The Potential Impact of COVID-19 on Aesthetic Fellowship Programs.

BACKGROUND: The COVID-19 pandemic has brought about immense change in health care. Surgical specialties in particular have had to make major adjustments because of the cancellation of nonemergent surgeries. Aesthetic surgery fellowships are uniquely affected because of the high number of elective cases and the length of the fellowship. The impact of the COVID-19 pandemic on current and upcoming aesthetic surgery fellows has not been studied. OBJECTIVE: The aim of this article was to study the potential impact of the COVID-19 pandemic on both American Society for Aesthetic Plastic Surgeons-endorsed and nonendorsed aesthetic fellowship programs. METHODS: A 23-question anonymous web-based survey was sent to aesthetic surgery fellowship directors with an active program in the United States. Surveys were collected from April 18, 2020, through May 14, 2020, with Qualtrics and then analyzed with Microsoft Excel. A 7-question follow-up survey was sent to directors, and a 23-question survey was sent to aesthetic surgery fellows. Data for these surveys were collected from June 6, 2020, through August 18, 2020. The surveys asked questions pertaining to adjustments and impact on current fellow training, as well as possible impact on fellows starting in 2020 and 2021. RESULTS: There was a 65.5% (19 of 29) response rate for the initial director survey, a 31% (9 of 29) rate for the director follow up survey, and a 28% (9 of 32) rate for the fellow-specific survey. All directors and fellows reported that the pandemic had some impact on aesthetic fellow training. A total of 5.3% of directors reported that they believe COVID-19 would have a "significant impact" on their fellows becoming well-trained aesthetic surgeons, whereas 66.7% of fellows reported that it will have a "mild impact." Predicted impact on future fellows was not as significant. CONCLUSION: Telemedicine, educational efforts, and standardization of guidelines can be increased to minimize loss of training due to COVID-19. Ongoing evaluation and shared experiences can assist fellowships in customizing programs to provide well-rounded education during the pandemic.

Neck rejuvenation--anatomy and clinical correlation.

The restoration of the aesthetic contour of the neck is a challenging but important component of facial rejuvenation. Numerous techniques have been developed to improve the aesthetic outcome. We plan to give an overview of anatomic principles and their clinical correlation.

Promotion of incisional wound repair by human mesenchymal stem cell transplantation.

The purpose of this study was to determine the effect of transplanted human mesenchymal stem cells (hMSCs) on wound healing. In this model, full-thickness cutaneous wounds were created by incision in the skin of adult New Zealand white rabbits and treated by transplanted hMSCs into the wounds. Wound healing was evaluated by histological analysis and tensiometry over time. A total of 15 New Zealand white rabbits with 10 wounds per animal were examined in this study. Animals were treated with hMSCs and euthanised at 3, 7, 14, 21 and 80 days after manipulation. The hMSCs were labelled with a fluorescent dye (CM-DiI), suspended in phosphate-buffered saline and used to treat full-thickness incisional wounds in rabbit skin. Tensiometry and histology were used to characterise the wound-healing rate of the incisional wounds. These results showed that transplanted hMSCs significantly inhibited scar formation and increased the tensile strength of the wounds. Importantly, MSCs from genetically unrelated donors did not appear to induce an immunologic response. In conclusion, human mesenchymal stem cell therapy is a viable approach to significantly affect the course of normal cutaneous wound healing and significantly increase the tensile strength.

Suture suspension technique for midface and neck rejuvenation.

Seventeen patients averaging 51 years of age underwent 23 surgical procedures, including suture suspension for both midface and neck rejuvenations. A 3/0 polypropylene thread with bioabsorbable cones with multiple point fixations in addition to 2 x 0.5-cm polypropylene surgical mesh are used in this technique. The mean postoperative, follow-up time was 9 months. Of the 17 patients, 12 underwent this procedure for midface rejuvenations, 3 for facial palsy, 5 for neck aesthetic procedures, 2 for brow ptosis, and 1 for brow asymmetry. The average number of sutures used for each face was 4 and 2 were used for each neck. The authors present an anatomic study for the safe placement of sutures, the surgical technique, and a microscopic photo documentation of the fibrosis around the suture knot and cone. All patients developed temporary edema. Two patients had a moderate aesthetic improvement of the face, and 1 patient underwent resuspension of the sutures 4 months postsurgery. Overall early patient satisfaction at 9 months was 90%. This technique has the potential to be a useful and effective clinical tool for minimally invasive face and neck rejuvenations.

