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.

Age as a Risk Factor in Abdominoplasty.

Background: Recent studies reviewing large patient databases suggested that age may be an independent risk factor for abdominoplasty. However, these investigations by design considered only short-term major complications. Objectives: The purpose of this investigation was: (1) to compare the safety of abdominoplasty in an elderly and younger patient population; (2) to determine the complication rates across all spectrums: major, minor, local, and systemic; and (3) to evaluate complications occurring both short and long term. Methods: Abdominoplasty procedures performed from 2010 to 2015 were retrospectively reviewed. Subjects were divided into two groups: ≤59 years old and ≥60 years old. Major, minor, local, and systemic complications were analyzed. Patient demographics, comorbidities, perioperative details, adjunctive procedures were also assessed. Results: A total of 129 patients were included in the study: 43 in the older and 86 in the younger age group. The median age of The elderly and young groups was 65.0 and 41.5 years, respectively (P < .001). No statistically significant differences in major, minor, local, or systemic complications were found when both age groups were compared. Major local, major systemic, minor local, and minor systemic in the elderly were 6.9%, 2.3%, 18.6%, and 2.3%, while in the younger patients were 9.3%, 4.7%, 10.5%, and 0.0%, respectively (P > .05). Median follow-up time of the elderly (4.0 months) was no different than the younger (5.0 months) patients (P > .07). Median procedure time in the elderly (4.5 hours) was no different than the younger group (5.0 hours) (P = .4). The elderly exhibited a greater American Society of Anesthesiologist score, median body mass index (28.7 vs 25.1 kg/m2), and number of comorbidities (2.7 vs 0.9) (P < .001). Conclusions: There was no significant difference in either major or minor complications between the two groups. This suggests that with proper patient selection, abdominoplasty can be safely performed in the older age patient population. Level of Evidence: 2.

Pterygopalatine Fossa Anatomy for a Surgical Approach to Sphenopalatine Ganglion.

The sphenopalatine ganglion is an extracranial neural structure within the pterygopalatine fossa. Modulation of this region via implantation of a neuromodulatory device presents a novel therapy for the treatment of facial and head pain. Yet sex, race, and genetic factors contribute to morphological variations between individuals. This study defines the standards and variations of the bony landmarks surrounding the pterygopalatine fossa. One hundred dry skulls were analyzed from the Hamann-Todd osteological collection. Ten anatomical dimensions were measured on each side of the face for each specimen (vidian foramen, zygomatic buttress, zygomatic maxillary suture, pyriform rim, infraorbital rim, pterygoid maxillary suture, greater palatine foramen, auditory canal, and pterygoid fossa). A statistical analysis was performed for both sides of the face based on sex and race. When stratified by sex, 7 of the 10 measurements revealed a statistically significant difference bilaterally. When stratified by race, 5 of the 10 measurements demonstrated a statistically significant difference bilaterally. Both male and African American skulls showed greater hemifacial values bilaterally when compared with their respective counterparts. The only statistically significant measurement on both the left and right sides of all skulls was the length from the vidian foramen to the infraorbital rim. Defining the anatomical mean distance between skull landmarks and highlighting differences between sex and race not only provides further insight into relative skull anatomy, but also sets the stage for device innovation.

Who is Publishing in Facial Cosmetic Surgery? A Citation Analysis Across Specialties Over Five Decades.

BACKGROUND: Competition among our sister cosmetic specialties continues to increase. Once a field dominated by plastic surgeons, there is a clear trend toward increased competition from core and non-core disciplines. While these marketplace trends are obvious, how such competition has affected academia or peer reviewed publications is less clear. OBJECTIVES: We analyzed the most cited peer reviewed facial aesthetic literature over the past five decades to see if marketplace trends are echoed in a similar manner across the academic disciplines of plastic surgery, otolaryngology, dermatology, and ophthalmology. METHODS: The top 50 cited articles for each decade from the 1970s to the 2010s were identified for the topics of facelift, rhinoplasty, browlift, and blepharoplasty using the Thomson/Reuters Web of Knowledge. Data collected were: the number of citations/article, first authors' specialty affiliation, and journal specialty affiliation. Data were plotted graphically and trends were analyzed. RESULTS: With regards to first authorship, plastic surgery had the highest percentage across all surgeries at every time point, except for rhinoplasty from 2010-present, when otolaryngology had a higher percentage (48% vs 40%). Observed trends demonstrated: (1) increasing contributions from otolaryngology in rhinoplasty, facelift, and browlift; and (2) increasing contributions from ophthalmology in blepharoplasty. Plastic surgery journals are the most common platform for publication across all four surgeries. CONCLUSIONS: Plastic surgeons, and plastic surgery journals, still remain a strong force in academic facial cosmetic surgery. However, it appears that the competition from non-plastic surgeons observed in clinical practice is being mirrored in the area of journal publications. We as a specialty need to continue to strive for high quality academic productivity.

