Global Prevalence and Preferences of Progressive Tension Suture Usage in Abdominoplasties.

BACKGROUND: Abdominoplasty is one of the most popular esthetic procedures. Seroma is the most frequent postoperative complication. Two decades of literature have described benefits of quilting sutures/progressive tension sutures (PTS) in reducing seroma rates and other complications in abdominoplasties. Despite this, PTS have not been universally adopted by plastic surgeons (ISAPS international survey on aesthetic/cosmetic procedures performed in 2020, 2021) Furthermore, PTS techniques and preferences vary widely. OBJECTIVE: The aim of this study is to determine the prevalence of PTS use, reasons for reluctance to utilize them, and variety of techniques utilized by plastic surgeons performing abdominoplasties internationally. METHODS: A 13-question survey was emailed via ISAPS to 3842 plastic surgeons internationally. Responses were collected and analyzed. RESULTS: Of the 272 respondents, the majority, 58%, currently use PTS. 46% were introduced to PTS during training. Only PTS training exposure was found to significantly correlate with current usage. Only 22% of North American trainees were exposed to PTS compared to 40-62% of trainees from other geographies. Of respondents who utilize PTS, most, 74%, combine them with drains. The majority use interrupted sutures, 65%, while 19% utilize a running suture, and the remaining 16% combine interrupted and running sutures. Of respondents who do not currently utilize PTS, the most common reason stated is that the surgeon's technique works well without them, 73%, which was significantly correlated with years in practice. CONCLUSION: Globally, most plastic surgeons currently utilize PTS (typically with drains) with training exposure being a significant predictor. There are still areas to address reluctance to implement them and use them without drains. LEVEL OF EVIDENCE III: 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 .

A Crowdsourced Evaluation of Facial Averageness and Attractiveness.

BACKGROUND: Evolutionary psychologists have demonstrated that humans are attracted to individuals who possess average anatomy for the population. OBJECTIVES: The aim of this study was to prove that a composite of average facial features would be more attractive to raters than the cohort utilized to create the composite. METHODS: The male and female cohorts each consisted of 41 standardized frontal-view monochrome photographs, with 1 composite image derived from the other 40 real images. Amazon Mechanical Turk, a widely used crowdsourcing platform, was utilized to obtain ratings of images ranging from 1 to 7, with 1 and 7 being least and most attractive, respectively. The strength of the preference for the composite over the real images was assessed by the difference between the mean rating of the composite and real images. RESULTS: In total, 870 and 876 respondents were recruited to rate the male and female cohorts, respectively. For the male and female cohorts, the composite image was rated significantly higher than the rest of the cohort overall and across all ages, genders, and countries of residence (all P < 0.0001). For both cohorts, the strength of the preference was significantly higher for European respondents and lower for South American and nonbinary respondents (all P < 0.05). CONCLUSIONS: This study reveals that average facial anatomy is perceived as most attractive across all demographics, a finding that is hoped to serve as a stepping stone for further studies leading to objective cosmetic quantifications and integrating evidence-based medicine into aesthetic surgery.

Seromas: How to Prevent and Treat Them-a 20-Year Experience.

Seromas are a common complication in plastic surgery. In this article, the authors describe their approach to the prevention and treatment of seromas and include a discussion of the evolution of their techniques. They provide specific technical details for many body contouring operations, including abdominoplasty, belt lipectomy, brachioplasty, and thighplasty. Many of the authors' techniques question the traditional dictums of plastic surgery, and they hope to encourage others to consider novel techniques for the treatment and prevention of seromas.

Seromas: How to Prevent and Treat Them-a 20-Year Experience.

Seromas are a common complication in plastic surgery. In this article, the authors describe their approach to the prevention and treatment of seromas and include a discussion of the evolution of their techniques. They provide specific technical details for many body contouring operations, including abdominoplasty, belt lipectomy, brachioplasty, and thighplasty. Many of the authors' techniques question the traditional dictums of plastic surgery, and they hope to encourage others to consider novel techniques for the treatment and prevention of seromas.

The Surgical Suture.

Surgeons must select the optimal suture materials for tissue approximation to maximize wound healing and scar aesthetics. Thus, knowledge regarding their characteristics is crucial to minimize ischaemia, excess wound tension, and tissue injury. This article describes the selection of various suture materials available today and their intended design. Modern suture material should have predictable tensile strength, good handling, secure knot-tying properties, and could be enhanced with an antibacterial agent to resist infection. Tensile strength is limited by suture size. The smallest suture size that will accomplish the purpose should be chosen to minimize tissue trauma and foreign material within tissues. Monofilament suture has lower resistance when passed through tissues, whereas multifilament sutures possesses higher tensile strength and flexibility but greater tissue friction and pose risks of suture sinus and infection. Natural absorbable sutures derived from mammalian collagen undergo enzymatic degradation whereas synthetic polymers undergo hydrolysis. Collagen or polymer structures in the suture can be modified to control absorption time. In contrast, nonabsorbable sutures typically cause an inflammatory reaction that eventually encapsulates by fibrous tissue formation. Excess reaction leads to chronic inflammation, suboptimal scarring, or suture extrusion. More recently, barbed sutures have transformed the way surgeons approximate wounds by eliminating knots, distributing wound tension, and increasing efficiency of closure. Similarly, modern skin adhesives function both as wound closure devices as well as an occlusive dressing. They eliminate the need for skin sutures, thus improving scar aesthetics while sealing the wound from the external environment.