Open repair of ventral incisional hernias.

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

Effect of adenoviral mediated overexpression of fibromodulin on human dermal fibroblasts and scar formation in full-thickness incisional wounds.

Fibromodulin, a member of the small leucine-rich proteoglycan family, has been recently suggested as a biologically significant mediator of fetal scarless repair. To assess the role of fibromodulin in the tissue remodeling, we constructed an adenoviral vector expressing human fibromodulin cDNA. We evaluated the effect of adenovirus-mediated overexpression of fibromodulin in vitro on transforming growth factors and metalloproteinases in fibroblasts and in vivo on full-thickness incisional wounds in a rabbit model. In vitro, we found that Ad-Fibromodulin induced a decrease of expression of TGF-beta(1) and TGF-beta(2) precursor proteins, but an increase in expression of TGF-beta(3) precursor protein and TGF-beta type II receptor. In addition, fibromodulin overexpression resulted in decreased MMP-1 and MMP-3 protein secretion but increased MMP-2, TIMP-1, and TIMP-2 secretion, whereas MMP-9 and MMP-13 were not influenced by fibromodulin overexpression. In vivo evaluation by histopathology and tensile strength demonstrated that Ad-Fibromodulin administration could ameliorate wound healing in incisional wounds. In conclusion, although the mechanism of scar formation in adult wounds remains incompletely understood, we found that fibromodulin overexpression improves wound healing in vivo, suggesting that fibromodulin may be a key mediator in reduced scarring.

Mastectomy with breast reconstruction in previously augmented patients: indications for implant removal.

Surgeons performing breast reconstruction in previously augmented patients can either leave the preexisting implant in place and incorporate the implant into the reconstruction, or remove the implant, usually performing an implant exchange. The focus of this study is to identify indications for implant removal in previously augmented patients undergoing mastectomy with breast reconstruction. We performed a retrospective chart review of patients who underwent breast reconstruction from 1997-2007 at University of Alabama, Birmingham Medical Center. Of these patients, 54 had previous augmentation with silicone or saline implants. Twenty-two of these underwent bilateral breast reconstruction, making a total of 76 reconstructed breasts. Patients were followed for a mean of 2.1 years (range 0.1-5.1 years). The mean body mass index was 23.0 (range 18-30). Implants were explanted in all but one patient. Reasons for implant removal or exchange included subglandular position (n = 39), aged silicone implant (n = 50), rupture or leak (n = 24), implant exposure (n = 1), and infection (n = 1). Some patients had more than one reason for explantation. We recommend removal of preexisting implants for patients who have implants in a subglandular position, ruptures or leaks, site infections, implant exposures, capsular contractures, pain, indolent seromas, aged silicone implants, poor cosmesis, plans for or history of radiotherapy, and close proximity of tumor to implant. We also remove implants to respect patient preferences and to achieve symmetry in our reconstruction. Consequently, we find in our practice that most of previously augmented patients who undergo breast reconstruction will also undergo implant removal.

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

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

Reconstruction of the abdominal wall for incisional hernia repair.

BACKGROUND: Abdominal wall reconstruction with mobilization of autologous tissue has evolved as a reliable option for patients with incisional hernias. METHODS: With the aim of evaluating morbidity and recurrence rates in patients who underwent abdominal wall reconstruction for incisional hernia repair, we retrospectively reviewed the charts of 188 patients treated between 1996 and 2003. RESULTS: Primary approximation of the fascial defect was achieved in 77% and was reinforced by either mesh placement or rectus muscle advancement. The remaining 23% were reconstructed either by mesh placement, components separation, or distant flap mobilization. Median follow-up was 15 months. Overall morbidity rate was 38%; recurrence rate was 13%. Dimensions of the hernia and intraoperative enterotomies were associated with postoperative complications. Lack of complete restoration of the myofascial abdominal wall continuity was associated with recurrence. CONCLUSIONS: In patients with incisional hernias, techniques involving autologous tissue mobilization are safe and associated with low recurrence rates.

Dissection Technique for Abdominoplasty: A Prospective Study on Scalpel versus Diathermocoagulation (Coagulation Mode).