Milestones Contributing to the Evolution of Craniofacial Surgery.

Craniofacial surgery (CFS) has a rich history of collaboration with a wide variety of surgical and nonsurgical specialties. This has resulted in a large volume of publications across this spectrum of subspecialties cataloging the advancements across the field. The authors aim to analyze the characteristics of the most cited articles in CFS. A literature search was performed using the Thomson/Reuters Web of Knowledge database to identify the top 50 most cited articles in CFS. The articles were analyzed for journal distribution, total citations, year of publication, citations per year, number of authors, type of article, institution, departmental affiliation, national affiliation, and top contributors. The articles were extracted from an assortment of 21 journals. The number of citations per article ranged from 115 to 1092 (average of 185). Forty-eight percent of articles were published in the 1990s, and 22% in the 2000s. The average number of years since publication until the present time was 21.34 (range 6-45 y). The most cited article (1092 citations and 52 citations/y) was an article by McCarthy et al on human mandible lengthening via gradual distraction. Departmental distribution indicated that the majority were attributable to departments of Plastic and Reconstructive Surgery for 21 articles (42%). Twenty articles were categorized under cranial defect/bone substitutes, 12 under craniosynostosis, 7 under surgical modeling, 6 under distraction osteogenesis, and the remaining 5 under other. These articles qualitatively represent important milestones in CFS. This study affirms the potential value of "number of citations" as a meaningful metric when assessing the importance of an article within CFS.

Complications Following Breast Augmentation In Transfeminine Individuals: A Systemic Review And Meta-Analysis.

BACKGROUND: Breast augmentation is the most commonly performed procedure for gender affirmation in transfeminine individuals. While adverse events among breast augmentation in cis-gender females were well-described, their relative incidence in transfeminine individuals patients is less elucidated. AIM: This study aims to compare complication rates after breast augmentation between cisgender females and transfeminine patients and to evaluate the safety and efficacy of breast augmentation in transfeminine individuals. METHODS: PubMed, the Cochrane Library, and other resources were queried for studies published up to Jan 2022. A total of 1864 transfeminine patients from 14 studies were included in this project. Primary outcomes including complications (capsular contracture, hematoma or seroma, infection, implant asymmetry/malposition, hemorrhage, skin or systemic complications), patient satisfaction, and reoperation rates were pooled. A direct comparison of these rates was performed against historical rates in cisgender females. RESULTS: Within the transfeminine group, pooled rate of capsular contracture was 3.62% ((95% CI, 0.0038-0.0908); hematoma/seroma was 0.63% ((95% CI: 0.0014-0.0134); infection incidence was 0.08% (95% CI, 0.0000-0.0054); implant asymmetry was 3.89% (95% CI, 0.0149-0.0714). There was no statistical difference between rates of capsular contracture (p=0.41) and infection (p=0.71) between the transfeminine vs cis-gender groups, while there were higher rates of hematoma/seroma (p=0.0095) and implant asymmetry/malposition (p<0.00001) in the transfeminine group. CONCLUSION: Breast augmentation is an important procedure for gender affirmation, and in transfeminine individuals carries relatively higher rates of post-operative hematoma and implant malposition relative to cisgender females.

Utility of Negative Pressure Wound Therapy: Raising the Bar in Chest Masculinization Surgery.

