Purse-String DIEPplasty: A Technique to Improve Aesthetic Outcome of Autologous Breast Reconstruction.

The purse-string DIEPplasty technique is a method to improve aesthetic outcomes in breast reconstruction using deep inferior epigastric perforator (DIEP) free flaps. Traditionally, DIEP flaps, harvested from the lower abdomen, take on a triangular shape that can lead to sub-optimal aesthetic outcomes with occasionally poor breast projection, irregular contours, or minimal upper pole fullness. The purse-string DIEPplasty technique addresses these issues by using a 0 Polydioxanone continuous purse-string suture through the Scarpa's fascia to modify the harvested flap's shape before inset, giving it a more round base and a central dome-like projection similar to an implant. This method mimics the shape of a breast implant, enhancing the flap's projection, volumetric efficiency, and overall shape, leading to a reconstructed breast with improved aesthetic qualities. This technique represents a potential advancement in reconstructive breast surgery, aiming to reduce the extent of revision procedures and improve patient satisfaction. Further research, however, is needed to validate its effectiveness over time and assess potential complications.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 .

The Effects of Body Mass Index on Postoperative Complications in Patients Undergoing Autologous Free Flap Breast Reconstruction.

BACKGROUND: The prevalence of obesity in the United States exceeds 40%, yet perioperative effects of higher body mass index (BMI) in autologous breast reconstruction remain poorly studied. The purpose of this study was to investigate BMI's impact on postop complications in abdominal and gluteal-based autologous breast reconstruction. METHODS: We conducted a retrospective study using TriNetX, a health care database containing de-identified data from more than 250 million patients. Patients undergoing autologous breast reconstruction were identified by Current Procedural Terminology codes. Four cohorts were established by BMI class: <24.99, 25 to 29.99, 30 to 34.99, and 35 to 39.99 kg/m2. Outcomes of interest were defined by International Classification of Diseases,Tenth Revision (ICD-10) codes. A two-sample t-test was performed to compare incidence of postoperative complications between cohorts within 3 months of surgery. Patients with a BMI < 24.99 kg/m2 served as the control. Cohorts were balanced on age, race, and ethnicity. RESULTS: We identified 8,791 patients who underwent autologous breast reconstruction. Of those, 1,143 had a BMI < 24.99 kg/m2, 1,867 had a BMI of 25 to 29.99 kg/m2, 1,396 had a BMI of 30 to 34.99 kg/m2, and 559 had a BMI of 35 to 39.99 kg/m2. Patients with a BMI of 25 to 29.99 kg/m2 had a significantly increased risk of cellulitis. Patients with a BMI of 30 to 34.99 and 35 to 39.99 kg/m2 had a significantly increased risk of cellulitis, surgical site infection, need for debridement, wound dehiscence, and flap failure. CONCLUSION: Our study illustrates that there is an increased risk of postoperative complications associated with higher BMI classes. Understanding these data are imperative for providers to adequately stratify patients and guide the procedural decision-making.

Evaluation of the Impact of Physical Therapy on Patients with Macromastia Seeking Breast Reduction Surgery.

BACKGROUND: Macromastia significantly impairs women's quality of life, with treatments such as physical therapy (PT) often providing only temporary relief. Insurance routinely denies breast reduction surgery, despite little relief after conservative treatments. Research on the efficacy of PT for macromastia is limited. OBJECTIVES: This study investigated the efficacy of PT for macromastia and identified patient factors associated with progression to surgery. METHODS: We conducted a retrospective cohort study of patients with macromastia between 2017 and 2021. We collected data on presenting symptoms, attempted conservative treatments, PT duration, and whether surgery was performed. All patients were invited to participate in a survey regarding their symptoms, treatments, and responses to treatments. A multiple logistic regression was used to evaluate symptoms associated patients progressing to a breast reduction. RESULTS: Among the 327 patients identified with macromastia, 312 (95.41%) reported back pain and 272 (83.18%) attempted PT. Of the 72 (22.02%) patients who responded to the survey, 152 (46.48%) underwent subsequent surgery. The mean time from initial consultation to surgery was 283 days. Bra strap grooving was associated with progression to surgery (OR=1.90, CI=1.02-3.54). Mean patient-reported pain levels decreased after surgery compared to after PT (pre-PT=7.1, post-PT=7.1, post-surgery=3.1, P<0.001). CONCLUSIONS: Patients frequently undergo PT prior to breast reduction surgery despite no significant reduction in pain, while those who undergo surgery experience permanent relief and significantly reduced pain. Patients with bra strap grooving are more likely to progress to surgery. The requirement for PT as a prerequisite for surgery by insurance companies should be reevaluated.

