Reporting Practices on Immunosuppression and Rejection Management in Face Transplantation: A Systematic Review.

BACKGROUND: Face transplantation is a demanding operation requiring complex planning and expert technical performance. While the documentation of successes of the first transplants is impressive, there are lacunae in reporting of institutional protocols for other critical operation components, namely, immunosuppression, graft surveillance, and management of rejection and graft failure. The purpose of this review is to assess protocol reporting by face transplant teams to determine where we, as a plastic surgery community, can improve. METHODS: A systematic review of PubMed was conducted to identify literature on face transplants published from November, 2005, starting with the first successful transplant to December, 2018. English-language articles were reviewed for reporting of protocols on antimicrobial prophylaxis, immunosuppression, graft surveillance, and management of rejection and graft failure. RESULTS: A total of 44 face transplantation patients were identified. Protocols for antimicrobial prophylaxis, immunosuppressive induction, and maintenance immunosuppression were reported for 61%, 75%, and 73% of patients, respectively. Protocols for graft surveillance and medical management of rejection were reported for 70% of patients in both cases. Surgical salvage strategies to manage graft failure were documented for 43% of patients. CONCLUSION: The current literature on face transplantation does not include consistent reporting on critical aspects of patient care. Medical protocols outlining guidelines for immunosuppression, graft surveillance, and management of rejection and graft failure are the most critical factors determining overall transplant success. However, they are underreported in the literature. Development and communication of standardized protocols is essential to improve patient outcomes and maximize the results of this procedure.

Analysis of Immediate versus Delayed Sternal Reconstruction with Pectoralis Major Advancement Versus Turnover Muscle Flaps.

BACKGROUND: The pectoralis major muscle flap is a versatile reconstructive option for deep sternal wound infections (DSWI). The timing and surgical technique of bilateral pectoralis major muscle advancement flaps versus unilateral pectoralis major muscle turnover and unilateral pectoralis major muscle advancement flap on patient outcomes remain to be elucidated. The purpose of this investigation was to compare timing, immediate versus delayed reconstruction, and the surgical technique in patients with deep sternal wounds infections on patient outcomes. METHODS: A retrospective review of patients who underwent sternal reconstruction with pectoralis major muscle was conducted. Patients diagnosed with DSWI after undergoing cardiac surgery were included for analysis. Patients were divided by flap timing and flap type for analyses. Bivariate tests were performed to compare patient clinical characteristics. Outcomes of interest were rates of postoperative complications, same admission mortality, reoperation, readmission, operating room time, and length of stay. RESULTS: A total of 88 patients were included for analyses (n = 57 bilateral advancement, n = 31 unilateral advancement with unilateral turnover; n = 62 immediate, and n = 26 delayed). Baseline characteristics did not differ between groups of flap type or timing. When postoperative complication rates were compared, the rate of tissue necrosis was significantly greater in patients with unilateral advancement with unilateral turnover flaps (n = 6 [19.4%]) compared with bilateral advancement flaps (n = 2 [3.5%]; p = 0.021). Mortality during admission did not differ with respect to flap type but differed significantly with respect to flap timing (immediate n = 7 [11.3%], delayed n = 9 [34.6%]; p = 0.015). Length of stay differed significantly by both type and timing (type: bilateral advancement = 26.9 ± 22.6 days, unilateral turnover = 38.0 ± 26.7 days, p = 0.042; timing: immediate = 26.8 ± 22.1 days, delayed = 40.2 ± 27.8, p = 0.019). CONCLUSION: Patients who underwent pectoralis major muscle advancement flaps had lower incidence of tissue necrosis. Furthermore, the timing of immediate sternal reconstruction was associated with a decreased hospital length of stay.

Patient-Reported Satisfaction and Quality of Life in Postmastectomy Radiated Patients: A Comparison between Delayed and Delayed Immediate Autologous Breast Reconstruction in a Predominantly Minority Patient Population.

