrected skeletal dysplasia on facial appearance. The ultimate goal is to allow the informed consent process to incorporate these esthetic consequences and to facilitate patient decision making. This article serves as Part I of a 2-part series reviewing a surgeon's approach to patients who present with facial skeletal disharmony after orthodontic treatment with dental compensation.

A surgeon's perspective on the uncorrected skeletal deformity. Part II: The role of esthetic surgery for orthognathic camouflage.

Orthognathic camouflage refers to the use of procedures other than traditional orthognathic surgery for correction of facial dysmorphology that reflects underlying skeletal discrepancy that was either not addressed on initial orthodontic evaluation or not corrected by nonsurgical treatment of the malocclusion. The authors aim to illustrate to the orthodontic community the common clinical presentation of patients who seek consultation from a surgeon citing dissatisfaction with their facial appearance secondary to orthodontic correction of the malocclusion with dental compensation but without surgical correction of the underlying skeletal discrepancy. This article summarizes the orthognathic camouflage procedures that are available as options for correction of such deformities without subjecting the patient to the potential morbidity and prolonged recovery associated with orthognathic surgery. This manuscript represents Part II of a two-part series describing a surgeon's approach to patients who present with facial skeletal disharmony after orthodontic treatment with dental compensation for malocclusions associated with an underlying skeletal discrepancy.

Incorporating the Osseous Genioplasty Into Rejuvenation of the Lower Face.

BACKGROUND: The chin plays a critical role in the shape, projection, and soft tissue support of the lower face. Osseous genioplasty is a powerful tool in facial rejuvenation as it allows for optimal control of the resulting chin dimensions and improvement in submental and submandibular laxity. Osseous genioplasty can be used alone or in combination with other facial rejuvenation procedures to achieve an optimal result. OBJECTIVES: The aim of this study was to present the senior author's approach to skeletal analysis of the lower facial third and propose an algorithm that can be used to optimize skeletal support of the overlying soft tissue laxity while maintaining an aesthetic facial shape and proportion of the chin. METHODS: All patients undergoing cosmetic osseous genioplasty for soft tissue rejuvenation of the lower face and/or perioral region with the senior author between 2010 and 2021 were retrospectively reviewed. Complications, including infection, numbness, and prolonged ecchymosis, were recorded. RESULTS: A total of 37 patients underwent cosmetic osseous genioplasty. The average age of the cohort was 44.5 years. Twenty-six patients (70.3%) were female. Eleven patients (29.7%) underwent genioplasty alone. In addition to genioplasty, 8 patients (21.6%) underwent orthognathic surgery, 5 patients (13.5%) underwent platysmaplasty and liposuction, and 2 patients (5.4%) underwent facelift. The authors propose an algorithm to guide evaluation of the lower facial third to help determine the possible role of osseous genioplasty for facial rejuvenation based on each patient's unique facial characteristics. CONCLUSIONS: In properly selected patients, osseous genioplasty can improve lower facial projection, submandibular laxity, and perioral soft tissue support while also optimizing facial shape and proportion.

Patient Representation and Diversity in Plastic Surgery Social Media.

BACKGROUND: Plastic surgeons increasingly use social media as a means for patient engagement, trainee education, and research dissemination. Appropriate patient diversity on these platforms is critical to promote interaction with all patients and ensure adequate training of plastic surgeons to work with diverse populations. OBJECTIVES: This study aimed to assess patient representation, particularly of racial and ethnic groups, among plastic surgery Instagram accounts. METHODS: Nine Instagram accounts of plastic surgery journals and professional organizations were analyzed for posts containing patient images between April 2015 and June 2020. Each unique patient image was assessed for demographic factors. Skin tone was analyzed as a proxy for racial diversity, with Fitzpatrick scale scores of 1 to 3 indicating white and 4 to 6 indicating nonwhite. Univariate analysis was performed to determine differences in representation. RESULTS: A total of 6719 posts from 5 journal and 4 professional organization accounts were found to contain 2547 unique patient images. Overall, 88.14% of patient images had white skin tone, whereas only 11.86% displayed nonwhite skin tone. Cosmetic procedure patient images had a higher frequency of white skin tone than reconstruction images (89.93% vs 81.98%, P < 0.001). When compared with US Census data and the ASPS Annual Report data on race of patients undergoing plastic surgery, our data revealed significant underrepresentation of patients of color on social media (P < 0.001). CONCLUSIONS: This study highlights the underrepresentation of patients of color within social media imagery. Equitable representation of patients on social media is important to decrease patient barriers to healthcare and improve physician training to engage with diverse populations.