BACKGROUND: Prophylactic use of negative pressure wound therapy (NPWT) has been shown to decrease the incidence of postoperative complications. This study aimed to evaluate the utility of NPWT in chest masculinization with free nipple graft (FNG). METHODS: All consecutive male patients undergoing chest masculinization with FNG by a single provider at a single center were reviewed. Postoperative treatment with either NPWT or standard wound care (SWC) defined this study's cohorts. Patient characteristics and postoperative complications were compared between patients receiving NPWT versus SWC. RESULTS: One hundred thirty-one patients with 262 closed breast incisions (NPWT=72, SWC=190) met inclusion criteria. Overall complications were higher in the SWC cohort (n=80/190, 42%) compared to the NPWT cohort (n = 13/72, 18%, p < 0.001). The NPWT group had significantly lower rates of partial nipple graft loss (9/72, 12.5% versus 47/190, 24.7%, p = 0.031), seroma formation (1/72, 1.4% versus 15/190, 7.9%, p = 0.037), and nipple hypopigmentation (6/72, 8.3% versus 36/190, 18.9%, p = 0.024) when compared to the SWC cohort. Time to drain removal was significantly faster in the NPWT group (NPWT 7 days versus SWC 9 days, p ≤ 0.001). CONCLUSIONS: Patients receiving NPWT over their closed incisions following chest masculinization with FNG were found to have significantly lower rates of partial nipple graft necrosis, seroma formation, and time to drain removal compared to those receiving SWC. Future prospective, randomized studies to further elucidate the role of NPWT in top surgery are warranted.

Sclerotherapy as an alternative treatment for complex, refractory seromas.

Traditional therapy for seromas often entails compression, aspiration, drainage, or surgical excision and re-closure; however, more complex, treatment-refractory seromas may require additional treatment. Sclerotherapy has been well documented in the treatment of simple pleural effusions, vascular malformations, lymphoceles and seromas. However, little evidence is available on the efficacy of sclerotherapy in complex, treatment-refractory seromas that develop post-operatively in patients with complex medical histories. We present a case series highlighting the use of sclerotherapy by interventional radiology as an alternative or adjunctive treatment method for chronic, high-volume post-operative seromas recalcitrant to multiple attempts of traditional treatment. At long-term follow-up, the seromas resolved after a maximum of four rounds of sclerotherapy with various combinations of known sclerosants. Highly complex cases of large, chronic seromas may be refractory to conservative modalities and re-closure. Sclerotherapy can be considered an alternative method or adjunctive treatment for chronic, recalcitrant post-operative seromas.

The Effect of Age on Fat Distribution in the Neck Using Volumetric Computed Tomography.

BACKGROUND: Neck fat distribution plays an important role in aging, yet how fat distribution changes with age is largely unknown. This study used volumetric computed tomography in live patients to characterize neck fat volume and distribution in young and elderly women. METHODS: A retrospective analysis was conducted of head and neck computed tomographic angiographs of 20 young (aged 20 to 35 years) and 20 old (aged 65 to 89 years) women. Fat volume in the supraplatysmal and subplatysmal planes was quantified. Distribution of fat volume was assessed by dividing each supraplatysmal and subplatysmal compartment into upper, middle, and lower thirds. RESULTS: Total supraplatysmal fat volume was greater than subplatysmal in all patients. Young patients had more total supraplatysmal fat than old patients (p < 0.0001). No difference was found between age groups in subplatysmal fat (p > 0.05). No difference was found between upper/middle/lower third supraplatysmal fat volumes in young patients. When comparing supraplatysmal thirds within the elderly population, the middle third fat volume (28.58 ± 20.01 cm3) was greater than both upper (18.93 ± 10.35 cm3) and lower thirds (15.46 ± 11.57 cm3) (p < 0.01). CONCLUSIONS: This study suggests that total supraplatysmal fat volume decreases with age. Older patients had more fat volume in the upper and middle thirds compared with the lower third of the supraplatysmal fat compartment, whereas young patients had more evenly distributed fat. These results suggest that fat deposition and redistribution in the neck occur with age and may be a contributing factor to the obtuse cervicomandibular angle of the elderly.

A Novel Application of Magnetic Resonance Imaging to Surgical Planning of Penile Inversion Vaginoplasty.

