The Mastoid Crevasse and 3-Dimensional Considerations in Deep Plane Neck Lifting.

BACKGROUND: Advances in face and neck lifting involve release of tethering points along the superficial musculoaponeurotic system-platysma complex to freely manipulate the deep natural glide plane in the face and neck. OBJECTIVES: The aim of this article was to determine a combination of deep plane techniques for addressing the face and neck and to elucidate, for the first time, a measurable endpoint for the gonial angle. Analysis of deep plane tethering and decussation zones was also undertaken. METHODS: Extended deep plane surgery performed in 79 patients (158 hemifaces; age, 30-75 years; 95% female), over a 3-month period, was reviewed. Patients were followed for 1 year. Measurements were performed systematically during deep plane face and neck lifting. RESULTS: Before intervention, the mean [standard deviation] gonial depth was 9.4 [3.6] mm on the left and 8.3 [2.7] mm on the right. The mean depth created below the gonial angle when measuring the traditional suspension to the anterior mastoid was 15.8 [3.3] mm on the left and 13.7 [2.5] mm on the right. The distance postoperatively when measuring the gonial depth after performing the crevasse technique was 23.2 [2.2] mm on the left and 22.5 [2.5] mm on the right. This represents a mean increase in the advancement of 7.4 mm on the left and 8.8 mm on the right (average, 8.1 mm) which was demonstrated to be statistically significant bilaterally (P < .0001). CONCLUSIONS: The deep plane techniques described here aid manipulation of the deep plane and deep neck space, while also providing measurable endpoints and more effective modes of fixation by utilizing the mastoid crevasse. The use of techniques that release tension and allow redrape produce the most natural and well-balanced results.

Defining the Ideal Reduction Mammoplasty: A Crowdsourcing Study.

BACKGROUND: Reduction mammoplasty relieves macromastia symptoms while improving breast aesthetics, though the ideal breast aesthetically has been shown to differ culturally in previous crowdsourcing studies. Better understanding these differences can aid in setting postoperative expectations. OBJECTIVES: The aim of this study was to characterize the ideal reduction mammoplasty according to demographics such as gender, ethnicity, socioeconomic status, and education. METHODS: A crowdsourcing platform was used to collect 10,169 de-identified responses. Users completed one of three surveys, either a preoperative, postoperative, or preoperative and postoperative paired survey. The preoperative and postoperative surveys addressed 10 breast measurements including upper breast slope, projection proportion, nipple position, breast width, and breast fullness. The paired pre- and postoperative survey assessed nipple areolar complex (NAC), chest fit, symmetry improvement, and scarring. RESULTS: Preoperative images were rated more aesthetic than postoperative images. This was consistent across all demographics evaluated. Female, African American, Asian, participants aged 55+, and participants with no high school degree or a graduate degree found the most improvement in breast symmetry (p = 0.001, p = 0.002, p = 0.027, p < 0.001, p = 0.01). Male and Hispanic participants were most likely to see no change in symmetry (p = 0.008, p = 0.04), and South Asian participants found breasts less symmetric postoperative (p < 0.001). There were significant demographic differences in aesthetic ratings of NAC, scarring, and breast fit. CONCLUSIONS: Perceived breast aesthetics after reduction mammoplasty vary significantly across demographics including gender, ethnicity, age, socioeconomic status, and educational achievement. Surgeons should consider demographics when planning each patient's reduction mammoplasty.

Patients' Views on AI for Risk Prediction in Shared Decision-Making for Knee Replacement Surgery: Qualitative Interview Study.

