Immune Checkpoint Inhibitors-Associated Generalized Lipodystrophy: Reconstructive Challenges of an Emerging and Distinct Form of Lipodystrophy.

Total and permanent loss of facial and nonfacial fat is a rare side effect of immune checkpoint inhibitors (ICIs). Consequently, effective treatment modalities for patients remain undefined. Here, we discuss the surgical treatment of a patient with both ICI-related acquired generalized lipodystrophy (AGL). We additionally performed a comprehensive literature review (Cochrane, Embase, and MEDLINE) to summarize what is known about ICI-related lipodystrophy and available treatments for this rare complication. A 66-year-old female diagnosed with metastatic lung adenocarcinoma started ICI (pembrolizumab) treatment. She developed generalized lipodystrophy 13 months after her first cycle. Her primary concern was the loss of facial fat volume, which significantly aged her appearance. The patient underwent a 2-staged restoration of her facial fat compartments using dermal grafts from the lower abdomen and medial thighs. The patient recovered uneventfully and was satisfied with the aesthetic improvement at 18 months of follow-up. The authors identified 8 case reports with patients with ICI-AGL. The mean age was 53.63 years, and the mean BMI was 36.72 kg/m2. The average onset of symptoms was 7.44 months after ICI initiation. None of the studies described any sort of surgical or nonsurgical options to restore the volume of the facial fat compartments. The management of combined facial and nonfacial lipodystrophy remains challenging due to the lack of suitable autologous fat donor sites. In this report, the authors demonstrate that staged volume restoration can be achieved using autologous dermal grafts from the thigh, making it a viable reconstructive option in this subset of patients.

How We Look At Mature Faces-An Eye-Tracking Investigation Into the Perception of Age.

BACKGROUND: It is still unclear which facial region contributes most to the perception of an aged face when evaluated by eye-tracking analyses. OBJECTIVES: The authors sought to apply eye-tracking technology to identify whether mature faces require longer fixation durations than young faces and which facial region contributes most to the perception of a mature face. METHODS: Eye-tracking analyses were conducted in 74 volunteers (37 males, 37 females; 43 ≤ 40 years, 31 > 40 years) evaluating their gaze pattern and the fixation durations for the entire face and 9 facial subregions. Frontal facial images of 16 younger (<40 years) and older (>40 years) gender-matched individuals were presented in a standardized setting. RESULTS: Independent of age or gender of the observer, a younger stimulus image was viewed shorter than an older stimulus image with 0.82 (0.63) seconds vs 1.06 (0.73) seconds with P < 0.001. There was no statistically significant difference in their duration of a stable eye fixation when observers inspected a male vs a female stimulus image [0.94 (0.70) seconds vs 0.94 (0.68) seconds; P = 0.657] independent of the observer's age or gender. The facial image that captured the most attention of the observer (rank 9) was the perioral region with 1.61 (0.73) seconds for younger observers and 1.57 (0.73) seconds for older observers. CONCLUSIONS: It was revealed that the perioral region attracts the most attention of observers and contributes most to an aged facial appearance. Practitioners should be mindful of the importance of the perioral region when designing an aesthetic treatment plan.

Endoscopic Browlift in Patients With Receding Hairlines.

ABSTRACT: Patients with receding or high hairlines have traditionally been considered unfavorable candidates for endoscopic brow lift as this can further lengthen the hairline. We analyzed outcomes in patients that underwent a novel endoscopic brow lift technique with placement of incisions and anchoring Endotine Forehead Devices (CoApt Systems Inc, Palo Alto, CA, USA) directly at the natural forehead crease lines, in an effort to minimize elevation of the hairline, whereas providing well-hidden scars. We retrospectively reviewed all patients who underwent this new Endotine and incision placement between 2016 and 2020. Preoperative and postoperative photographs of all patients were analyzed to determine the postoperative changes in brow elevation and forehead length proportion (defined as length from cranium to chin).The forehead length proportion was unchanged pre- and post-operatively, with no statistically significant differences noted (P = 0.48). The average brow position elevation ranged from 2.78 mm in the medial location to 5.05 mm in the lateral location. All patients were happy with their appearance and had improved visual fields postoperatively. The forehead scars healed well and were well hidden in forehead rhytids at long term follow-up.This novel endoscopic brow lift technique provides an option to utilize a minimally invasive approach in patients with receding hairline. With this technique, visible scars were minimized, whereas still being able to achieve reasonable brow elevation. Thus, our approach enables long term maintenance of brow elevation with inconspicuous scars in the forehead.