The Surgical Needle.

A variety of modern surgical needles are available to today's surgeon. However, a surgeon's preference of surgical needles, is usually influenced by experience, ease of use, and the postoperative result, such as scar quality. This article describes the selection of needle designs available, and their intended clinical applications. Key factors in the basic design of the surgical needle include, the quality of its alloy, surface coating, and needle geometry. The needle alloy provides strength and ductility. Silicon coating maintains the sharpness and consistency of penetration of the needle. Sharpness is also determined by the angle of the point and taper ratio of the needle. Needle sizes range from extremely fine microsurgical needles to very thick needles for sternal closure. Needlepoint type is selected based on the particular tissue type where they are used. A conventional cutting needle is used for tough tissue, such as skin, whereas a reverse cutting needle is selected to reduce the risk of tissue cutout. Round-body needles are used in tissues that are easy to penetrate and in crucial procedures such as tendon repair, where suture cutout would be disastrous. A blunt-point, round-body needle dilates rather than cuts, and is preferred in abdominal fascial closure, to prevent inadvertent visceral injury and bleeding. The taper-cut needle punctures and then dilates and is used for vascular anastomosis. Although the needle and suture choice are entirely the surgeon's, this article hopefully may serve as a reference for those who are deciding on these issues critically.

Evidenced-Based Approach to Abdominoplasty Update.

The following publication was compiled as an evidence-based update for plastic surgeons performing abdominoplasty from a review of the published literature on that subject between January 2014 and February 2017. It is an overview of various aspects of abdominoplasty including preoperative patient assessment, variations and advances in both surgical and anesthetic technique, patient safety, and outcomes. It is intended to serve as an adjunct to previously published evidence-based reviews of abdominoplasty.

Predictive risk factors of venous thromboembolism in autologous breast reconstruction surgery.

BACKGROUND: Venous thromboembolism (VTE) can be a significant cause of morbidity and mortality in autologous breast reconstruction surgery. The aim of this study was to evaluate the effect of patient characteristics, comorbidities, payer type, reconstruction type, reconstruction timing, radiation, chemotherapy, and teaching status of hospital on VTE (deep venous thrombosis and/or pulmonary embolism) in autologous breast reconstructive surgery. METHODS: Using the Nationwide Inpatient Sample (NIS) database, we examined the clinical data of patients who underwent autologous breast reconstructive surgery in 2009 to 2010 in the United States. Univariate and multivariate regression analyses were performed to identify factors predictive of in-hospital VTE. RESULTS: A total of 35,883 patients underwent autologous breast reconstructive surgery during this period. Overall rate of VTE was 0.13%. The highest rate of VTE (0.26%) was observed in pedicled transverse rectus abdominis myocutaneous flap. Patients who experienced VTE had significantly longer mean hospital stay (11.6 vs 3.9 days; P < 0.001) and higher mean total hospital charges ($146,432 vs $61,794; P < 0.001) compared with non-VTE patients; however, there was no significant difference observed in mortality rate (VTE, 0.0% vs non-VTE, 0.04%; P = 0.886). Using multivariate regression analysis, immediate reconstruction after mastectomy (adjusted odds ratio [AOR], 5.4), older than 65 years (AOR, 4.2), obesity (AOR, 3.7), history of chemotherapy (AOR, 3.5), and chronic lung disease (AOR, 2.5) were associated with higher risk of VTE. There was no association between race, payer type, diabetes, hypertension, liver disease, congestive heart failure, peripheral vascular disease, chronic kidney disease, smoking, reconstruction type, radiation, or teaching status of hospital on VTE. CONCLUSIONS: In patients undergoing autologous breast reconstruction surgery, immediate reconstruction, older than 65 years, obesity, history of chemotherapy, and chronic lung disease are all independent predictors of higher VTE. Surgeons should consider these factors and use appropriate prophylaxis to minimize the risk of VTE development.

Preference for Averaging in East Asian Faces: A Source of Potential Guidance in Aesthetic Plastic Surgery.