BACKGROUND: The use of artificial intelligence (AI) in decision-making around knee replacement surgery is increasing, and this technology holds promise to improve the prediction of patient outcomes. Ambiguity surrounds the definition of AI, and there are mixed views on its application in clinical settings. OBJECTIVE: In this study, we aimed to explore the understanding and attitudes of patients who underwent knee replacement surgery regarding AI in the context of risk prediction for shared clinical decision-making. METHODS: This qualitative study involved patients who underwent knee replacement surgery at a tertiary referral center for joint replacement surgery. The participants were selected based on their age and sex. Semistructured interviews explored the participants' understanding of AI and their opinions on its use in shared clinical decision-making. Data collection and reflexive thematic analyses were conducted concurrently. Recruitment continued until thematic saturation was achieved. RESULTS: Thematic saturation was achieved with 19 interviews and confirmed with 1 additional interview, resulting in 20 participants being interviewed (female participants: n=11, 55%; male participants: n=9, 45%; median age: 66 years). A total of 11 (55%) participants had a substantial postoperative complication. Three themes captured the participants' understanding of AI and their perceptions of its use in shared clinical decision-making. The theme Expectations captured the participants' views of themselves as individuals with the right to self-determination as they sought therapeutic solutions tailored to their circumstances, needs, and desires, including whether to use AI at all. The theme Empowerment highlighted the potential of AI to enable patients to develop realistic expectations and equip them with personalized risk information to discuss in shared decision-making conversations with the surgeon. The theme Partnership captured the importance of symbiosis between AI and clinicians because AI has varied levels of interpretability and understanding of human emotions and empathy. CONCLUSIONS: Patients who underwent knee replacement surgery in this study had varied levels of familiarity with AI and diverse conceptualizations of its definitions and capabilities. Educating patients about AI through nontechnical explanations and illustrative scenarios could help inform their decision to use it for risk prediction in the shared decision-making process with their surgeon. These findings could be used in the process of developing a questionnaire to ascertain the views of patients undergoing knee replacement surgery on the acceptability of AI in shared clinical decision-making. Future work could investigate the accuracy of this patient group's understanding of AI, beyond their familiarity with it, and how this influences their acceptance of its use. Surgeons may play a key role in finding a place for AI in the clinical setting as the uptake of this technology in health care continues to grow.

Microscope-Assisted Arterial Anastomosis in Adult Living Donor Liver Transplantation: A Systematic Review and Meta-analysis of Outcomes.

BACKGROUND: Living donor liver transplantation (LDLT) has expanded the availability of liver transplant but has been associated with early technical complications including the devastating complication of hepatic artery thrombosis (HAT), which has been reported to occur in 14% to 25% of LDLT using standard anastomotic techniques. Microvascular hepatic artery reconstruction (MHAR) has been implemented in an attempt to decrease rates of HAT. The purpose of this study was to review the available literature in LDLT, specifically related to MHAR to determine its impact on rates of posttransplant complications including HAT. METHODS: A systematic review was conducted using PubMed/Medline and Web of Science. Case series and reviews describing reports of microscope-assisted hepatic artery anastomosis in adult patients were considered for meta-analysis of factors contributing to HAT. RESULTS: In all, 462 abstracts were screened, resulting in 20 studies that were included in the meta-analysis. This analysis included 2,457 patients from eight countries. The pooled rate of HAT was 2.20% with an overall effect size of 0.00906. CONCLUSION: Systematic literature review suggests that MHAR during LDLT reduces vascular complications and improves outcomes posttransplant. Microvascular surgeons and transplant surgeons should collaborate when technical challenges such as small vessel size, short donor pedicle, or dissection of the recipient vessel wall are present.

Molecular and Histological Evidence Detailing Clinically Observed Skin Improvement Following Cryolipolysis.

BACKGROUND: In addition to body contouring, there is anecdotal and clinical evidence of reduced laxity caused by skin tightening after cryolipolysis. However, it has not been established how cryolipolysis triggers dermal changes. OBJECTIVES: The aim of this study was to investigate the fundamental mechanisms behind clinically observed dermal changes by molecular and immunohistochemistry (IHC) analytical methods. METHODS: This feasibility study involved 7 subjects who received cryolipolysis treatment. Tissue samples were harvested from 3 days to 5 weeks after treatment. RNA-sequencing examined differential gene expression of major collagens. RNA in situ hybridization (RNA-ISH) investigated the distribution of 1 of the gene markers for collagen type I (COL1A1). IHC for procollagen type I, heat shock protein 47 (HSP47), transforming growth factor ß (TGF-ß), and tropoelastin was performed and quantified. RESULTS: Gene expression analysis highlighted a gradual upregulation of collagen mRNA genes. RNA-ISH confirmed upregulation of COL1A1 mRNA and showed a homogeneous distribution through the dermis. IHC showed increases in protein expression. Quantification revealed a 3.62-fold increase of procollagen type I (P < 0.0071), a 2.91-fold increase of TGF-ß (P < 0.041), a 1.54-fold increase of HSP47 (P < 0.007), and a 1.57-fold increase of tropoelastin (P < 0.39) compared with untreated areas. CONCLUSIONS: This study revealed significant induction of molecular and protein markers of type I collagen, which supports neocollagenesis and may play an essential role in clinically relevant skin improvement. A dermal remodeling process driven by increased TGF-ß and higher expression of HSP47 was observed. Overall, these data provide the first evidence of dermal remodeling and clarify the mechanism by which cryolipolysis may induce skin improvement.