Seminal Studies in Facial Reanimation Surgery: Consensus and Controversies in the Top 50 Most Cited Articles.

ABSTRACT: Facial paralysis can impair one's ability to form facial expressions that are congruent with internal emotion. This hinders communication and the cognitive processing of emotional experience. Facial reanimation surgery, which aims to restore full facial expressivity is a relatively recent undertaking which is still evolving. Due in large part to published techniques, refinements, and clinical outcomes in the scientific literature, consensus on best practice is gradually emerging, whereas controversies still exist.Taking stock of how the discipline reached its current state can help delineate areas of agreement and debate, and more clearly reveal a path forward. To do this, the authors have analyzed the 50 seminal publications pertaining to facial reanimation surgery. In longstanding cases, the free gracilis transfer emerges as a clear muscle of choice but the nerve selection remains controversial with prevailing philosophies advocating cross facial nerve grafts (with or without the support of an ipsilateral motor donor) or an ipsilateral motor donor only, of which the hypoglossal and nerve to masseter predominate. The alternative orthodoxy has refined the approach popularized by Gillies in 1934 and does not require the deployment of microsurgical principles. Although this citation analysis does not tell the whole story, surgeons with an interest in facial reanimation will find that this is a good place to start.

Quantitative Mobility Analysis of the Face and its Relevance for Surgical and Non-surgical Aesthetic Facial Procedures.

BACKGROUND: Understanding the degree of facial mobility upon postural changes is of great clinical relevance especially if facial assessment, facial measurements and/or facial markings are done in an upright position, but facial procedures are performed in a supine position. OBJECTIVE: The objective of this study is to investigate regional facial skin displacement and facial volume changes in individuals between upright and supine positions. METHODS: This multi-center study analyzed a total of 175 study participants with a mean age of 35.0 (10.2) years and a mean body mass index of 24.71 (3.5) kg/m2. 3D surface scanning technology with automated registration and alignment was utilized, and multivariate analyses were performed with adjustment for age, gender, body mass index, facial skin sagging and laxity. RESULTS: The medial face displaced less than the lateral face in both cranial (0.88 mm) and in lateral (0.76 mm) directions, and the lower face displaced more than the middle face in both cranial (1.17 mm) and lateral directions (1.37 mm). Additionally, the medial face lost, on average, 3.00cc whereas the lateral face increased by 5.86cc in volume; the middle face increased by 2.95cc, whereas the lower face decreased by 0.98cc in volume. All p < 0.001. CONCLUSION: Practitioners should be mindful that there is a statistically significant change in facial soft tissues between the upright and supine positions and that the magnitude of the change does not necessarily reflect on the aging process alone but is a multi-factorial process which should be individualized for each patient's needs. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Layered Anatomy of the Nose: An Ultrasound-Based Investigation.

BACKGROUND: An increasing number of soft tissue filler procedures in the nasal region has been reported. Concomitant with demand, the number of complications has risen due to the difficulty in administering filler in a region where soft tissue layering is complex. OBJECTIVES: The authors sought to describe the layered soft tissue arrangement of the nose as it relates to the underlying arterial vasculature and to define safer zones for nasal filler enhancement. METHODS: A total of 60 (28 males and 32 females) study participants were investigated with respect to their layered anatomy in the midline of the nose utilizing ultrasound imaging. The presence and extent of the layered arrangement was examined as well as the depth of the arterial vasculature. RESULTS: In the mid-nasal dorsum, a 5-layer arrangement was observed in 100% (n = 60) of all investigated cases, whereas it was found to be absent in the nasal radix and tip. The 5-layer arrangement showed an average extent of 26.7% to 67.5% in relation to nasal length. The nasal arteries coursed superficially in 91.7% of all cases in the nasal radix, in 80% in the mid-nasal dorsum, and in 98.3% in the nasal tip. CONCLUSIONS: Soft tissue filler administration in the nose carries the highest risk for irreversible vision loss compared with any other facial region. The safety of soft tissue filler rhinoplasty procedures is enhanced by knowledge of the layered anatomy of the nose, the location and depth of the major nasal vasculature, and employment of maneuvers to decrease the risk of blindness.