Background: Relatively little research has been done on the application of objective tools in guiding Ethnic Plastic Surgery in Asian patients. The evolutionary psychology theory of koinophilia, or love of average features, presents the basis for a solution to build a foundation for crowd-sourced East Asian aesthetic standards. Objectives: The authors hypothesize that the averaged composite face in a cohort will be viewed as significantly more attractive than their respective cohort. Methods: Cohorts were created based on the gender of the individual in the photograph (40 females and 40 males of East Asian descent). Two surveys were created, 1 for the female cohort and the other for the male. The surveys assessed the aesthetic preference of each photograph using a Likert scale ranging from 1 to 7. Surveys were distributed using the popular crowdsourcing program Amazon Mechanical Turk (Amazon, Seattle, WA). Results: The authors received 875 respondents for the male cohort survey and 876 respondents for the female cohort survey. For both the female and male cohorts, the composite images had a statistically significantly higher rating (P < .001) than the mean of the other images. Among other significant demographic findings, when considering both ethnicity and location of residence, Asian raters living in Asia preferred the composite significantly more than Asian raters living in North America (P < .001). Conclusions: Raters' preference for the composite average face is in concordance with the evolutionary psychology literature. Thus, this study affirms the utility of using facial composites to guide surgeons in identifying aesthetic standards for patients of East Asian descent.

Characterizing the Impact of Chitosan on the Nucleation and Crystal Growth of Ritonavir from Supersaturated Solutions.

The addition of polymeric materials is often used to delay nucleation or crystal growth and maintain the high supersaturation of amorphous drugs. Therefore, this study aimed to investigate the impact of chitosan on the supersaturation behavior of drugs with a low recrystallization tendency and elucidate the mechanism of its crystallization inhibition in an aqueous solution. It was carried out using ritonavir (RTV) as a model of poorly water-soluble drugs categorized as class III of Taylor's classification, while chitosan was used as a polymer, and hypromellose (HPMC) was used for comparison. The inhibition of the nucleation and crystal growth of RTV by chitosan was examined by measuring the induction time. The interactions of RTV with chitosan and HPMC were evaluated by NMR measurements, FT-IR, and an in silico analysis. The results showed that the solubilities of amorphous RTV with and without HPMC were quite similar, while the amorphous solubility was significantly increased by the chitosan addition due to the solubilization effect. In the absence of the polymer, RTV started to precipitate after 30 min, indicating that it is a slow crystallizer. Chitosan and HPMC effectively inhibited the nucleation of RTV, as reflected by a 48-64-fold enhancement in the induction time. Furthermore, NMR, FT-IR, and in silico analysis demonstrated that the hydrogen bond interaction between the amine group of RTV and a proton of chitosan, as well as the carbonyl group of RTV and a proton of HPMC, was observed. This indicated that the hydrogen bond interaction between RTV and chitosan as well as HPMC can contribute to the crystallization inhibition and maintenance of RTV in a supersaturated state. Therefore, the addition of chitosan can delay nucleation, which is crucial for stabilizing supersaturated drug solutions, specifically for a drug with a low crystallization tendency.

Two Surgeons' Approaches to the Upper Body Lift: A Video Discussion.

Body contouring post massive weight loss is becoming increasingly more common. In this article and accompanying video, 2 experienced surgeons, Jeffrey Kenkel, MD, and Al Aly, MD, discuss the upper body lift procedure through a moderated discussion. The goal of this article is to elucidate the similarities and differences between the surgeons' guiding principles and specific approaches to this procedure. Topics covered in this discussion include indications, intraoperative sequencing, male chest, brachioplasty, closing technique, postoperative complications, and the typical postoperative course.

The Impact of Comorbidities on Patient Outcomes in the Upper Body Lift: A Retrospective Review.

Background: Nonsurgical and surgical weight loss options have improved over the past several decades resulting in an increased number of patients who present with body contour deformities. This review focuses on the upper truncal deformity. This deformity is discernable by its residual tissue laxity in the upper arm, back, lateral chest, and breast. Objective: The purpose of this study is to evaluate the morbidity of this procedure when these regions are treated in one operative setting. Methods: A retrospective chart review of patients who underwent an upper body lift for truncal deformities after massive weight loss by the senior author between August 2006 and December 2019 was performed. Patient comorbidities and demographics, preoperative parameters, operative factors, and minor and major complications were assessed. Results: No intraoperative or major complications occurred. The overall complication rate was 71% (20/28), which were all minor and most related to wound breakdown. Using logistical regression analysis, we found that neither BMI nor amount of weight resected contributed to a higher complication rate in this cohort. Simple matching coefficients analysis identified anemia, hypertension, lifetime smoking history, celecoxib use, and multiple concurrent procedures as comorbidities and intraoperative factors with an increased risk for adverse outcomes. Conclusions: This review helps define the role of upper body lift in the care of patients with massive weight loss and addresses the morbidity of a comprehensive approach to upper body deformity. Appropriate patient selection, preoperative patient counseling, sound operative technique, and supportive postoperative care can help to avoid adverse outcomes.

What is new in abdominoplasty?

The purpose of this article is to first review the traditional abdominoplasty procedure. Current studies focused upon improvements in abdominoplasty surgery and results of surgery will then be discussed.Abdominoplasty is a familiar procedure in plastic surgery and has increased in numbers performed by more than 300% in the past decade ((Brauman & Capocci, 2009).