BACKGROUND: Delayed immediate (DI) autologous breast reconstruction consists of immediate postmastectomy tissue expander placement, radiation therapy, and subsequent autologous reconstruction. The decision between timing of reconstructive methods is challenging and remains to be elucidated. We aim to compare patient reported outcomes and quality of life between delayed and DI reconstruction. METHODS: A retrospective review of all patients, who underwent autologous breast reconstruction at Montefiore Medical Center from January 2009 to December 2016, was conducted. Patients who underwent postmastectomy radiotherapy were divided into two cohorts: delayed and DI autologous breast reconstruction. Patients were mailed a BREAST-Q survey and their responses, demographic information, complications, and need for revisionary procedures were analyzed. RESULTS: A total of 79 patients met inclusion criteria: 34.2% (n = 27) in the delayed and 65.8% (n = 52) in the DI group. 77.2% (n = 61) of patients were a minority population. Patients in each cohort had similar baseline characteristics; however, the DI cohort was more likely to have bilateral reconstruction (46.2% [n = 24] vs. 7.4% [n = 2]; p = 0.0005) and to have major mastectomy flap necrosis (22.4% [n = 17] vs. 0.0% [n = 0]; p = 0.002). Premature tissue expander removal occurred in 17.3% (n = 9) of patients in the DI group. BREAST-Q response rates were 44.4% (n = 12) in the delayed group and 57.7% (n = 30) in the DI group. Responses showed similar satisfaction with their breasts, well-being, and overall outcome. CONCLUSION: Delayed and DI autologous breast reconstruction yield similar patient-reported satisfaction; however, patients undergoing DI reconstruction have higher rates of major mastectomy necrosis. Furthermore, patients in the DI group risk premature tissue expander removal.

Rank and Research: The Correlation Between Integrated Plastic Surgery Program Reputation and Academic Productivity.

BACKGROUND: Determinants of residency program reputation are multifactorial and include operative training, academic productivity, and geographic location. However, little is known about these relationships. This study aims to investigate the correlation between academic reputation of integrated plastic surgery programs and the research productivity of their respective full time faculty members. METHODS: Program rankings were identified from the 2016 Doximity standings and divided into 4 quartiles (Q1-Q4). Full-time faculty and program directors were identified through program websites. Publications by faculty members from 2000 to 2015 were identified through PubMed. Variables collected included affiliated institution, date of publication, authorship position, and journal. RESULTS: A total of 67 programs with 607 full-time faculty members were identified. Although not significantly different, program directors had a higher mean number of publications compared with faculty members for Q1, Q2, and Q4. Program departmental chairs had a significantly higher mean number of publications for Q1 and Q2. The Q1 faculty had a significantly higher mean number of publications as compared with Q2, Q3, and Q4. Although all quartiles had similar mean first author publications, Q1 and Q2 had more middle and last author publications. In addition, the higher-ranked programs were more likely to have faculty as middle authors of articles with more contributors. They were also more likely to publish in Plastic Reconstructive Surgery compared with other journals. CONCLUSIONS: Academic reputation of integrated plastic surgery residency programs is correlated with the scholarly activity of full-time faculty.

Risk Factors for Postoperative Venous Thromboembolic Complications after Microsurgical Breast Reconstruction.

BACKGROUND: Venous thromboembolism (VTE) is a significant cause of postoperative morbidity and a focus of patient safety initiatives. Despite giving appropriate prophylaxis in accordance with the Caprini risk assessment model, we observed a high incidence of VTE in patients undergoing microsurgical breast reconstruction at our institution. To explore factors contributing to these events, we compared patients undergoing microsurgical breast reconstruction who sustained postoperative VTEs to those who did not. METHODS: A retrospective review of all patients who underwent microsurgical free flap breast reconstruction at Montefiore Medical Center from January 2009 to January 2016 was conducted. Patients were divided into two cohorts; those sustaining postoperative VTE and those who did not. Patients were compared based on demographics, comorbidities, operative time, estimated intraoperative blood loss, need for transfusion, volume of transfusion, and discharge on postoperative aspirin. RESULTS: A total of 133 patients underwent microsurgical breast reconstruction during the study period. Nine patients (6.8%) had postoperative VTE and there was one (0.8%) death. Patients having VTE were more likely to be Hispanic (33.3%, n = 3) in the VTE group versus 8.1% (n = 6) in the control group (p = 0.011), more likely to have an increased mean transfusion volume (455.5 ± 367.8 vs. 139.51 ± 221.7 mL, p = 0.03), and were more likely to be discharged without aspirin (77.8%, n = 7 and 58.1%, n = 72; p = 0.003). CONCLUSION: Patients sustaining postoperative VTE after microsurgical breast reconstruction are more likely to have an increased volume of blood transfusions and lack of discharge on postoperative aspirin.