Intraoperative Ultrasound Imaging in Silicone Filler Removal.

ABSTRACT: Dermal filler injections, one of the most commonly performed procedures in facial esthetic surgery, are rising in popularity. This has also led to an increase in nonmedical grade filler injections performed by nonmedical personnel, including that of injectable silicone. Surgical removal of silicone fillers is challenging, as the hydrophobic material often disperses within the soft tissue as droplets. This can lead to a systemic inflammatory reaction requiring steroid treatment. MRI localization of the filler material does not enable intraoperative guidance, and palpitation of the material is challenging since the filler droplets are often too small to palpate and located in multiple planes. We present a case demonstrating the advantages of utilizing intraoperative ultrasound to localize and silicone filler material. Utilizing this technique, we were able to achieve a high degree of excision of silicone filler material and the patient was able to stop her previous necessary immunosuppressive steroid regimen successfully.

Surgical and Patient-Reported Outcomes in Patients With PEEK Versus Titanium Cranioplasty Reconstruction.

BACKGROUND: Several materials are available for cranioplasty reconstruction and consensus regarding the ideal material is lacking. The goal of this study is to present surgical and patient-reported outcomes with PEEK versus Titanium alloplastic cranioplasty. METHODS: A retrospective review of all patients who underwent alloplastic cranioplasty with PEEK or Titanium from 2010 to 2017 was conducted. Patient demographics and complications were abstracted and analyzed. Information regarding patient-reported outcomes was collected through a telephone survey. RESULTS: A total of 72 patients (median age 55 years) who underwent 77 cranioplasties were identified (38% PEEK, n = 29; 62% Titanium, n = 48). Overall complication rates were similar between the PEEK (24%, n = 7) and Titanium groups (23%, n = 11), P = 0.902. Similarly, implant failure was similar between the 2 groups (7% in PEEK (n = 2), 13% in Titanium (n = 6), P = 0.703). History of radiation was associated with increased rate of infection in patients with Titanium mesh cranioplasty (38% in radiated patients (n = 3), 3% in nonradiated patients (n = 1), P = 0.012) but not PEEK implants (0% infection rate in radiated patients (n = 0), 15% in nonradiated patients (n = 4), P = 1.000). A total of 24 patients (33% response rate) participated in the telephone survey. All PEEK cranioplasty patients who responded to our survey (n = 13) reported good to excellent satisfaction, while 72% of our titanium mesh cohort (n = 8) described good or excellent satisfaction and 27% (n = 3) reported acceptable result. CONCLUSION: Cranial reconstruction is associated with high satisfaction among cranioplasty patients with PEEK or Titanium showing comparable complications, failure, and patient-reported satisfaction rates. Patients with history of radiotherapy demonstrated a higher infection rate when titanium mesh was used.

Signal-To-Noise Ratio Calculations to Validate Sensor Positioning for Facial Muscle Assessment Using Noninvasive Facial Electromyography.

The evaluation of neuromodulator treatment outcomes can be performed by noninvasive surface-derived facial electromyography (fEMG) which can detect cumulative muscle fiber activity deep to the skin. The objective of the present study is to identify the most reliable facial locations where the motor unit action potentials (MUAPs) of various facial muscles can be quantified during fEMG measurements. The study population consisted of five males and seven females (31.0 [12.9] years, body mass index of 22.15 [1.6] kg/m2). Facial muscle activity was assessed in several facial regions in each patient for their respective muscle activity utilizing noninvasive surface-derived fEMG. Variables of interest were the average root mean square of three performed muscle contractions (= signal) (µV), mean root mean square between those contraction with the face in a relaxed facial expression (= baseline noise) (µV), and the signal to noise ratio (SNR). A total of 1,709 processed fEMG signals revealed one specific reliable location in each investigated region based on each muscle's anatomy, on the highest value of the SNR, on the lowest value for the baseline noise, and on the practicability to position the sensor while performing a facial expression. The results of this exploratory study may help guiding future researchers and practitioners in designing study protocols and measuring individual facial MUAP when utilizing fEMG. The locations presented herein were selected based on the measured parameters (SNR, signal, baseline noise) and on the practicability and reproducibility of sensor placement.