Transfeminine patients undergoing vaginoplasty frequently require reoperation due to dissatisfaction with insufficient vaginal dimensions. The goal of this study was to evaluate the role of preoperative imaging with magnetic resonance imaging (MRI) in establishing appropriate patient expectations and surgical planning for vaginoplasty procedures. In this retrospective review, we identified all patients that received MRI before undergoing penile inversion vaginoplasty by a single surgeon from 2019 to 2020. Our findings suggest that MRI can provide valuable information that can be used to set realistic expectations with patients as well as for operative planning for vaginoplasty procedures. Unlike traditional planning, MRI eliminates subjectivity in its estimate of vaginal depth. Future studies should incorporate a larger patient population and objectively analyze the impact of preoperative imaging on patient satisfaction and other measures of operative outcomes.

A controlled cost and outcomes analysis of acellular dermal matrix and implant-based reconstruction.

INTRODUCTION: The use of acellular dermal matrix (ADM) for breast reconstruction continues to change in both single- and two-stage reconstruction. Determining optimal outcomes clinically, aesthetically, financially as well as for the patient's quality of life has become a priority. METHODS: A retrospective review of implant-based reconstructions was performed at a single center from 2010 to 2016, with patients blindly matched 1:1:1 into three cohorts based on reconstruction type: 1) single stage direct to implant with ADM, 2) two-stage tissue expander to implant (TE/I) without ADM, and 3) two-stage TE/I with ADM. Relative cost between groups, esthetic outcomes, and quality of life within each group was analyzed. RESULTS: Group 1 was more likely to be older and use intraoperative angiography, but with fewer overall surgeries and postoperative visits (p<0.001). There was no statistically significant difference in reconstructive success among all three groups (p = 0.85). Cost was significantly higher for group 3 relative to groups 1 and 2. Overall appearance was higher in groups 1 and 3 relative to group 2, with radiation therapy the only independent factor. Group 1 had higher scores using Breast-Q for the physical well-being domain (p = 0.01). CONCLUSION: This is the first study to incorporate clinical outcomes, esthetic visual grading, and patient-reported quality within the same cohort of individuals, considering both use of ADM and staging. Despite the added ADM cost, it is proven safe, eliminates time and cost associated with tissue expanders, decreases post-operative visits and can lead to equally as functional and aesthetically pleasing outcomes in single- and two-stage breast reconstructions.

Relevant Surgical Anatomy of Pterygomaxillary Dysjunction in Le Fort III Osteotomy.

BACKGROUND: Le Fort III osteotomy represents the foundation of surgical correction for midface hypoplasia. One serious complication of Le Fort III osteotomy is severing the internal maxillary artery or its branches during osteotome advancement for pterygomaxillary dysjunction. This study sought to characterize the relevant surgical anatomy of the infratemporal fossa and of the internal maxillary artery as it enters the pterygomaxillary fissure. METHODS: Bilateral midface dissections were performed on 15 fresh, normocephalic adult cadavers (30 hemifaces). Four superficial anatomical measurements were performed on the surface of the face, followed by 10 deep measurements of the internal maxillary artery and its branches relative to the infratemporal fossa and its surrounding bony landmarks. RESULTS: The distance from the anterosuperior aspect of the zygomatic arch to the sphenopalatine artery entering the pterygomaxillary fissure was 38.9 ± 3.2 mm. The distance from the alveolar process of the maxillary bone to the sphenopalatine artery entry into the pterygomaxillary fissure was 30.3 ± 6.4 mm. The zygomaticofrontal suture was 43.4 ± 8.5 mm from the sphenopalatine artery entry into the pterygomaxillary fissure, 58.8 ± 8.0 mm from the pterygomaxillary junction, and 74.9 ± 6.5 mm from the maxillary alveolar process. The distance from the sphenopalatine artery to the posterior superior alveolar artery was 14.4 ± 4.1 mm. Elevation of the internal maxillary artery from the lateral pterygoid plate was 5.8 ± 2.5 mm. CONCLUSION: This study characterizes the surgical anatomy of the infratemporal fossa in the context of Le Fort III osteotomies and their associated pterygomaxillary dysjunctions.