BACKGROUND: The purpose of this study was to evaluate the effect of the dissection technique on outcomes and complications after a full abdominoplasty, comparing 2 different techniques used to raise the abdominal flap: the steel scalpel and the diathermocoagulation device on coagulation mode. METHODS: A prospective study was performed at a single center from January 2009 to December 2011 of patients submitted to abdominoplasty with umbilical transposition. Two groups were identified: group A, abdominoplasty performed with steel scalpel/knife; and group B, abdominoplasty performed with diathermocoagulation on coagulation mode. Several variables were determined: general characteristics, time until drain removal, daily and total volume of drain output, length of hospital stay, operative time, readmission, reoperation, emergency department visits, and local and systemic complications. RESULTS: A total of 119 full abdominoplasties were performed in women (group A, 39 patients; group B, 80 patients). There were no statistically significant differences between groups with respect to general characteristics, except for body mass index, comorbidities, and weight of the surgical specimen; there were no differences for operative time, systemic complications, hematoma, and necrosis incidence. The scalpel group had a highly significant reduction of 54.56% on total drain output, and a 2.65 day reduction on time to drain removal and no reported cases of seroma or healing problems (difference of 81.25% and 90.00%, respectively, between the 2 groups). CONCLUSIONS: Performing abdominal dissection with scalpel had a beneficial effect on patient recovery, as it reduced time requested for drain removal, total drain output, and incidence of seroma and wound healing problems.

Aesthetic eyelid ptosis correction: a review of technique and cases.

Upper eyelid ptosis can present both functional and aesthetic problems. Because proper correction of ptosis can be difficult to achieve, numerous surgical procedures have been developed. Plication of levator aponeurosis can be combined with aesthetic blepharoplasty and facial rejuvenation procedures to successfully address ptosis. The authors assessed the effectiveness of levator aponeurosis plication for correction of acquired upper eyelid ptosis in patients presenting for concomitant cosmetic facial procedures. The medical records of 74 consecutive patients (68 women and six men) who had upper eyelid ptosis correction in conjunction with cosmetic facial procedures from January of 1994 to January of 2000 were reviewed. During this period, 400 endoscopic forehead lifts and 479 face lifts were performed. The correction was performed through an external upper blepharoplasty approach removing an ellipse of skin and orbicularis muscle. Once the orbital septum was opened, a plication of the levator aponeurosis was accomplished by one or more horizontal mattress sutures of 6-0 clear nylon (with the first bite placed at or just medial to the vertical level of the pupil). The average follow-up period was 14 months. Long-term correction of the ptosis was excellent. The complications were minor, with the most common occurrence being asymmetry. Revisions were performed on only four patients. Correction of ptosis can be performed safely and effectively in conjunction with periorbital and facial rejuvenation. The technique described is simple, reliable, and reproducible.

Rejuvenation of the midface by elevating the malar fat pad: review of technique, cases, and complications.

The midface is an area where definite and consistent improvement is still hard to achieve. Vertical suspension of the malar fat pad is an effective midface lift that complements facial rejuvenation to obtain an overall appearance of youth and beauty while maintaining the personal features of the patient. To substantiate its effectiveness, the authors evaluated the complications and long-term results of the malar fat pad elevation proper and in conjunction with other facial procedures. A retrospective review of the medical records of 458 consecutive patients who underwent malar fat pad elevation by the senior author (B.C.D.) from January of 1994 to January of 2000 was conducted. Because 14 patients had their malar fat pad re-elevated, the number of midface lifts totaled 472. Of these, 437 had a combined superficial musculoaponeurotic system excision and tightening, 19 had a combined limited superficial musculoaponeurotic system plication/imbrication, and 16 had elevation of the malar fat pad only. Elevating the malar fat pad appears to be a sound, straightforward, and effective means of rendering a youthful midface. It consistently reshapes the malar eminence, softens the nasolabial fold, and rejuvenates the lower eyelid. This technique provides lasting results, with an acceptable complication rate. Facial nerve injury, in particular, was infrequent and temporary. In addition, the prehairline scar happened to be quite inconspicuous, especially in patients older than 55 years. This experience confirms that malar fat pad elevation is a safe and effective method to rejuvenate the central third of the face.

Endoscopic forehead lift: review of technique, cases, and complications.