Thin Perforator Flaps for Reconstruction of the Lower Extremity.

Thin flaps, a modification of traditional flaps that minimize the need for debulking and revision, offer unique advantages in the field of lower limb reconstruction. Advances in the field of microsurgery have made this streamlined method of reconstruction a viable solution for soft tissue coverage in patients with both trauma and nonhealing wounds. Better understanding of anatomy has allowed for flap harvest above the fascia level and the Scarpal plane. These modifications allow for flap transfer with thicknesses more comparable to the native anatomy of the lower leg, ankle, and foot. Flap survival is comparable to traditional techniques with greater potential for improved patient-centered outcomes.

Insta-Grated Plastic Surgery Residencies: 2020 Update.

BACKGROUND: Recent evidence shows accelerating worldwide adoption of social media and suggests a commensurate increase in social media use by integrated plastic surgery residency programs in the United States. Programs nationwide are now making strides to include a longitudinal social media component in their plastic surgery curriculum. OBJECTIVES: The aim of this study was to investigate the use of Instagram by plastic surgery residency programs and to describe trends in adoption, volume, and content. METHODS: Current active Instagram accounts affiliated to integrated plastic surgery residency programs were surveyed to identify date of first post, number of posts, number of followers, number of followings, engagement rate, most-liked posts, and content of posts. All data were collected on May 12, 2020. RESULTS: Sixty-nine out of 81 (85.2%) integrated plastic surgery residency programs had Instagram accounts, totaling 5,544 posts. This represents an absolute increase in program accounts of 392% since 2018. The 100 most-liked posts were categorized as: promotion of the program/individual (46), resident life (32), promotion of plastic surgery (14), and education (8). CONCLUSIONS: Instagram use by plastic surgery residency programs has drastically increased since it was first evaluated in 2018. This trend will continue as we reach near saturation of residency programs with accounts. We remain steadfast in our belief that the advantages of social media use by plastic surgeons and trainees are far outweighed by the potential community-wide impacts of violations of good social media practice on peers, patients, and the general public.

The Addition of Partial or Circumferential Liposuction to Abdominoplasty Is Not Associated With a Higher Risk of Skin Necrosis.

BACKGROUND: Combining abdominoplasty with liposuction is a common practice for optimal patient aesthetic outcomes. In the past, several practitioners have argued against liposuction due to the potential for vascular insufficiency, especially with central liposuction. Despite these concerns for flap damage with resultant necrosis, the incidence of this complication has not been comprehensively investigated. OBJECTIVES: The authors therefore examined the incidence of necrotic complications, including skin and fat necrosis as well as partial/total flap loss, in patients who underwent abdominoplasty alone (AA) or abdominoplasty with partial or circumferential liposuction (APCL). METHODS: Literature searches were performed in PubMed/Medline and Embase with no query limits. For the systematic review, data from the studies were extracted into a form including primary author, publication year, study design, number of AA and APCL patients, abdominal zone(s) treated with liposuction, average lipoaspirate volume, follow-up time, necrotic complications, and revision procedures. A meta-analysis was separately performed for 13 studies that included patients who underwent both AA and APCL. RESULTS: The overall rate of necrotic complications was lower in the APCL group (0.39%) compared with the AA group (1.01%). The incidence of necrotic complications was low for all patients, with a pooled partial flap loss rate of 0.24% and a pooled skin necrosis rate of 0.23%. The forest plots revealed that patients who underwent APCL do not face a higher risk of skin necrosis or revision compared with those who underwent AA. CONCLUSIONS: Performing APCL is a safe combined procedural approach and can confer added benefits of improved patient satisfaction and aesthetic outcomes.

The Efficacy of Negative Pressure Wound Therapy and Antibiotic Beads in Lower Extremity Salvage.