Telemedicine in International Cleft Care: A Systematic Review.

BACKGROUND: Cleft lip and cleft palate (CLP) are among the world's most common congenital malformation and has a higher prevalence in developing nations due to environmental and genetic factors. Global efforts have been developed in order to prevent and treat the malformation. Telemedicine has been implemented in various humanitarian global missions with success and is currently the primary means of care due to COVID-19. OBJECTIVE: To assess the benefits and barriers of telehealth in the care of patients with CLP through a global approach. METHODS: Systematic review of the PubMed and Cochrane Review databases with relevant terms related to telemedicine in cleft lip and palate surgery. RESULTS: Eight articles fit the inclusion criteria and suggested benefits with the use of telemedicine in regard to education, preoperative, and postoperative care as well as increased access to underserved populations. Barriers included connectivity and accessibility concerns. CONCLUSION: Telehealth is a beneficial way to evaluate patients with CLP in developing countries with proper care and follow-up to reduce complications and to improve health outcomes.

A Cadaveric Anatomical and Histological Study of Recipient Intercostal Nerve Selection for Sensory Reinnervation in Autologous Breast Reconstruction.

BACKGROUND: Autologous breast reconstruction (ABR) has grown in popularity due to improved aesthetic and long-term patient reported outcomes, but data regarding sensory reinnervation of autologous flaps remain limited. Traditionally, the lateral cutaneous branch of the fourth intercostal nerve has been used for flap neurotization, but the use of the anterior cutaneous branch of the intercostal nerves (ACB) offer a more optimal location to the microsurgical field when using internal mammary vessels for the microanastomosis. This study aimed to evaluate the optimum ACB recipient site level for sensory nerve coaptation in ABR. METHODS: Twelve hemi-chests were dissected from six fresh cadaveric females. Costal cartilages were removed and the anterior cutaneous intercostal nerve (ACB) and the lateral (subcutaneous) division of the anterior cutaneous branch (LACB) of the intercostal nerve were exposed. Anatomical measurements were recorded, and nerve samples were evaluated histologically with carbonic anhydrase staining to differentiate sensory fascicles. Assessment of fascicular diameter, axonal counts, and fascicular area were compared. RESULTS: A total of 75 nerve specimens were assessed. The ACB was identified at all levels (100%) and the subcutaneous LACB was noted consistently in the second to fourth rib space (96% cadavers), with a median length of 43, 37.5, and 37 mm, respectively. Across all rib spaces, the fascicular and axonal counts were comparable between the LACB and ACB. Nerves in the second intercostal space had a significantly larger mean fascicular area mean (112,816 ± 157,120 µm2) compared with that in the fourth (mean 26,474 ± 38,626 µm2), p = 0.03. Axonal count of sensory fascicles was the highest in the second intercostal nerves (p < 0.05). CONCLUSION: This study provides anatomical and histological basis to determine the optimum recipient site choice for sensory coaptation in microsurgical breast reconstruction. This would aid in operative decision-making regarding the ideal recipient anterior cutaneous intercostal nerve branches for recipient site coaptation in ABR.

The Impact of Breast Symmetry on Eye Movement and Gaze Pattern: An Eye-Tracking Investigation.

BACKGROUND: The objective assessment of beauty remains challenging despite ongoing research efforts. A new method of objectively determining the aesthetic appeal of body features by analyzing gaze patterns and eye movements has recently been investigated. OBJECTIVES: The objective of this study was to assess, by means of objective eye-tracking technology, differences in the gaze patterns of observers presented with standardized 3-dimensional images showing different degrees of breast asymmetry. METHODS: A total of 83 Caucasian study participants with a mean age of 38.60 (19.8) years were presented with 5 images depicting varying degrees of breast asymmetry. In addition to the assessment of eye movements, participants were asked to rate the aesthetic appeal and the asymmetry of the breasts on a 5-point Likert scale. RESULTS: Overall, the data showed that participants' rating of the breasts' aesthetic appeal was inversely related to the level of asymmetry. The mean [standard deviation] time until fixation was shortest for the image depicting the greatest breast asymmetry (50 cc) at 0.77 [0.7] seconds (P < 0.001). In addition, the mammary region was also viewed longest in this image at 3.76 [0.5] seconds (P < 0.001). A volume difference of 35 cc between breasts deflected the observers' gaze significantly toward the larger of the asymmetric breasts (P < 0.001). CONCLUSIONS: Surgeons should focus on achieving symmetric breast volume (ie, differences <35 cc between breasts) to avoid noticeable asymmetry with regard to breast size.

