Utilization of Virtual Consultations in Facial Plastic Surgery during the COVID-19 Pandemic.

BACKGROUND: The coronavirus disease 2019 pandemic affected many aspects of medical practice, particularly surgical fields. The American College of Surgery initially recommended the cancellation of all elective procedures. As a result, virtual consultations (VCs; a form of telemedicine), became widely used in the field of facial plastic and reconstructive surgery. With more facial plastic and reconstructive surgeons (FPRS) conducting both in-person and virtual visits, it is imperative to understand how VCs are utilized in practice. METHODS: An electronic, anonymous survey was distributed to 1,282 electronic mail addresses in the 2018 American Academy of Facial Plastic and Reconstructive Surgery directory. The survey collected responses on various topics including demographic information and past, current, and future use of VCs. RESULTS: The survey yielded 84 responses. Most surgeons (66.7%) were 11+ years out of fellowship. There was a significant increase in the percentage of VCs scheduled after the pandemic than before (p = 0.03). FPRS most frequently responded that VCs should always be followed by an in-person visit (48.6%). A majority of FPRS (66.2%) believe that VCs have improved the delivery of health care in at least some cases. Almost all FPRS (86.5%) plan on using VCs after the pandemic. CONCLUSION: Since the pandemic, VCs are more frequently used by surgeons and are mostly utilized as an initial patient visit. A majority of FPRS believe that VCs have improved health care in at least some cases, and plan on using VCs after the pandemic.

Local Anesthetic Facelift.

A thorough medical history is critical in patient selection for local anesthesia facelifting. Patients with no prior issues with dental procedures and no history of significant anxiety are better candidates. Simplifying local anesthesia mixtures and using dilute concentrations will minimize dosing errors and decrease risk of local anesthesia toxicity. Oral anxiolytics can be used with caution to minimize patient anxiety. Pulse oximetry, telemetry, and blood pressure monitoring should be performed with any addition of oral or IV sedation/anxiolytic. The short-scar anterior facelift is ideal for local anesthesia due to the limited deep-plane dissection and shorter procedure duration.

Lip Augmentation.

This article examines 6 questions about lip augmentation answered by 3 experts in their field of facial plastic surgery. The topics covered include high-yield areas such as injection, surgical enhancement, rhytid resurfacing, implants, complications, and technique changes over the years. All the authors answered these questions in a "How I do it" manner to provide the reader with a true understanding of their thoughts and techniques. This article provides a practical resource to all physicians and practitioners performing lip augmentation on some of the most common questions and issues.

A Cross-sectional Analysis of Adverse Events and Litigation for Injectable Fillers.

IMPORTANCE: Injectable fillers are increasing in popularity as a noninvasive option to address concerns related to facial aging and volume loss. To our knowledge, there have been no large-scale analyses of adverse events and associated litigation related to filler injections. OBJECTIVES: To determine risks of injectable fillers and analyze factors raised in litigation related to injectable fillers. DESIGN, SETTING, AND PARTICIPANTS: In this cross-sectional review, the US Food and Drug Administration's (FDA) manufacturer and user facility device experience (MAUDE) database was evaluated for complications from the use of the following fillers: Juvederm, Restylane, Belotero, Sculptra, Radiesse, Artefill, Bellafill, and Juvederm Voluma from 2014 to 2016. The Westlaw Next database was used to identify jury verdicts. MAIN OUTCOMES AND MEASURES: Complications were organized by type of filler used, location of injection, and severity. Intra-arterial injections without sequelae and those resulting in blindness or necrosis were considered severe complications. Factors raised during the litigation process were also analyzed. RESULTS: Of 1748 adverse events analyzed, most cases stemmed from cheek (751 [43.0%]) or lip (524 [30.0%]) injection. Commonly reported adverse events reported included swelling (755 [43.2%]) and infection (725 [41.5%]). Among FDA-reported complications, blindness was significantly associated with dorsal nasal injections (P < .001). Vascular compromise with and without sequela of dermal necrosis and blindness were significantly associated with Radiesse injections P < .001. Of the 9 malpractice cases identified, two-thirds involved allegations of inadequate informed consent, and the median award in cases resolved with payment was $262 000. CONCLUSIONS AND RELEVANCE: Although specific complication profiles vary by material and injection site, common adverse events associated with injectable fillers include swelling and infection. More serious events include vascular compromise, resulting in necrosis and blindness; these events are also raised in cases involving litigation. This analysis illustrates the importance of outlining these risks in a comprehensive preoperative informed consent process. LEVEL OF EVIDENCE: NA.

Efficacy and Safety of Artiss Fibrin Tissue Sealant Use in Rhytidectomy: A Review of 120 Cases.