BACKGROUND: Antibiotic beads and negative pressure wound therapy (NPWT) represent two methods of wound management used during staged debridement in the post-trauma limb salvage pathway. The efficacy of NPWT and antibiotic beads in preventing infection remains unclear. METHODS: This study is a retrospective review of patients with traumatic lower extremity open fractures who received NPWT and/or antibiotic beads before soft tissue reconstruction at an urban level 1 trauma center between August 2007 and December 2015. Patients with wound infections before application of NPWT and/or antibiotic beads were excluded. RESULTS: In 73 lower extremities requiring soft tissue coverage, 46 received antibiotic beads and 48 received NPWT. Overall infection rate was 15.1%. Use of antibiotic beads was associated with a decreased risk of infection (6.4% versus 30.7%; P = 0.01). Use of NPWT was associated with an increased risk of one or more complications (45.7% versus 4.2%; P = 0.001). The development of infection was associated with a greater period of time between application of antibiotic beads (22 ± 13 versus 12 ± 6 d, P = 0.01) or NPWT (23 ± 15 versus 10 ± 11 d, P = 0.004) and soft tissue coverage. Overall limb salvage rate was 95.9%; secondary amputation was associated with development of infection (P = 0.001) but not with use of NPWT or antibiotic beads. CONCLUSIONS: Antibiotic beads may prevent infections in patients awaiting soft tissue coverage of wounds. NPWT may contribute to a greater rate of complication. Limb salvage was successful in most cases regardless of method of wound management.

Outcomes of Intracranial Versus Subcranial Approaches to the Frontofacial Skeleton.

PURPOSE: An intracranial approach to the craniomaxillofacial skeleton can be effective for correcting complex craniofacial dystoses such as frontofacial hypoplasia, hypertelorism, and orbital dystopia. However, the significant morbidity resulting from the high complication rates has limited intracranial use. Given the need for intracranial approaches for certain clinical indications, the present study reevaluated intracranial frontofacial procedures to determine their safety and outcomes. PATIENTS AND METHODS: A retrospective review was performed of all frontofacial procedures completed between 2007 and 2017 at a single institution. Patients who had undergone monobloc distraction alone or with facial bipartition, facial bipartition alone, or box osteotomy were included in the intracranial cohort. Those who had undergone Le Fort III distraction, advancement, or a combination with Le Fort I were included in the subcranial cohort. The recorded data included demographics, previous craniofacial surgery, and operative events. The complications rates were compared between the 2 cohorts. RESULTS: The present study included 65 patients-35 subcranial and 30 intracranial. The rates of previous craniomaxillofacial (P = .193) and intracranial (P = .340) surgery were equivalent between the 2 cohorts. Of the 30 intracranial and 35 subcranial patients, 26.7% and 34.3% experienced complications (P = .218). The intracranial patients experienced more dural tears (53.3 vs 5.7%; P < .0001); however, no significant differences were observed in cerebrospinal fluid leakage. Reintubations (n = 3; 4.5%) occurred exclusively in the subcranial group. No significant differences in the major and minor complication rates were observed between the 2 cohorts. CONCLUSIONS: Intracranial and subcranial frontofacial procedures are associated with an equal risk of major and minor complications. Given the lack of an increase in risk, intracranial frontofacial procedures should be considered for the management of complex craniofacial dystoses.

The Ideal Male Nipple-Areola Complex: A Critical Review of the Literature and Discussion of Surgical Techniques for Female-to-Male Gender-Confirming Surgery.

INTRODUCTION: Top surgery (mastectomy and masculinization of the chest) is a key gender affirming operation for many female-to-male transgender patients. Positioning of the nipple-areola complex (NAC) is a crucial part of this procedure. To date, there are no standards as to where to place the new NAC based on the patient's anatomy, to achieve the most aesthetically pleasing result. OBJECTIVE: The objectives of this study were to review the literature and analyze the anatomical averages for NAC shape, width, and height as well as vertical and horizontal placement and to compile the recommendations and proposed equations of NAC placement based on chest wall measurements, chest wall landmarks, and body habitus. METHODS: A systematic review of the literature was conducted in the spring of 2018. Eleven articles met the inclusion criteria, with objective measurements of, and guidelines for, positioning the male NAC in men that had not been preselected for being aesthetically perfect. RESULTS: The average diameter for a round NAC was 25.9 mm (SD, 2.5 mm), and the width and height of the oval-shaped NAC were found to be 25.3 mm (SD, 2.6 mm) and 20.1 mm (SD, 0.75 mm), respectively. The average sternal notch to nipple distance was found to be 19.3 cm (SD, 1.7 cm). The average internipple distance was 22.3 cm (SD, 1.6 cm). CONCLUSIONS: The data are inconclusive about the effects of anatomical measurements on NAC vertical and horizontal position, but areola diameter is reasonably consistent. There are a wide variety of guidelines and algorithms offered for determining these measurements.