Understanding Facial Muscle Aging: A Surface Electromyography Study.

BACKGROUND: Facial aging is a multifactorial process that involves all tissues of the face, including skin, muscles, fat, ligaments, and bone. Whereas robust evidence is available for age-related changes of bone and facial fat, the influence of age on facial muscle activity is poorly understood. OBJECTIVES: The objective of this study was to investigate the motor unit action potential of facial muscles by utilizing surface-derived, noninvasive electromyography in young and old healthy volunteers. METHODS: The study investigated a total of 32 healthy volunteers with a mean [standard deviation] age of 42.6 [19.6] years (range, 21-82 years) and a mean BMI of 23.9 [2.7] kg/m2 (range, 18.5-29.7 kg/m2) by performing surface-derived, noninvasive facial electromyography. Nine facial muscles were investigated bilaterally, resulting in a total of 1632 measurements of the signal, baseline noise, and signal-to-noise ratio of these muscles. RESULTS: The results of the study revealed that age does not significantly influence the signal (P = 0.234), the baseline noise (P = 0.225), or the signal-to-noise ratio (P = 0.432) of younger individuals (<30 years) vs older individuals (>50 years) in a gender- and BMI-matched statistical model. Exceptions were the zygomaticus major muscle (reduced activity), procerus muscle (increased activity), and corrugator supercilii muscle (increased activity). CONCLUSIONS: The results of this facial electromyography study may help to increase the understanding of facial aging. Future studies need to reproduce the results presented herein to further increase our understanding of facial aging.

Extremity free fillet flap for reconstruction of massive oncologic resection-Surgical technique and outcomes.

BACKGROUND AND OBJECTIVES: The purpose of this study is to present our experience using free fillet flaps to reconstruct massive oncologic defects of the upper and lower extremity. METHODS: A retrospective chart review was performed to include patients who underwent oncologic resection followed by reconstruction using free fillet flaps from July 2001 to October 2018. Patient demographics, clinical and surgical characteristics, and postoperative complications were reviewed. RESULTS: In total, 12 patients were identified and included in this study. Mean age was 48.9 years old. Five patients had extended forequarter amputations and seven patients had external hemipelvectomies, all for locally advanced tumors. Mean tumor size was 15 ± SD 6.4 cm, and negative tumor margins were achieved in all the patients. Mean flap size was 1028 ± SD 869 cm2 . The mean follow-up was 13 months. There were no partial or total flap losses in the postoperative period. Two patients had flap-related postoperative complications, including flap bleeding and wound dehiscence. Median survival was 18 months. CONCLUSION: The free fillet flap is a safe, reliable, and valuable approach for reconstructing oncological defects. It offers the advantage of avoiding donor site morbidity, while providing extensive soft-tissue coverage as a one-step solution for massive oncologic defects.

Landmarks in Facial Rejuvenation Surgery: The Top 50 Most Cited Articles.

BACKGROUND: Facial rejuvenation procedures are common in plastic surgery. OBJECTIVES: The aim of this study was to report the 50 most cited articles in the field of aesthetic facial rejuvenation surgery and provide a simple educational resource for plastic surgeons. METHODS: The authors utilized the Web of Science Citation Index to identify the 50 most cited articles related to surgery for facial rejuvenation published from 1950 to 2019. Articles were classified according to their level of evidence, type of study, country of publication, and topic of interest: facelift, blepharoplasty, brow lift, neck lift, or combined areas. RESULTS: The mean number of citations per article was 137, and the majority of articles (n = 19) were published between 1990 and 1999. The most prevalent topic was facelift surgery (n = 24), followed by articles discussing combined procedures (n = 13), blepharoplasty (n = 6), brow lift (n = 4), and neck lift (n = 3). Most of the articles were classified as clinical (n = 26), followed by basic science studies (n = 12) and review articles (n = 12). Among the articles amenable to grading level of evidence (n = 26), most (n = 24) presented their findings utilizing level IV evidence. The nation of origin for most of the articles (n = 41) was the United States. CONCLUSIONS: Articles addressing facelift surgery represented the largest proportion of peer-reviewed landmark publications in aesthetic facial surgery research. A simple educational resource is presented to encourage the appreciation of the research in this field.