Mechanical analysis of the vascularized fibular graft prosthetic composite (VFGPC) for internal hemipelvectomy reconstruction.

INTRODUCTION: The vascularized fibular graft prosthetic composite (VFGPC) is used for reconstruction after internal hemipelvectomy. The purpose of this study was to create a mathematical model that calculates the mechanical effects of the vascularized fibular graft on the VFGPC. METHODS: The effects of the VFG positioning were calculated based on three-dimensional static analyzes to determine the direction, magnitude, and distribution of the forces through the prosthesis and VFG. The shear stress (SS) and cyclic loads to failure (CLF) were calculated. By varying the location of the VFG on the sacrum the zone of acceptable placement was calculated. RESULTS: Utilization of the VFG decreased the forces through the implant by 15-35% and decreased SS 20-54%, depending on stance. The CLF improved by 94%. The zone of acceptable placement for the VFG was found to be between 0° and 15° of the vertical axis in the sagittal plane and 0° and 30° of the posterior axis in coronal plane. CONCLUSION: Determining the position of the VFG pre-operatively allows for the creation of a customized cutting jig can be utilized to create graft allowing for accurate fibular osteotomies, minimization of ischemia time, and decreased intra-operative handling of the graft.

Carotid Reconstruction with Bovine Carotid Heterograft after En Bloc Resection of Squamous Cell Carcinoma with Direct Internal Carotid Invasion.

We report a novel use of Artegraft (North Brunswick, NJ) bovine heterograft for carotid reconstruction after resection of a neck squamous cell carcinoma (SCC). A 65-year-old man presented with a large left neck SCC encasing and invading the cervical internal carotid artery (ICA). Computed tomography angiography revealed an incomplete Circle of Willis, and no viable vein conduit on duplex mapping. The patient underwent en bloc resection including portion of the cervical ICA followed by reconstruction with Artegraft which was well tolerated. This represents the first case report of tumor invasion of the ICA reconstructed using Artegraft as conduit.

Evaluation of the Relationship between Age and Outcome after Microvascular Reconstruction among Patients with Recurrent Head and Neck Squamous Cell Carcinoma.

Background In patients with head and neck squamous cell carcinoma (HNSCC), disease recurrence remains a significant obstacle to long-term survival. If possible, surgical salvage with reconstruction remains the best treatment option for patients with recurrence. Currently, there is no literature discussing whether age should preclude microvascular reconstruction in these patients. We hypothesize that older age alone does not affect outcomes. Methods A retrospective chart review of patients with HNSCC at our institution between 2008 and 2015 was performed. Patients were included if they underwent simultaneous resection and flap reconstruction for recurrent HNSCC. Data collected included age, sex, primary site, type of reconstruction, previous treatments, postoperative complications (systemic and reconstructive), and overall survival. Results A total of 65 patients met inclusion criteria for the review: 42 (64.6%) patients ≤70 years and 23 (35.4%) patients > 70 years. Overall survival was not significantly different between the younger and older groups (p = 0.199). Five-year survival was 60.1% in the younger group and 46.8% in the older group. No significant difference was found in reconstructive complication rates (p = 0.179) or systemic complication rates (p = 0.241) between the two groups. Multivariate logistic regression analysis further showed no significant association between patients' age (≤70 years or > 70 years) and reconstructive complications (p = 0.396) or systemic complications (p = 0.119). Conclusion Age is not significantly associated with complications among patients undergoing resection and reconstruction for recurrent HNSCC. Microvascular reconstruction remains a feasible option in older patients with recurrent HNSCC. Advanced age alone should not preclude the surgical management of recurrent HNSCC.