A Randomized Controlled Trial Comparing a Medial Stabilized Total Knee Prosthesis to a Cruciate Retaining and Posterior Stabilized Design: A Report of the Clinical and Functional Outcomes Following Total Knee Replacement.

BACKGROUND: The purpose of this randomized controlled trial was to compare the performance of 3 total knee joint replacement (TKJR) designs 6 months after the surgery. METHODS: Patients were recruited between March 2015 and March 2018. Patients with osteoarthritis consented for TKJR were randomly allocated to a medial stabilized (MS), cruciate retaining (CR), or posterior stabilized (PS) design. Primary outcome measures were self-reported improvement in pain and function 6 months after TKJR, using the Oxford Knee Score. Secondary outcome measures were the Western Ontario and McMaster Universities Osteoarthritis Index, Veterans RAND 12-item Health Survey, Knee Society Score 2011, Timed Up and Go test, and Six-Minute Walk Test. Twelve-month outcomes were also measured. RESULTS: Ninety participants enrolled, 83 were randomized: PS (n = 26), CR (n = 28), and MS (n = 29) designs. One case withdrew before surgery: planned use of non-study implant; 7 did not complete all outcome measures. No 6-month between-group difference was observed for the primary outcome. A 6-month difference was observed in Knee Society Score 2011 Satisfaction: MS favored over CR and PS. Clinically meaningful 12-month differences in Western Ontario and McMaster Universities Osteoarthritis Index Pain, Function, and Global Subscales were observed: MS favored over CR. Twelve-month differences occurred in Veterans RAND 12-item Health Survey mental well-being, favoring MS and PS over CR. CONCLUSION: MS prosthesis can be expected to yield similar clinical and functional outcomes to PS and CR designs 6 months after TKJR, and patients were more satisfied with their outcome. Compared with CR, patients with MS prosthesis also reported superior pain, function, and quality-of-life outcomes at 12 months.

Contemporary Management of Alopecia: A Systematic Review and Meta-analysis for Surgeons.

BACKGROUND: The decision of surgical approach for hair restoration often involves evaluation of the type of alopecia; however, the impact of surgical hair restoration from existing techniques in specific population subsets has not been comprehensively investigated. OBJECTIVES: The authors sought to systematically review the literature on micrografts, minigrafts, mini-micrografts, tissue grafts, tissue flaps and expanders, as well as evaluate graft survival and satisfaction within specific populations in a meta-analysis. METHODS: PubMed and Scopus literature searches between 1980 and 2018 yielded 57 articles for systematic review and 34 articles for meta-analysis. Study design, mean patient age and gender, patient alopecia type, surgical hair restoration technique, number of treatment areas, mean follow-up, graft survival rate and satisfaction rate were extracted from each study, and a meta-analysis was performed. RESULTS: The pooled rates of graft survival were 84.98% (95% CI 78.90-91.06) using micrografts and 93.11% (95% CI 91.93-94.29) using micrografts and minigrafts in nonscarring alopecia patients, as well as 88.66% (95% CI 80.12-97.20) using micrografts and 86.25% (95% CI 74.00-98.50) using micrografts and minigrafts in scarring alopecia patients. The pooled rates of satisfaction were 89.70% (95% CI 82.64-96.76) using micrografts and 97.00% (95% CI 92.48-100.0) using micrografts and minigrafts in nonscarring alopecia patients, as well as 97.80% (95% CI 94.59-100.0) using micrografts and 88.70% (95% CI 66.49-100.0) using micrografts and minigrafts in scarring alopecia patients. Dot plots depict rates of graft survival rate from micrografts and satisfaction from micrografts and minigrafts. CONCLUSION: Surgical hair restoration for nonscarring and scarring alopecia yields high graft survival and satisfaction rates. 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.

Uncovering Lymphatic Transport Abnormalities in Patients with Primary Lipedema.