Profile of Adipose-Derived Stem Cells in Obese and Lean Environments.

BACKGROUND: With the demand for stem cells in regenerative medicine, new methods of isolating stem cells are highly sought. Adipose tissue is a readily available and non-controversial source of multipotent stem cells that carries a low risk for potential donors. However, elevated donor body mass index has been associated with an altered cellular microenvironment and thus has implications for stem cell efficacy in recipients. This review explored the literature on adipose-derived stem cells (ASCs) and the effect of donor obesity on cellular function. METHODS: A review of published articles on obesity and ASCs was conducted with the PubMed database and the following search terms: obesity, overweight, adipose-derived stem cells and ASCs. Two investigators screened and reviewed the relevant abstracts. RESULTS: There is agreement on reduced ASC function in response to obesity in terms of angiogenic differentiation, proliferation, migration, viability, and an altered and inflammatory transcriptome. Osteogenic differentiation and cell yield do not show reasonable agreement. Weight loss partially rescues some of the aforementioned features. CONCLUSIONS: Generally, obesity reduces ASC qualities and may have an effect on the therapeutic value of ASCs. Because weight loss and some biomolecules have been shown to rescue these qualities, further research should be conducted on methods to return obese-derived ASCs to baseline. LEVEL 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.

Cell-Based Therapies in Vascularized Composite Allotransplantation.

BACKGROUND: Dendritic cells (DCs) are bone marrow-derived, professional antigen-presenting cells with tolerogenic function. The ability of DCs to regulate alloantigen-specific T cell responses and to promote tolerance has aligned them ideally for a role in vascularized composite allotransplantation (VCA). In this study, we summarize the current evidence for DC therapies for tolerance induction to alleviate the requirement for chronic immunosuppression. METHOD: A comprehensive and structured review of manuscripts published on VCA was performed using the MEDLINE and PubMed databases. All eligible studies published from the year 2000 to 2017 were included in the final results. RESULT: Nineteen original preclinical and clinical studies that employed cell therapy for VCA were included in this review. In vivo DC therapy was found to direct the alloimmune response toward either transplant rejection or tolerance in VCA models. While injection of mature DCs rapidly increases T-cell activity in humans and promotes transplant rejection, the injection of immature DCs acts as an immunosuppressant and inhibits T-cell activity. In addition to immature DCs, mesenchymal stem cells were also found to have a positive effect on allotransplantation of solid organs and bone marrow via cytokine expression which decreases the alloreactive effector lymphocytes and increases CD4+/CD25+/FoxP3 Tregs. Despite the promising findings, the efficacy of cell-based therapies varies greatly across studies, partly due to different methods of cell isolation and purification techniques, source, route and timing of administration, and combination immunosuppressive therapy. CONCLUSION: Additional research is needed to evaluate the efficacy and safety of DC and other cell-based therapeutic measures in human allotransplant recipients. Future direction will focus on the development of novel methods to reduce immunosuppression and develop more individualized management, as well as the clinical application of basic research in the mechanisms of immunologic tolerance.

A Systematic Review of the Use of Telemedicine in Plastic and Reconstructive Surgery and Dermatology.