Nonoperative Molding of Congenital Ear Deformities: The Impact of Birth-Initiation Delay on Correction Outcome.

Ear molding can improve the majority congenital ear deformities when employed early after birth. However, the best time to initiate treatment remains debated. In describing one surgeon's experience over the past near decade, this study aims to highlight differences conferred by treatment timing. The authors hypothesize that auricular outcomes are superior when deformities are molded beginning in the first 3 weeks of life. A retrospective review (2010-2018) of 272 cases was performed to compare early initiation of molding (<3 weeks of birth) and delayed initiation (>3 weeks). The mean patient age was 20.4 days and the mean follow-up was 0.5 months. The overall treatment was approximately 31 days. The number of devices required was similar (2.3 versus 2.5) between early and delayed molding cases, but fall-outs (1.0 versus 0.7, P = 0.02) and replacements (0.9 versus 0.6, P = 0.004) were more common after delayed molding. Skin complications developed in 13.6% (37) of ears overall and did not differ by treatment timing. Follow-up surgery was reported in 2 (0.7%) ears. The 85% of families reported subjective satisfaction with the final outcome; satisfaction was significantly higher for early cases (97% versus 79%, P = 0.03). Ear molding of congenital ear deformities should begin within 3 weeks of birth. From our experience, setting realistic expectations helps limit discrepancies between expectation and outcome.

Psychometric findings and normative values for the CLEFT-Q based on 2434 children and young adult patients with cleft lip and/or palate from 12 countries.

BACKGROUND: Patients with cleft lip and/or palate can undergo numerous procedures to improve appearance, speech, dentition and hearing. We developed a cleft-specific patient-reported outcome instrument to facilitate rigorous international measurement and benchmarking. METHODS: Data were collected from patients aged 8-29 years with cleft lip and/or palate at 30 hospitals in 12 countries between October 2014 and November 2016. Rasch measurement theory analysis was used to refine the scales and to examine reliability and validity. Normative CLEFT-Q values were computed for age, sex and cleft type. RESULTS: Analysis led to the refinement of an eating and drinking checklist and 12 scales measuring appearance (of the face, nose, nostrils, teeth, lips, jaws and cleft lip scar), health-related quality of life (psychological, social, school, speech distress) and speech function. All scales met the requirements of the Rasch model. Analysis to explore differential item functioning by age, sex and country provided evidence to support the use of a common scoring algorithm for each scale for international use. Lower (worse) scores on CLEFT-Q scales were associated with having a speech problem, being unhappy with facial appearance, and needing future cleft-related treatments, providing evidence of construct validity. Normative values for age, sex and cleft type showed poorer outcomes associated with older age, female sex and having a visible cleft. INTERPRETATION: The CLEFT-Q represents a rigorously developed instrument that can be used internationally to collect and compare evidence-based outcomes data from patients aged 8-29 years of age with cleft lip and/or palate.

Self-Report Scales to Measure Expectations and Appearance-Related Psychosocial Distress in Patients Seeking Cosmetic Treatments.

BACKGROUND: The use of screening scales in cosmetic practices may help to identify patients who require education to modify inappropriate expectations and/or psychological support. OBJECTIVES: To describe the development and validation of scales that measure expectations (about how one's appearance and quality of life might change with cosmetic treatments) and appearance-related psychosocial distress. METHODS: The scales were field-tested in patients 18 years and older seeking facial aesthetic or body contouring treatments. Recruitment took place in clinics in the United States, United Kingdom, and Canada between February 2010 and January 2015. Rasch Measurement Theory (RMT) analysis was used for psychometric evaluation. Scale scores range from 0 to 100; higher scores indicate more inappropriate expectations and higher psychosocial distress. RESULTS: Facial aesthetic (n = 279) and body contouring (n = 90) patients participated (97% response). In the RMT analysis, all items had ordered thresholds and acceptable item fit. Person Separation Index and Cronbach alpha values were 0.88 and 0.92 for the Expectation scale, and 0.81 and 0.89 for the Psychosocial Distress scale respectively. Higher expectation correlated with higher psychosocial distress (R = 0.40, P < .001). In the facial aesthetic group, lower scores on the FACE-Q Satisfaction with Appearance scale correlated with higher expectations (R = -0.27, P = .001) and psychosocial distress (R = -0.52, P < .001). In the body contouring group, lower scores on the BODY-Q Satisfaction with Body scale correlated with higher psychosocial distress (R = -0.31, P = .003). Type of treatment and marital status were associated with scale scores in multivariate models. CONCLUSIONS: Future research could examine convergent and predictive validity. As research data are accumulated, norms and interpretation guidelines will be established. LEVEL OF EVIDENCE: 2 Risk.