Trends in Gender-Affirming Surgeries in the United States from 2010 to 2021.

Introduction: In 2017, an estimated 1.6 million adults and 150,000 teenagers identified as transgender in the United States. With ever-changing legislative developments regarding health care benefits for this population and the increasing number of patients presenting for gender-affirming surgery (GAS), there is a scarcity of literature on the temporal trends within the past decade. The objective of this study was to examine the temporal trends of the utilization of GAS. Methods: We conducted a cross-sectional study using TriNetX, a federated research network containing deidentified aggregate patient data. Using International Code of Disease (ICD) and Current Procedural Terminology (CPT) codes, we identified patients with a diagnosis of gender dysphoria who underwent GAS from 2010 to 2021. Basic demographic information and complications were analyzed. Complications of interest included site failure, infection, and systemic complications. Results: We identified a total of 8,403 patients who underwent GAS between January 2010 and December 2021. The number of procedures per year increased nearly 500% between 2016 and 2021 from 421 procedures to 2,224 procedures. Our demographic results were consistent with previous survey-based studies. The average age of patients who underwent masculinizing surgeries was consistently younger than those who underwent feminizing surgeries. Most patients undergoing GAS were of white race. The overall complication rate was 4.7%. Conclusion: In conclusion, our study reveals a significant and rapid rise in the utilization of GAS in the United States, with a fivefold increase in procedures between 2016 and 2021. The demographic characteristics and low complication rates observed highlight the evolving landscape of health care for transgender individuals and the need for ongoing assessment and support in this field.

Opioid-Prescribing Patterns in Body Contouring Surgery.

BACKGROUND: The United States is experiencing the highest opioid overdose death rate in our nation's history. Misuse and addiction to opioids, including prescription pain relievers, is a serious national crisis that affects public health as well as social and economic welfare. OBJECTIVES: The aim of the study was to critically evaluate postoperative opioid-prescribing patterns. METHODS: The PearlDiver database (Colorado Springs, CO) was queried for body contouring patients from 2010 to 2020. We identified patients that underwent panniculectomy, abdominoplasty, brachioplasty, thighplasty, mastopexy, breast augmentation, breast reduction, and liposuction for analysis. We subsequently analyzed the opioid use, with a focus on comorbid conditions and complications that are associated with increased use of opioids. RESULTS: A total of 56,773 patients underwent body contouring surgery. The most common opioid prescribed was hydrocodone with acetaminophen (37,017 patients). Average days of therapy was 17.92 days. Comorbid conditions and postoperative complications were examined for risk of increased opioid prescriptions. Patients with peripheral vascular disease and smoking were prescribed significantly more morphine milliequivalents (MME) of opioids than patients without peripheral vascular disease (871.97 vs 535.41; P < .001) and smoking (1069.57 vs 440.84; P < .001). Patients who developed surgical site infection, disruption of wound, and venous thromboembolism were prescribed a significantly higher MME of opioids (1213.63 vs 561.59; P < .001). CONCLUSIONS: Our data provide information on opioid prescription patterns in the body contouring population, with focused review of comorbid conditions and complications in relation to opioid-prescribing patterns. We hope that the data will improve opioid prescription habits among plastic surgeons in the setting of a global opioid crisis.