Hematoma formation has persisted as the most common complication in rhytidectomy. The objective of this study is to determine the efficacy and safety of Artiss (Baxter) for use in rhytidectomies. In addition, we determine the use of fibrin tissue sealants by facial plastic surgeons. In this retrospective chart review, 120 patients in a single private practice were identified who underwent a rhytidectomy from August 2013 to January 2015 by a single facial plastic surgeon. The last 60 rhytidectomies performed with Tisseel (Baxter) were compared with the first 60 rhytidectomies performed with Artiss. All perioperative or postoperative complications were identified and recorded, focusing on the incidence of hematoma. In addition, a six-question survey was created and sent to all members of the American Academy of Facial Plastic and Reconstructive Surgery. Results of the survey were recorded and analyzed for trends or patterns in the data. In total, 120 patients were assessed. In the Tisseel group, two complications of fluid collection requiring needle aspiration were recorded. No other complications were found. In the Artiss group, 10 complications were recorded, including 9 fluid collections requiring needle aspiration and 1 hematoma. In total, 179 members of the American Academy of Facial Plastic and Reconstructive Surgery completed the six-question survey. Of all respondents, 61 (34%) use tissue sealants for rhytidectomies, whereas 118 (66%) do not. Artiss is efficacious and safe for use in rhytidectomies. Its use obviates the need for surgical drains, and complications are minimal and similar in rate to the use of Tisseel.

Impact of Postreconstitution Room Temperature Storage on the Efficacy of IncobotulinumtoxinA Treatment of Dynamic Lateral Canthus Lines.

BACKGROUND: The efficacy of botulinum neurotoxin type A after prolonged storage at room temperature is currently unknown. This randomized, double-blinded, split-face study investigated the impact of postreconstitution 25°C storage for 1 week on the clinical efficacy of incobotulinumtoxinA in the treatment of lateral canthus lines. PATIENTS AND METHODS: Twenty-one participants with at least mild to moderate crow's feet at maximum contraction on the Crow's Feet Grading Scale (CFGS) underwent injection to each lateral canthus area with 10 U of freshly reconstituted and room temperature-stored product and followed for 4 months. Responders were defined as those demonstrating at least a 1-point improvement on their CFGS score. RESULTS: At each visit (2 weeks and 1, 2, 3, and 4 months), there was no statistical difference in the rate of responders between the fresh and the stored products. In addition, the percentage of responders displaying a 2-point versus a 1-point improvement and response longevity did not statistically differ between both products for the entire 4-month study duration. CONCLUSION: Prolonged storage of incobotulinumtoxinA at room temperature does not appear to significantly alter its efficacy or longevity in the treatment of dynamic lateral canthus lines.

Aesthetic modification to the rintala flap: a case series.

BACKGROUND: Defects of the nasal dorsum have historically been repaired based on size and with respect to subunit principle. This case series provides a previously undescribed option for correcting defects of the nasal dorsum 1.5-2.5 cm in size. The foremost advantages of this technique are preservation of nasal subunit integrity and the integration of subtle nasal tip rotation. METHODS: We present a case series involving five consecutive patients aged 49-74 after Mohs excision for malignancies of the nasal dorsum. Defects were corrected using the aesthetic modification to the Rintala flap over a 10-year period by two primary surgeons. CONCLUSIONS: The aesthetic modification to the Rintala flap should be considered as a reconstruction option for patients with defects of the nasal dorsum between 1.5 and 2.5 cm in size, especially for those patients desiring rotation of the nasal tip. 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 .

Latest innovations for tattoo and permanent makeup removal.

The goal of this article is to reveal the latest techniques and advances in laser removal of both amateur and professional tattoos, as well as cosmetic tattoos and permanent makeup. Each pose different challenges to the removing physician, but the goal is always the same: removal without sequelae. The authors' technique is detailed, and discussion of basic principles of light reflection, ink properties, effects of laser energy and heat, and outcomes and complications of tattoo removal are presented.

Cannulas for facial filler placement.

With more physicians performing injections to the face in increasingly sophisticated ways, techniques must evolve accordingly. Injectables are no longer mere wrinkle fillers but true panfacial volumizers that are placed in many different planes and tissues of the face, in contrast to fillers of the past used for the dermis. This development is providing better results previously not achievable with off-the-shelf fillers. Microcannulas represent a step forward in enhancing surgeons' ability to fill the face with less discomfort, edema, and ecchymosis, with faster recovery. Microcannulas will probably play a role in volume replacement for many years to come.

HAM56 and CD68 antigen presenting cells surrounding a sarcoidal granulomatous tattoo.

CONTEXT: Tattoos are produced by introducing colorants of various compositions into the skin, either accidentally or for cosmetic purposes. CASE REPORT: A 62-year-old male presented with a cosmetic tattoo and requested a total excision of the lesion. Dermatopathologic analysis of the excised tissue with hematoxylin and eosin examination, as well as immunohistochemistry was performed. H&E staining demonstrated classic histologic features of a tattoo. Utilizing immunohistochemistry, dermal histiocytic antigen presenting cells stained with HAM56 and CD68 antibodies; the staining was present surrounding the tattoo pigment. CONCLUSIONS: We identified two macrophage markers (HAM56 and CD68) surrounding dermal tattoo pigment. A minimal dermal inflammatory immune was noted to the tattoo pigment. Moreover, the immune response and/or tolerance to tattoos is not well characterized. We suggest that tattoo materials and techniques could be utilized in therapeutic delivery for diseases such recessive dystrophic epidermolysis bullosa, potentially preventing immune rejection of gene therapy agents.