BACKGROUND: Although lipedema is often clinically distinguished from lymphedema, there is considerable overlap between the two entities. The purpose of this study was to evaluate lymphoscintigraphic findings in patients with lipedema to better characterize lymphatic flow in this patient population. METHODS: Patients with lipedema receiving lymphoscintigraphy between January 2015 and October 2017 were included. Patient demographics, clinical characteristics, and lymphoscintigraphic findings were extracted. Klienhan's transport index (TI) was utilized to assess lymphatic flow in patient's lower extremities (LEs).Scores ranged from 0 to 45, with values > 10 denoting pathologic lymphatic transport. RESULTS: A total of 19 total patients with lipedema underwent lymphoscintigraphic evaluation. Mean age was 54.8 years and mean body mass index was 35.9 kg/m2. Severity of lipedema was classified as stage 1 in five patients (26.3%), stage 2 in four patients (21.1%), stage 3 in four patients (21.1%), and stage 4 in six patients (31.6%). The mean TI for all extremities was 12.5; 24 (63.2%) LEs had a pathologic TI, including 7 LEs with stage 1 (29.2%), 3 LEs with stage 2 (12.5%), 6 LEs with stage 3 (25.0%), and 8 LEs with stage 4 lipedema (33.3%). The mean TI was significantly greater for extremities with severe (stage 3/4) lipedema than those with mild or moderate (stage 1/2) lipedema (15.1 vs. 9.7, p = 0.049). Mean difference in TI scores between each LE for individual patients was 6.43 (standard deviation +7.96). CONCLUSION: Our results suggest that patients with lipedema have impaired lymphatic transport, and more severe lipedema may be associated with greater lymphatic transport abnormalities.

Defining "Ideal Abs" Through a Crowdsourcing-Based Assessment.

BACKGROUND: There were almost 12 million nonsurgical cosmetic procedures performed in the United States in 2016, which represented a 12% increase from the previous year, and popularity is expected to continue rising. Furthermore, nonsurgical fat reduction and body contouring have experienced a dramatic increase in popularity among both men and women. However, there has been very little work focused on the public's perception of the ideal abdominal muscles. OBJECTIVES: The authors sought to analyze patient perspectives on ideal abdominal contours and attitudes towards methods of improving the appearance of the abdomen. METHODS: A prospective cross-sectional study of 718 random volunteers recruited through Amazon Mechanical Turk was conducted. A survey instrument was administered to all study participants to assess the importance of ab symmetry, pec muscle definition, serratus muscle definition, and natural feel. RESULTS: Study participants across all ages, gender, ethnicity, and marital status indicated that a 6-pack was the ideal abdominal muscle count. They also rated the symmetry (61.06 ± 1.87) and natural feel of abs (60.72 ± 1.75) as the 2 most important aesthetic features in consideration of ideal abs. Study participants who reported exercising more than twice a week expressed a greater interest in nonsurgical procedures to achieve ideal abs (P = 0.007). CONCLUSIONS: "Ideal abs" are 6 in number, symmetric, and feel natural. Millennials are much more willing to consider nonsurgical options to achieve ideal abs instead of surgery. Individuals who maintain a high level of fitness are, interestingly, more likely to want ideal abs and nonsurgical methods to achieve them.

Breast implant-associated anaplastic large cell lymphoma, a systematic review and in-depth evaluation of the current understanding.

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a T-cell neoplasm that arises in the capsule around breast implants. While an association with implants has been proposed, no causal link has been identified and the pathophysiology and natural history of BIA-ALCL remain unknown. A literature review of 391 articles was performed to assess the current understanding of BIA-ALCL and to provide a balanced and unbiased view of the current controversy surrounding the disease.

Penile Reinnervation Surgery: A Comprehensive Review of the Literature.

BACKGROUND: Modern approaches to erectile dysfunction (ED) often entail the use of multimodal medical therapy and surgery; however, with recent advances in microsurgery, new options may exist for patients suffering from ED. This comprehensive review of the literature serves to reevaluate anatomical and physiological principles that mediate erection to improve understanding for reconstructive surgeons hoping to offer new interventions. METHODS: A search strategy for this review was agreed upon by all authors. Articles were divided into 2 categories - primary and secondary. Primary articles were defined as those in which the anatomy of the pelvis and/or perineum was the primary focus of the article, whereas secondary did not directly focus on anatomic considerations. Select historical texts and textbook chapters were also included to provide well established and critical anatomical evidence for this review. RESULTS: Several approaches may be used to restore nerve function to treat neurogenic and vasculogenic ED. Somatic sensory loss can be treated by either direct neurorrhaphy or neuroplasty in the location of disruption. Microvascular techniques also exist to improve flow or to repair small vessels injured in the pelvis. Classical approaches to impotence include vein stripping to reduce venous outflow or direct vascularization to improve inflow. CONCLUSIONS: Postradical prostatectomy ED has been demonstrated to improve with microsurgical interventions. In the coming years, innovation will continue and collaboration between plastic surgeons and urologists will allow us to tackle this common and difficult problem.