Analysis of Complications in Patients With a History of Cannabis Use and Tobacco Use Undergoing Implant-Based Breast Reconstruction.

BACKGROUND: There is limited information regarding the perioperative effects of marijuana in breast reconstructive surgeries. OBJECTIVES: The objective of this study was to explore the association between a history of cannabis use and postoperative complications in the setting of implant-based breast reconstruction. METHODS: Two databases, TriNetX and PearlDiver, were queried for patients undergoing implant-based breast reconstruction. Patients were divided into 4 groups based on active ICD-10 diagnostic codes: (1) cannabis use only, (2) tobacco use only, (3) cannabis and tobacco use, and (4) neither cannabis nor tobacco use. Associations with postoperative complications were analyzed with a logistic regression test. RESULTS: TriNetX search revealed that 327 patients had an active diagnosis of cannabis use only and 1118 had an active diagnosis of tobacco use only. Patients in the cannabis only cohort had a significantly increased risk of developing surgical site infection. Patients in the tobacco only cohort had significantly increased risk of developing wound dehiscence, need for debridement, and surgical site infection. The PearlDiver search included 472 patients who had an active diagnosis of both cannabis and tobacco use and 17,361 patients with a diagnosis of tobacco use only. Patients with a diagnosis of cannabis and tobacco use had a significantly increased risk of developing postoperative complications including surgical site infection, wound dehiscence, need for incision and drainage, and debridement. CONCLUSIONS: Patients undergoing implant-based breast reconstruction with an active diagnosis of cannabis with or without tobacco use were at increased risk of developing postoperative complications, and the risk was even higher in patients using both tobacco and cannabis.

Improving Gender-Affirming Surgery Terminology: A Multicenter Patient Survey.

BACKGROUND: To promote patient safety and build trust, plastic surgeons must use patient-centered language when discussing gender-affirming surgery. However, the existing terminology has not been evaluated from a patient perspective. This study sought to understand how gender-affirming surgery patients from 3 US geographic regions perceive common terminology. METHODS: An anonymous, 24-item electronic survey was distributed to gender-affirming surgery patients seen in Tennessee, Colorado, and California. After institutional review board exemption, the survey instrument was pretested and piloted with gender-affirming surgery patients. Internal consistency was assessed by computation of Cronbach α (0.87). RESULTS: A total of 306 participants completed the survey: 68 from a Tennessee academic center (response rate, 56%), 131 from a California private practice (response rate, 8%), and 107 from a Colorado academic center (response rate, 53%). A greater proportion of respondents felt the terms "top surgery" and "bottom surgery" were appropriate (83% and 82%, respectively) relative to "chest surgery" and "genital surgery" (41% and 30%, respectively). More respondents favored the phrase "gender-affirming surgery" than "gender-confirming surgery" (86% vs 67%). Nearly half (43%) perceived the phrase "sex reassignment surgery" as inappropriate. Most respondents (80%) preferred their surgeon ask for their pronouns. CONCLUSIONS: Optimizing communication is an actionable way for plastic surgeons to improve the healthcare experiences of gender-affirming surgery patients. "Top surgery" and "bottom surgery" are favored terms, and "gender-affirming surgery" is the preferred name for this discipline. Language preferences should be openly discussed with each patient to ensure professional communication.

No-Charge Nonsurgical Facial Aesthetic Clinic in a Residency Program: A Single-Center Experience.