How Well Do They Convert? Trending ASAPS Presentations to Publication From 1995-2010.

BACKGROUND: The American Society for Aesthetic Plastic Surgery (ASAPS) sponsors an annual conference that promotes education, advocacy, and care. There, researchers deliver abstracts as podium and poster presentations. Subsequently, ASAPS encourages submitting these research findings for publication. Yet, many never become published manuscripts. OBJECTIVES: To quantify the conversion rates of oral abstract presentations to publication from 1995 to 2010. Secondary objectives included evaluating trends in presentations, publications, time to publication, and published journal distribution. METHODS: Comprehensive literature search in PubMed cross-referencing oral abstract presentations and determining peer-reviewed publication status. The conversion rate and time to publication was calculated. RESULTS: A total of 569 oral presentations met the inclusion criteria. The mean annual presentations was 35.6. A total of 360 presentations became journal publications. The mean annual publications was 22.5. The mean conversion rate was 63.3% (R2, 0.1271; P-value of .23). The mean time to publication was 19.8 months. Most publications occurred within two years of presentation (87.5%). Publications appeared in Plastic and Reconstructive Surgery (PRS, 48.6%), Aesthetic Surgery Journal (ASJ, 27.8%), Aesthetic Plastic Surgery (APS, 5.6%), Annals of Plastic Surgery (AnnPS, 4.2%), Clinics in Plastic Surgery (CPS, 3.9%), and other journals (10%). Trending ASJ publications vs other journals in five year intervals demonstrated an increase from 18.7% to 58.8%. CONCLUSIONS: While the number of presentations and publications declined, the time to publication, and conversion rate remained largely the same. Despite its short existence, ASJ became the predominant journal publishing ASAPS abstracts by the end of the study period.

Update on Post-mastectomy Lymphedema Management.

Lymphedema is a chronic, progressive condition caused by an imbalance of lymphatic flow. Upper extremity lymphedema has been reported in 16-40% of breast cancer patients following axillary lymph node dissection. Furthermore, lymphedema following sentinel lymph node biopsy alone has been reported in 3.5% of patients. While the disease process is not new, there has been significant progress in the surgical care of lymphedema that can offer alternatives and improvements in management. The purpose of this review is to provide a comprehensive update and overview of the current advances and surgical treatment options for upper extremity lymphedema.

Palliative Reconstruction for the Management of Incurable Head and Neck Cancer.

BACKGROUND: Surgical management of head and neck cancer is resource intensive and physiologically demanding. In patients with incurable disease, although the indications for surgery are not well defined, palliative benefit can be significant. The goal of this investigation was to compare outcomes of patients who underwent resection and reconstruction of head and neck cancer with curative intent with those who underwent similar procedures with palliative intent. METHODS: A retrospective review of patients who underwent reconstruction for head and neck cancer between 2008 and 2014 was conducted. Patients were divided into curative and palliative groups. Outcomes assessed included postoperative complications and survival. RESULTS: A total of 147 patients who underwent 156 operations met inclusion criteria (27 palliative and 129 curative). In both cohorts, the most common histology was squamous cell carcinoma (SCC) and the most common primary tumor site was the oral cavity. There was no significant difference between the cohorts in the rates of systemic and reconstructive complications, postoperative hospital length of stay, 30-day mortality, and flap survival. Overall survival in palliative patients was significantly shorter compared with curative patients (median OS, 6.2 months vs. 56.1 months, respectively; p < 0.0001). Among patients undergoing palliative surgery, patients without carotid involvement and those with non-SCC were significantly more likely to have longer survival. CONCLUSION: Surgical resection with reconstruction is possible in head and neck oncologic patients undergoing palliative treatment. Palliative patients have similar short-term outcomes when compared with patients undergoing resection for curative intent. Quality-of-life and economic implications of these approaches deserve closer scrutiny.