BACKGROUND: Telemedicine, the use of information technology and telecommunication to provide healthcare at a distance, is a burgeoning field with applications throughout medicine. Given the visual nature of plastic surgery and dermatology, telemedicine has a myriad of potential applications within the field. METHODS: A comprehensive literature review of articles published on telemedicine since January 2010 was performed. Articles were selected for their relevance to plastic and reconstructive surgery and dermatology, and then reviewed for their discussion of the applications, benefits, and limitations of telemedicine in practice. RESULTS: A total of 3119 articles were identified in the initial query. Twenty-three articles met the inclusion criteria in plastic surgery (7 wound management, 5 burn management, 5 trauma, 4 free flap care, 2 in cleft lip/palate repair). Twenty-three (100%) reported a benefit of telemedicine often related to improved postoperative monitoring, increased access to expertise in rural settings, and cost savings, either predicted or actualized. Eight (35%) reported limitations and barriers to the application of telemedicine, including overdiagnosis and dependence on functional telecommunication systems. Sixty-six articles focused on telemedicine in dermatology and also demonstrated significant promise. CONCLUSIONS: Telemedicine holds special promise in increasing the efficiency of postoperative care for microsurgical procedures, improving care coordination and management of burn wounds, facilitating interprofessional collaboration across time and space, eliminating a significant number of unnecessary referrals, and connecting patients located far from major medical centers with professional expertise without impinging on-and in some cases improving-the quality or accuracy of care provided. Teledermatology consultation was found to be safe and has a comparable or superior efficacy to the traditional in-patient consultation. The system was consistently rated as convenient and easy to use by patients, referring physicians, and consulting dermatologists. Teledermatology has also been used as an educational tool for patients. A significant number of studies detailed strategies to improve the current state of teledermatology, either by implementing new programs or improving technologies. Telemedicine use is widespread among plastic surgeons and is enabling the spread of expertise beyond major medical centers. Further research is needed to conclusively demonstrate benefit in routine clinical care.

Penile Replantation: A Retrospective Analysis of Outcomes and Complications.

Purpose Penile replantation is an uncommonly performed procedure, which can alleviate physical and psychosocial sequelae of penile amputation. This study critically appraises the current literature on penile replantation. Methods A comprehensive literature search of the Medline, PubMed, and Google Scholar databases was conducted with multiple search terms related to penile replantation. Data on outcomes, complications, and patient satisfaction were collected. Results A total of 74 articles met inclusion criteria. One hundred and six patients underwent penile replantation, but outcome, complication, and satisfaction data were not standardized across all patients. Penile amputation most often resulted from self-mutilation or trauma. The majority were complete amputations (74.8%). Full sensation was maintained in 68.4% of patients. Most reported adequate urinary function (97.4%) and normal erection (77.5%). Skin necrosis (54.8%) and venous congestion (20.2%) were the most common complications. Urethral stricture (11.0%) and fistula (6.6%) were common urethral complications. Most (91.6%) patients reported overall satisfaction although there was a lack of patient-reported outcomes. Multivariate analysis suggested that complete amputation (ß = 3.15, 95% CI 0.41-5.89, p = 0.024), anastomosis of the superficial dorsal artery (ß = 9.88, 95% CI 0.74-19.02, p = 0.034), and increasing number of nerves coapted (ß = 1.75, 95% CI 0.11-3.38, p = 0.036) were associated with favorable sexual, urinary, and sensation outcomes. Increasing number of vessels anastomosed (ß = -3.74, 95% CI -7.15 to -0.32, p = 0.032) was associated with unfavorable outcomes. Conclusion Although penile replantation is associated with complications, it has a high rate of satisfaction and efficacy. Coaptation of multiple nerves and anastomosis of the superficial dorsal artery should be completed.

Endoscopic Browlift in the Receding Hairline Patient.

UNLABELLED: The upper third of the face, composed of the forehead and the brow, is a critical aesthetic subunit. Brow ptosis is a common presenting complaint for patients seeking elective improvement of their facial appearance. Browlift surgery has a long history of technique evolution, with various reported methods and refinements. Since the introduction of the endoscopic brow lifting in the 1990s, it has become widely accepted as an approach to forehead rejuvenation. Endoscopy provides minimal incisions in well hidden areas, avoiding long, visible scars. A great number of patients who seek forehead rejuvenation already have a receding hairline. The patient with a receding hairline has been viewed as an unfavorable candidate for the endoscopic browlift approach. This report describes the case of a 67-year-old man with a receding hairline that was referred for brow ptosis and upper eyelid dermatochalasis. An upper eyelid blepharoplasty and an endoscopic browlift were performed. Incisions were placed in the temporal region bilaterally, as well as a single central incision placed in the anterior hairline. Two small horizontal incisions were placed in forehead crease lines for placement of the anchoring pins. This technique allowed for ease of dissection and resulted in inconspicuous scars. There was no elevation of the hairline; the brow was examined to be at a normal position at the level of the supraorbital rim at 12 months postoperative. The patient was highly satisfied with the operative outcome. LEVEL OF EVIDENCE: V.