BACKGROUND: In 2014, the Accreditation Council for Graduate Medical Education set minimum case requirements for injectable procedures as a surrogate for procedural competency. Despite the implementation of resident-run aesthetic surgery clinics, evidence suggests that many feel inadequately prepared as they go into practice even after meeting this requirement. To address this issue, our institution has implemented a separate resident clinic dedicated to neurotoxin and filler injections. OBJECTIVE: The authors discussed the logistics and benefits of how residents, faculty, clinic staff, and industry representatives together have created a no-cost, volunteer patient-based resident injectable clinic. DESCRIPTION: Two half-day, no-cost clinics per week were established, with 1 clinic day coinciding with the chief resident aesthetic clinic. Designated staff coordinate patient visits and allocate specific rooms for this clinic. Industry representatives have provided injectable products at no cost through resident injectable education programs. Residents in postgraduation years 4 to 6 provide their own patients and perform procedures under direct faculty supervision. All encounters are documented in the electronic health record. To assess the utility of this clinic, a survey was sent to all recent graduates, some of whom participated in this program. Since its inception in May 2018, this injectable clinic has been running successfully with overwhelmingly positive feedback from all eligible residents who participated. To date, there have been no adverse events from these injections. CONCLUSIONS: At our institution, the no-cost, volunteer patient-based resident injectable clinic has provided regular educational opportunities for plastic surgery residents to increase their experience with injectable procedures.

Current Perceptions of the Aesthetically Ideal Position and Size of the Male Nipple-Areola Complex.

BACKGROUND: The dimensions of the nipple-areola complex (NAC) and its location on the chest wall are important aesthetic factors in male breast surgery. OBJECTIVES: This study examines the perceptions of aesthetic surgeons and the general population for the aesthetically ideal position and size of male NAC. METHODS: An online survey was distributed to the American Society for Aesthetic Plastic Surgery (ASAPS) members and to the general population. Parameters queried included demographics for all participants and academic details for ASAPS members. Both surveys included a male model picture with 16 separate choices for the NAC position from a frontal view, 5 choices for the NAC position from a lateral view, and 6 choices for the NAC dimensions. For all 3 sets of images, the participants were asked to rank the top 3 images they considered most "aesthetically pleasing" in descending order. A weighted scoring rule was created to quantitatively evaluate image choices. Standard statistical methods were employed for analysis. RESULTS: The survey was completed by 272 ASAPS members and 4909 participants from the general population. The top 3 choices for NAC location on frontal view were the same for ASAPS members and the general population. The most popular NAC location on lateral view was the same for both groups, but the preferred locations differed between the 2 groups for the second and third choices. The most popular dimensions of the NAC were 2 cm (vertical) × 3 cm (horizontal) followed by 2 cm × 2 cm for both groups. Comparison of the 3 top image choices scores between different ethnic groups and individuals with different gender or sexual orientation demonstrated similar trends. CONCLUSIONS: This survey identified the preferred position and dimensions of the NAC on the male breast for plastic surgeons and the general population. These parameters should be considered when counseling males undergoing breast surgery.

Surgical Site Infections in Aesthetic Surgery.

Surgical site infections represent one of the most common postoperative complications in patients undergoing aesthetic surgery. As with other postoperative complications, the incidence of these infections may be influenced by many factors and varies depending on the specific operation performed. Understanding the risk factors for infection development is critical because careful patient selection and appropriate perioperative counseling will set the right expectations and can ultimately improve patient outcomes and satisfaction. Various perioperative prevention measures may also be employed to minimize the incidence of these infections. Once the infection occurs, prompt diagnosis will allow management of the infection and any associated complications in a timely manner to ensure patient safety, optimize the postoperative course, and avoid long-term sequelae.

The Effect of Smoking in the Cosmetic Surgery Population: Analysis of 129,007 Patients.