Reconstruction of the pediatric midface following oncologic resection.

BACKGROUND: Sarcoma is the most common midface malignancy in children. While first-line treatment in adults is resection, the challenges associated with resection and reconstruction of these tumors in children often lead to radiation therapy as primary treatment. This report highlights the feasibility and efficacy of midface reconstruction in the pediatric population after resection. In most cases, the same principles utilized in reconstructing midface defects in adults hold for the pediatric population. PATIENTS AND METHODS: From 2008 to 2013 seven pediatric patients underwent resection and reconstruction for maxillary sarcomas. These patients ranged in age from 18 months to 20 years. Five patients were reconstructed with six microvascular free flaps. Two patients received pedicled flaps. Follow-up ranged from 15 months to 4.5 years. Reconstructive, oncological, and functional outcomes were analyzed. RESULTS: Seven patients underwent eight reconstructions for sarcomas of the maxilla. Flaps utilized included vertical rectus abdominis, anterolateral thigh, fibula, and temporoparietal fascia. One flap was complicated by venous thrombosis but was successfully salvaged after thrombectomy and revision using vein graft. One patient developed recurrence after initial flap placement and required salvage resection and a second free flap. Six patients were judged to have good facial symmetry and tolerated a regular oral diet with normal or near-normal dental occlusion. CONCLUSIONS: Standard primary therapy for sarcomas of the maxilla in the pediatric population consists of nonsurgical management. However, a radiation-first approach is associated with significant morbidity and makes surgical salvage more difficult. Based on our experience, microsurgical reconstruction of the pediatric midface is safe and effective, and should be considered a first-line treatment option for midface sarcomas in children. In general, there is no significant area of departure between the principles that govern midface reconstruction in adults and children.

Superficial temporal artery and vein as recipient vessels for scalp and facial reconstruction: radiographic support for underused vessels.

BACKGROUND: The choice of the recipient vessels for microsurgical reconstruction is based on proximity to the defect, vessel caliber, anatomic reliability, and ease of dissection. Traditionally in head and neck reconstruction, the superficial temporal artery and vein (STA/V) have been reserved as secondary recipient vessels. Others, including the facial artery (FA) and vein have been the preferred choice for facial reconstruction. METHODS: A retrospective analysis of all consecutive head and neck reconstructions using the STA/V by the senior author (E.S.G.) over a 5-year period was performed. Perioperative data were reviewed for all the patients. In a subset of patients, radiographic analysis was used to delineate STA and FA anatomy including vessel diameter and distances to standard anatomic landmarks. RESULTS: A total of 31 patients had 32 microsurgical reconstructions using the STA/V as recipient vessels. Radiographic analysis revealed no significant difference between the STA and FA diameters. The distances from the STA to the upper and middle face were significantly shorter relative to the FA, 64 versus 102 mm (p < 0.0001) and 72 versus 80 mm (p < 0.04), respectively. The distances from the lower face to the STA and FA were 56 and 30 mm, respectively (p < 0.0001). CONCLUSIONS: The STA/V can be used as first choice recipient vessels in head and neck reconstruction. Key features of these vessels include proximity to defect, acceptable caliber, predictable anatomic location, and relative ease of dissection. We recommend that the STA/V be considered recipient vessels of choice for reconstruction of defects of the face and scalp.

Safety of the supraclavicular artery island flap in the setting of neck dissection and radiation therapy.