Modified fixation of acrylic cranioplasty in the setting of titanium allergy.

Cranioplasty can be performed using a number of materials ranging from autologous tissue to metallic or acrylic alloplastic implants. In this report, we present a unique case of revision cranioplasty in a patient with titanium allergy using a prefabricated, custom-made polymethylmethacrylate implant and a modified fixation technique without plates or screws.

Assessing Patient-Reported Outcomes Following Orthognathic Surgery and Osseous Genioplasty.

Primary outcomes for orthognathic surgery and genioplasty patients include satisfaction with appearance, improved motor function, and enhanced quality of life. The goal of this study was to assess outcomes among patients undergoing these procedures, and to highlight the potential use of FACE-Q instrument for use in patients with dentofacial deformities. A total of 56 patients presenting for orthognathic surgery and/or osseous genioplasty completed the FACE-Q during preoperative and/or at postoperative visits. FACE-Q scores increased following surgery in satisfaction with facial appearance overall (+24.5, P < 0.01), satisfaction with lower face and jawline (+40.7, P < 0.01), and in all satisfaction with chin items (profile, prominence, shape, and overall). Patients also demonstrated increased social confidence (+8.9, P = 0.29). There was no improvement in psychologic well-being (-0.8, P = 0.92). All 3 surgical groups of patients experienced gains in satisfaction with appearance following surgery. Patients who underwent orthognathic surgery either alone or in combination with genioplasty demonstrated statistically significant improvements in satisfaction with facial appearance overall (P < 0.01 for both groups), whereas patients who underwent genioplasty alone did not (P = 0.13). In addition, patients who underwent orthognathic surgery combined with genioplasty demonstrated greater improvement in satisfaction with chin than patients who underwent genioplasty alone. In conclusion, patients who underwent orthognathic surgery and/or genioplasty demonstrated improvement in appearance and social confidence. The use of this model supports the successful outcomes possible for patients undergoing these procedures.

Development of Volunteer International Craniofacial Surgery Missions: The Komedyplast Protocol.

Volunteer surgical missions to provide cleft care to patients in developing countries has been done successfully for a number of years. Similar missions that provide craniofacial surgery introduce a dramatic step up in complexity. While articles have addressed protocols for the safe delivery of cleft care around the world, little has been written on volunteer craniofacial surgical missions. Komedyplast was established in March 2001 as a 501c(3) nonprofit organization to provide craniofacial surgical care to underserved populations and educate local surgeons in craniofacial principles. During 9 annual missions, the organization has provided surgical care to more than 150 patients with various complex, congenital, craniofacial conditions. The article addresses important safeguards that have been implemented to maximize safety and minimize risk.

Assessing Demographic Differences in Patient-Perceived Improvement in Facial Appearance and Quality of Life Following Rhinoplasty.

BACKGROUND: As rhinoplasty patient demographics evolve, surgeons must consider the impact of demographics on patient satisfaction. OBJECTIVES: The objective of this study was to identify independent demographic predictors of differences in satisfaction with appearance and quality of life following rhinoplasty utilizing the FACE-Q patient-reported outcome instrument. METHODS: Patients presenting for rhinoplasty completed the following FACE-Q scales: Satisfaction with Facial Appearance, Satisfaction with Nose, Social Function, and Psychological Well-being. Higher FACE-Q scores indicate greater satisfaction with appearance or superior quality of life. Pre- and post-treatment scores were compared in the context of patient demographics. RESULTS: The scales were completed by 59 patients. Women demonstrated statistically significant improvements in Satisfaction with Facial Appearance and quality of life while men only experienced significant improvement in Satisfaction with Facial appearance. Caucasians demonstrated statistically significant improvement in Satisfaction with Facial Appearance and quality of life while non-Caucasians did not. Patients younger than 35 years old were more likely to experience enhanced Satisfaction with Facial Appearance and quality of life compared with patients older than 35 years old. Patients with income ≥$100,000 were more likely to experience significant increases in Satisfaction with Facial Appearance and quality of life than patients with incomes <$100,000. CONCLUSIONS: In an objective study using a validated patient-reported outcome instrument, the authors were able to quantify differences in the clinically meaningful change in perception of appearance and quality of life that rhinoplasty patients gain based on demographic variables. The authors also demonstrated that these variables are potential predictors of differences in satisfaction.