Background: Smoking has been associated with several postoperative adverse outcomes across multiple surgical disciplines, but the literature is limited for aesthetic surgical procedures. Objectives: To compare complication rates between smokers and nonsmokers undergoing common cosmetic procedures, identify specific cosmetic procedures where smoking increases the risk of complications, and evaluate smoking as an independent risk factor for major complications following aesthetic surgery. Methods: A prospective cohort of patients undergoing cosmetic surgery between 2008 and 2013 was identified from the CosmetAssure database. Smoking was evaluated as a risk factor for major complications requiring emergency room visit, hospital admission, or reoperation within 30 days after surgery. Multivariate regression analysis was performed controlling for the effects of age, gender, body mass index, type of surgical facility, type of procedure, and combined procedures. Results: Of the 129,007 patients, 10,621 (8.2%) were smokers. All procedures examined, except breast augmentation, were more frequently performed in the nonsmoker cohort. Overall major complications were similar between smokers and nonsmokers (2.0% vs 1.9%, P = 0.57). In univariate analysis, surgical site infections (0.6% vs 0.5%, P = 0.04) were significantly higher among smokers, but suspected venous thromboembolism (0.2% vs 0.1%, P = 0.01) was significantly higher among nonsmokers. Notably, smokers had a higher risk of major complications after body procedures (2.9% vs 1.0%, P = 0.01), as well as thigh lifts (23.8% vs 3.6%, P < 0.01) and male breast surgery (3.7% vs 1.4%, P = 0.03). In multivariate analysis, smoking was found to be an independent predictor of surgical site infections (relative risk 1.61, P < 0.01). Conclusions: Smoking is an independent risk factor of major surgical site infections following aesthetic surgery. Body procedures, as well as thigh lifts and male breast surgery, have higher complication rates in smokers.

Aesthetic Surgical Procedures in Men: Major Complications and Associated Risk Factors.

BACKGROUND: The number of men undergoing cosmetic surgery is increasing in North America. OBJECTIVES: To determine the incidence and risk factors of major complications in males undergoing cosmetic surgery, compare the complication profiles between men and women, and identify specific procedures that are associated with higher risk of complications in males. METHODS: A prospective cohort of patients undergoing cosmetic surgery between 2008 and 2013 was identified from the CosmetAssure database. Gender specific procedures were excluded. Primary outcome was occurrence of a major complication in males requiring emergency room visit, hospital admission, or reoperation within 30 days of the index operation. Univariate and multivariate analysis evaluated potential risk factors for major complications including age, body mass index (BMI), smoking, diabetes, type of surgical facility, type of procedure, and combined procedures. RESULTS: Of the 129,007 patients, 54,927 underwent gender nonspecific procedures, of which 5801 (10.6%) were males. Women showed a higher mean age (46.4 ± 14.1 vs 45.2 ± 16.7 years, P < 0.01). Men had a higher BMI (27.2 ± 4.7 vs 25.7 ± 4.9 kg/m2, P < 0.01), and were more likely to be smokers (7.1% vs 5.7%, P < 0.01) when compared to women. Men demonstrated similar overall major complication rates compared to women (2.1% vs 2.1%, P = 0.97). When specific complications were analyzed further, men had higher hematoma rates, but lower incidence of surgical site infection. Additionally, major complications after abdominoplasty, facelift surgery, and buttock augmentation were noted to preferentially affect males. On multivariate analysis, independent predictors of major complications in males included BMI (RR 1.05), hospital or ambulatory surgery center procedures (RR 3.47), and combined procedures (RR 2.56). CONCLUSIONS: Aesthetic surgery in men is safe with low major complication rates. Modifiable predictors of complications included BMI and combined procedures.

Twenty-Year Review of a Single Surgeon's Experience Using a Unique Surgical Technique to Correct Lambdoidal Synostosis.

BACKGROUND: Numerous techniques for the surgical management of lambdoidal synostosis have been previously described; however, no best practice technique currently exists. Surgical procedures range from complete posterior calvarial reconstruction to distraction osteogenesis techniques. Our primary purpose is to describe a novel approach to correct unilateral or bilateral lambdoidal synostosis. METHODS: A retrospective review was performed on a single surgeon's experience with craniosynostosis (1994-2014). Specifically, craniosynostosis cases involving the lambdoidal suture, which were repaired using a novel 'tongue and groove' technique, were identified. RESULTS: A total of 664 craniosynostosis cases were retrieved, with 21 primarily involving the lambdoidal suture (3.2%). Of these, 18 were unilateral and 3 were bilateral lambdoidal synostosis. Male-to-female ratio was 3:1. Average age of first encounter with a craniofacial physician was 33 weeks (8 months). Average age at time of surgery was 43 weeks (10.75 months). Complications of this technique included 1 patient who experienced refusion of his lambdoidal suture and fusion of his sagittal suture, and 4 who returned for bone graft coverage of full-thickness calvarial defects owing to a lack of complete reossification. CONCLUSION: The "tongue and groove" technique represents a novel method for the management of lambdoidal synostosis with good esthetic outcomes, allowing immediate cranial stabilization with increased skull volume. This technique, used by the senior author for >20 years, provides a reproducible and reliable method of correcting lambdoidal synostosis.