Endoscopy has provided a significant improvement in the surgical rejuvenation of the upper face. It offers a minimally invasive alternative that avoids many of the undesirable effects associated with the coronal approach. The standard minimal access forehead endoscopic procedure consists of a subperiosteal undermining through three small triangular prehairline incisions. To successfully elevate the eyebrows, it is essential to release the periosteum at the level of the supraorbital rims and ablate the brow depressor muscles of the glabella. Until the periosteum reattaches itself, elevation is maintained by a temporary suspension suture between staples at the incision sites and 5 cm posterior to the hairline. The transverse closure of the triangular skin incisions achieves some additional elevation. The biplanar approach adds a partial subcutaneous undermining of the forehead to the endoscopic technique and allows plication of the frontalis muscle and excision of excess forehead skin. It is offered to patients with very ptotic eyebrows, deep transverse wrinkles, or a high forehead. The prehairline incision is a disadvantage but is tolerated quite well in older patients. The medical records of 393 consecutive patients who underwent endoscopic forehead lift from 1994 to 2000 were reviewed. Because seven patients had the endoscopic forehead lift repeated, the number of forehead endoscopies totaled 400. The complication rate was quite acceptable and did not markedly increase when a forehead lift was performed in combination with other facial procedures. The endoscopic forehead lift consistently attenuated the transverse forehead wrinkles, reduced the glabellar frown lines, and raised the eyebrows. It provided an appearance that was less tired and angry in addition to opening the area around the eyes. Long-term follow-up has shown that the endoscopic forehead lift produces lasting and predictable results.

Fine-tuning the endoscopic brow lift.

In the endoscopic brow lift, modifications in placement of incisions, extent and plane of dissection, and method of suspension can improve scars, reduce dynamic rhytids, and prevent alopecia, according to the authors. Changes in their technique over a 10-year period are discussed here. (Aesthetic Surg J 2002;22:69-71.).

Suture suspension of the malar fat pad.

BACKGROUND: Elevation of the malar fat pad by use of suture suspension to rejuvenate the central third of the face has been previously described. OBJECTIVE: The authors evaluated the ability of suture suspension to successfully elevate the malar fat pad. METHODS: Four fresh frozen cadaver dissections were studied. With the standard preauricular, subcutaneous approach, the malar fat pad was identified, and a suspension suture was placed at the inferior and lateral aspect of the fat pad. The vector of pull was directed vertically, and the tension that was applied to the suture was measured. The dermis was then elevated from the malar fat pad to examine suture placement and ensure that the dermis was not caught in the suture. RESULTS: An average tension of 11 lb was applied before rupture of the suture. In none of the cases did the suture pull through the malar fat pad. CONCLUSIONS: Suture suspension is an effective technique for elevation of the malar fat pad. The results are easy to reproduce and are very effective in addressing the changes that accompany aging and the descent of the malar fat pad. (Aesthetic Surg J 2002;22:446-450.).

Morphometric study (macroscopic and microscopic) of the lower abdominal wall.

BACKGROUND: Abdominoplasty using a more superficial plane of dissection has several advantages. Previous studies described a trilaminar structure (superficial and deep fat compartments separated by the Scarpa fascia) in the lower abdominal wall. This study aimed to gain a clearer understanding of compartment dominance and changes with increasing adiposity. METHODS: The study was performed on the surgical specimens of 41 female patients submitted to a full abdominoplasty. A morphometric study was performed on 82 sides to evaluate the thickness of the fat layers at predetermined locations (point A over the external oblique muscle and point B over the rectus abdominis muscle). A histologic study was performed in 31 samples to analyze the structure of the fat compartments and Scarpa fascia. RESULTS: A trilaminar structure was always present, and the Scarpa fascia did not become vestigial with increasing adiposity. Total thickness at point B was significantly higher than that at point A; this difference was mainly attributable to the superficial compartment. The deep fat compartment was always thinner than the superficial, corresponding to 25 percent of total thickness in point A and 23 percent in point B. It was less susceptible to an increase in thickness in cases of obesity. Histologic analysis demonstrated constant morphology, with an average Scarpa fascia thickness of 0.29 mm (point A) and 0.28 mm (point B). CONCLUSIONS: This study demonstrates a trilaminar structure with superficial compartment dominance and Scarpa fascia presence irrespective of adiposity in the lower abdominal wall. The deep fat compartment has a minor contribution to the lower abdominal wall thickness.