Aesthetic Otoplasty: Principles, Techniques and an Integrated Approach to Patient-Centric Outcomes.

BACKGROUND: Otoplasty is a century-old procedure that, through continued modifications, now has over two hundred different procedures described in the literature. In this article, we seek to describe the anatomy and principles of aesthetic otoplasty, as well as some of the key contributions to aesthetic otoplasty. This article will also outline some of the most commonly used techniques today and associated patient outcomes. METHODS: We present a review of the literature of relevant anatomy, pathophysiology and common techniques and outcomes. We also provide a discussion of several patients with associated techniques and outcomes. RESULTS: The treatment of prominent ear has developed through manipulation and experimentation. The outcomes are defined by the native anatomy, the surgical technique and the attention to patient-centered outcomes. CONCLUSION: Aesthetic otoplasty remains one of the most important surgical techniques and common procedures in plastic surgery. Using an integrated approach guided by known principles as well as patient goals allows for optimal outcome in aesthetic otoplasty. LEVEL OF EVIDENCE V: 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 .

Alloplastic Facial Implants: A Systematic Review and Meta-Analysis on Outcomes and Uses in Aesthetic and Reconstructive Plastic Surgery.

BACKGROUND: Alloplastic materials in facial surgery have been used successfully for various applications in the reconstructive restoration or aesthetic augmentation of the facial skeleton. The objective of this study was to conduct a comprehensive systematic review of alloplastic implant materials utilized to augment the facial skeleton stratified by anatomical distribution, indication, specific material used, and respective outcomes. METHODS: A comprehensive systematic review on alloplastic facial implant data was conducted utilizing Medline/PubMed database. Articles were stratified by (1) anatomic localization in the face, as well as (2) alloplastic material. RESULTS: A total of 17 studies (n = 2100 patients, follow-up range = 1 month-27 years) were included. Overall, mersilene mesh implants were associated with the highest risk of infection (3.38%). Methyl methacrylate implants were associated with the highest rate of hematoma (5.98%). Implants placed in the malar region (2.67%) and frontal bones (2.50%) were associated with the highest rates of infection. Implants placed in the periorbital region were associated with the highest rate of inflammation (8.0%), explantation (8.0%), and poor cosmetic outcome (17.0%). Porous implants were shown to be more likely to potentiate infection than non-porous implant types. CONCLUSIONS: Alloplastic facial implants are a reliable means of restoring facial symmetry and achieving facial skeletal augmentation with a relatively low complication profile. It is important for plastic surgeons to understand the relative risks for each type of implant to develop postoperative complications or poor long-term cosmetic results. Interestingly, porous implants were shown to be more likely to potentiate infection than non-porous implant types. 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 .

Cost-Utility Analysis of Surgical Decompression Relative to Injection Therapy for Chronic Migraine Headaches.

BACKGROUND: Common treatments for chronic migraine headaches include injection of corticosteroid and anesthetic agents at local trigger sites. However, the effects of therapy are short term, and lifelong treatment is often necessary. In contrast, surgical decompression of migraine trigger sites accomplishes the same goal yet demonstrates successful long-term elimination of chronic migraines. OBJECTIVES: Our primary objective was to perform a cost-utility analysis to determine which patients would benefit most from available treatment options in a cost-conscious model. METHODS: A cost-utility analysis was performed, taking into consideration costs, probabilities, and health state utility scores of various interventions. RESULTS: Injection therapy offered a minor improvement in quality-adjusted life-years (QALYs) compared with surgical decompression (QALY Δ = 0.6). However, long-term injection therapy was significantly costlier to society than surgical decompression: injection treatment was estimated to cost $106,887.96 more than surgery. The results of our cost-utility analysis thus conferred a positive incremental cost-utility ratio of $178,163.27 in favor of surgical decompression. CONCLUSIONS: Surgery provides a durable intervention and has been shown in this study to be extremely cost effective despite a very minor QALY deficit compared with injection therapy. If patients are identified who require treatment in the form of injections for less than 8.25 years, they may fall into a group that should not be offered surgery.