Incidence and Risk Factors for Major Surgical Site Infections in Aesthetic Surgery: Analysis of 129,007 Patients.

BACKGROUND: Surgical site infections (SSIs) represent one of the most common postoperative complications in patients undergoing aesthetic surgery. OBJECTIVES: This study reports the incidence and risk factors of major SSIs following aesthetic surgery. METHODS: A prospective cohort of patients who underwent aesthetic surgery between 2008 and 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of a major SSI requiring emergency room visit, hospital admission, or reoperation within 30 days of the index operation. Univariate and multivariate analysis evaluated potential risk factors for SSIs including age, gender, body mass index (BMI), smoking, diabetes, type of surgical facility, procedure by body region, and combined procedures. RESULTS: A total of 129,007 patients were identified, of which 599 (0.46%) had a major SSI. Mean age (43.8 ± 12.4 years vs 40.9 ± 13.9 years, P < .01) and BMI (27.3 ± 5.5 kg/m2 vs 24.3 ± 4.6 kg/m2, P < .01) were higher in patients with SSIs. Patients with a SSI were more likely to be smokers (10.5% vs 8.2%, P = .04) and diabetic (4.5% vs 1.8%, P < .01). Females suffered more SSI than males (0.5% vs 0.3%, P = .02). Trunk/extremity procedures had a higher incidence of SSI compared to breast or face procedures (0.9% vs 0.2%, P < .01). On multivariate analysis, independent predictors of SSI included age (Relative Risk [RR] 1.01), female gender (RR 1.86), BMI (RR 1.07), smoking (RR 1.61), diabetes (RR 1.58), hospital or ambulatory surgery center procedures (RR 1.39), trunk/extremity procedures (RR 2.42), and combined procedures (RR 1.88). CONCLUSIONS: SSIs following cosmetic surgical procedures are associated with numerous independent predictors, which should be taken into consideration when counseling patients undergoing aesthetic surgery. LEVEL OF EVIDENCE: 2 Risk.

Venous Thromboembolism in the Cosmetic Patient: Analysis of 129,007 Patients.

Background: Venous thromboembolism (VTE) is one of the most feared postoperative complications in cosmetic surgery. The true rate of VTE in this patient population remains largely unknown with current American Society of Plastic Surgeons (ASPS) prophylaxis recommendations partially extrapolated from other surgical specialties. Objectives: This study analyzed the risk factors for VTE in cosmetic surgical procedures. Methods: A prospective cohort of patients who underwent aesthetic surgery between 2008 and 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of a clinically significant VTE within 30 days of surgery. Risk factors analyzed included age, gender, body mass index (BMI), smoking, diabetes, type of surgical facility, procedure by body region, and combined procedures. Results: A total of 129,007 patients were identified, of which 116 (0.09%) had a confirmed VTE. Combined procedures had a significantly higher overall rate of VTE compared to solitary procedures (0.20% vs 0.04%, P < .01). On multivariate logistic regression, significant risk factors for VTE (P < .05) included body procedures (RR 13.47), combined procedures (RR 2.4), increasing BMI (RR 1.06), and age (RR 1.02). Gender, smoking, diabetes, and type of surgical facility were not found to be significant risk factors. Face procedures (0.01%) and breast procedures (0.01%) had the lowest VTE rates, followed by combined face/body (0.16%), body procedures (0.21%), and combined body/breast procedures (0.28%). Conclusions: The incidence of VTE after cosmetic procedures is relatively low. However, the risk increases with combined procedures as well as with particular body areas, most notably trunk and extremities. Equally, significant patient risk factors exist, including BMI and age.

Safety of Cosmetic Surgery in Adolescent Patients.

Background: Limited surgical literature currently exists that evaluates postoperative complications after cosmetic surgery in adolescents. Objectives: The purpose of this study was to determine the incidence of major postoperative complications in adolescent patients undergoing cosmetic surgery and compare their complication rates to older patients. Methods: A prospective cohort of patients undergoing cosmetic surgical procedures between 2008 and 2013 was identified from the CosmetAssure database. Demographics, clinical characteristics, surgical procedures, and major complications in adolescent patients (age 10-19 years) and older patients (≥20 years old) were compared. Risk factors analyzed included age, gender, body mass index, smoking, diabetes, type of surgical facility, procedure by body region, and combined procedures. Results: Overall, 3519 adolescents and 124,409 older patients underwent cosmetic surgical procedures. The adolescent cohort contained more men (20.0% vs 6.0%, P < 0.01), lower mean body mass index (22.6 ± 4.1 vs 24.4 ± 4.6, P < 0.01), lower prevalence of diabetes (0.8% vs 1.9%, P <0.01), and fewer smokers (5.9% vs 8.3%, P < 0.01) compared to the older patient cohort. Most commonly adolescent patients underwent breast followed by face and body procedures. Overall adolescent patients demonstrated a lower incidence of major postoperative complications compared to older patients after single (0.6% vs 1.5%, P < 0.01) and combined (1.2% vs 3%, P = 0.03) cosmetic procedures. Adolescent patients had lower complications rates after face, breast, and body procedures compared to the older cohort. The most common postoperative complications in adolescent patients were hematoma (0.34%) and infection (0.28%). Conclusions: Cosmetic surgical procedures in adolescent patients are safe with a lower rate of major postoperative complications compared to older patients. Level of Evidence: 2.

Aesthetic Breast Surgery and Concomitant Procedures: Incidence and Risk Factors for Major Complications in 73,608 Cases.

Background: Major complications following aesthetic breast surgery are uncommon and thus assessment of risk factors is challenging. Objectives: To determine the incidence and risk factors of major complications following aesthetic breast surgery and concomitant procedures. Methods: A prospective cohort of patients who enrolled into the CosmetAssure (Birmingham, AL) insurance program and underwent aesthetic breast surgery between 2008 and 2013 was identified. Major complications (requiring reoperation, readmission, or emergency room visit) within 30 days of surgery were recorded. Risk factors including age, smoking, body mass index (BMI), diabetes, type of surgical facility, and combined procedures were evaluated. Results: Among women, augmentation was the most common breast procedure (n = 41,651, 58.6%) followed by augmentation-mastopexy, mastopexy, and reduction. Overall, major complications occurred in 1.46% with hematoma (0.99%) and infection (0.25%) being most common. Augmentation-mastopexy had a higher risk of complications, particularly infection (relative risk [RR] 1.74, P < 0.01), than single breast procedures. Age was the only significant predictor for hematomas (RR 1.01, P < 0.01). Increasing age (RR 1.02, P = 0.03) and BMI (RR 1.09, P < 0.01) were risk factors for infection. Concomitant abdominoplasty was performed in 4162 (5.8%) female patients and was associated with increased risk of complications compared to breast procedures or abdominoplasty performed alone. Among men, correction of gynecomastia was the most common breast procedure (n = 1613, 64.6%) with a complication rate of 1.80% and smoking as a risk factor (RR 2.73, P = 0.03). Conclusions: Incidence of major complications after breast cosmetic surgical procedures is low. Risk factors for major complications include increasing age and BMI. Combining abdominoplasty with any breast procedure increases the risk of major complications. Level of Evidence: 2.

Incidence and Preoperative Risk Factors for Major Complications in Aesthetic Rhinoplasty: Analysis of 4978 Patients.

Background: Rhinoplasty remains one of the most common aesthetic procedures performed in the United States. Current literature on rhinoplasty complications is inconclusive and is based on retrospective reviews and small cohorts. Objectives: The purpose of this study was to examine the incidence and identify predictive risk factors for major complications following rhinoplasty alone or in combination with other aesthetic operations in a large, prospective, multicenter database study. Methods: A prospective cohort of patients undergoing rhinoplasty between May 2008 and May 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of major complications, defined as complications requiring an emergency room visit, hospital admission, or a reoperation within 30 days of the index operation. Univariate and multivariate analysis evaluated potential risk factors for major complications including age, gender, body mass index (BMI), smoking, diabetes, type of surgical facility, and combined procedures. Results: A total of 129,007 patients were identified, of which 4978 (3.9%) underwent a rhinoplasty. The overall complication rate was 0.7% (n = 37). Hematoma was the most common complication (0.2%), followed by infection (0.2%), and pulmonary complications (0.1%). Age ≥40 years was found to be an independent risk factor for developing complications. Age ≥40 years was found to have a relative risk of 2.05 (P = 0.04) for any major complication. Complications increased from 0.58% in rhinoplasty alone cases to 1.02% (P < 0.05) with the addition of 1 other body region to 2.09% with the addition of 2 other body regions (P < 0.05). The risk of pulmonary complications increased from 0.1% to 1% (P < 0.05) with the addition of rhinoplasty with 2 other body regions. Gender, type of facility, smoking status, and BMI ≥25 did not appear to significantly impact the risk for major complications. Conclusions: The major complication rate following rhinoplasty remains low. The risk is increased with age ≥40 years and with the addition of other cosmetic procedures. Pulmonary complications, although rare, do occur, and also increase when combining rhinoplasty with other aesthetic surgery. These findings are important to consider when planning rhinoplasty and educating patients on the safety of combined aesthetic surgeries. Level of Evidence: 2.

Cosmetic Liposuction: Preoperative Risk Factors, Major Complication Rates, and Safety of Combined Procedures.

BACKGROUND: Liposuction is among the most commonly performed aesthetic procedures, and is being performed increasingly as an adjunct to other procedures. OBJECTIVES: To report the incidence and risk factors of significant complications after liposuction, and to determine whether adding liposuction to other cosmetic surgical procedures impacts the complication risk. METHODS: A prospective cohort of patients who underwent liposuction between 2008 and 2013 was identified from the CosmetAssure database. Primary outcome was occurrence of major complications requiring emergency room visit, hospital admission, or reoperation within 30 days of the operation. Univariate and multivariate analysis evaluated risk factors including age, gender, body mass index (BMI), smoking, diabetes, type of surgical facility, and combined procedures. RESULTS: Of the 31,010 liposuction procedures, only 11,490 (37.1%) were performed as a solitary procedure. Liposuction alone had a major complication rate of 0.7% with hematoma (0.15%), pulmonary complications (0.1%), infection (0.1%), and confirmed venous thromboembolism (VTE) (0.06%) being the most common. Independent predictors of major complications included combined procedures (Relative Risk (RR) 4.81), age (RR 1.01), BMI (RR 1.05), and procedures performed in hospitals (RR 1.36). When examining specifically other aesthetic procedures performed alone or with liposuction, combined procedures had a higher risk of confirmed VTE (RR 5.65), pulmonary complications (RR 2.72), and infection (RR 2.41), but paradoxically lower hematoma risk (RR 0.77) than solitary procedures. CONCLUSIONS: Liposuction performed alone is a safe procedure with a low risk of major complications. Combined procedures, especially on obese or older individuals, can significantly increase complication rates. The impact of liposuction on the risk of hematoma in combined procedures needs further investigation.