BACKGROUND: The supraclavicular artery island flap (SAIF) has recently been repopularized as a versatile and reliable option for reconstruction of oncological head and neck defects. Prior ipsilateral neck dissection or irradiation is considered a relative contraindication to its use. The aim of this study was to describe the safety and utility of the SAIF for head and neck reconstruction in the setting of neck dissection and radiation. METHODS: A retrospective chart review was performed of consecutive SAIF reconstructions at two institutions between May 2011 and 2014. In addition to demographic data, comorbidities, indications, surgical characteristics, data about radiation treatment, and neck dissection were specifically recorded. Donor and recipient site complications were noted. Fisher exact test was performed to analyze if neck dissection or radiation were associated with complications. RESULTS: A total of 22 patients underwent SAIF reconstruction for an array of head and neck defects. Donor site infection was noted in one patient. Recipient site complications included, wound dehiscence (n = 2), orocutaneous fistula (n = 1), carotid blowout (n = 1), and total flap loss (n = 1). There was no association between prior neck dissection or radiation treatment and flap loss (p = 1.00). CONCLUSION: The SAIF is safe for use in patients who have had an ipsilateral neck dissection involving level IV or V lymph nodes and/or radiation treatment to the neck. It can be used alone or in combination with other flaps for closure of a variety of head and neck defects.

Computer-assisted design and computer-assisted modeling technique optimization and advantages over traditional methods of osseous flap reconstruction.

There is increased clinical use of computer-assisted design (CAD) and computer-assisted modeling (CAM) for osseous flap reconstruction, particularly in the head and neck region. Limited information exists about methods to optimize the application of this new technology and for cases in which it may be advantageous over existing methods of osseous flap shaping. A consecutive series of osseous reconstructions planned with CAD/CAM over the past 5 years was analyzed. Conceptual considerations and refinements in the CAD/CAM process were evaluated. A total of 48 reconstructions were performed using CAD/CAM. The majority of cases were performed for head and neck tumor reconstruction or related complications whereas the remainder (4%) were performed for penetrating trauma. Defect location was the mandible (85%), maxilla (12.5%), and pelvis (2%). Reconstruction was performed immediately in 73% of the cases and delayed in 27% of the cases. The mean number of osseous flap bone segments used in reconstruction was 2.41. Areas of optimization include the following: mandible cutting guide placement, osteotomy creation, alternative planning, and saw blade optimization. Identified benefits of CAD/CAM over current techniques include the following: delayed timing, anterior mandible defects, specimen distortion, osteotomy creation in three dimensions, osteotomy junction overlap, plate adaptation, and maxillary reconstruction. Experience with CAD/CAM for osseous reconstruction has identified tools for technique optimization and cases where this technology may prove beneficial over existing methods. Knowledge of these facts may contribute to improved use and main-stream adoption of CAD/CAM virtual surgical planning by reconstructive surgeons.

Ten-year evolution utilizing computer-assisted reconstruction for giant ameloblastoma.

BACKGROUND: The authors describe our current practice of computer-aided virtual planned and pre-executed surgeries using microvascular free tissue transfer with immediate placement of implants and dental prosthetics. METHODS: All patients with ameloblastomas treated at New York University (NYU) Medical Center during a 10-year period from September 2001 to December 2011 were identified. Of the 38 (36 mandible/2 maxilla) patients that were treated in this time period, 20 were identified with advanced disease (giant ameloblastoma) requiring aggressive resection. Reconstruction of the resultant defects utilized microvascular free tissue transfer with an osseocutaneous fibular flap in all 20 of these patients. RESULTS: Of the patients reconstructed with free vascularized tissue transfer, 35% (7/20) developed complications. There were two complete flap failures with consequent contralateral fibula flap placement. Sixteen patients to date have undergone placement of endosteal implants for complete dental rehabilitation, nine of which received immediate placement of the implants at the time of the free flap reconstruction. The three most recent patients received immediate placement of dental implants at the time of microvascular free tissue transfer as well as concurrent placement of dental prosthesis. CONCLUSIONS: To our knowledge, this patient cohort represents the largest series of comprehensive computer aided free-flap reconstruction with dental restoration for giant type ameloblastoma.

Topical Tranexamic Acid Does Not Reduce The Incidence Of Hematoma In Reduction Mammoplasty: A Double-Blinded, Randomized Placebo-Controlled Trial.

BACKGROUND: Breast reduction mammoplasty (BRM) is among the most common procedures in plastic surgery, with a 1-7% postoperative hematoma incidence reported. Tranexamic acid (TXA) has been shown to reduce perioperative bleeding and need for transfusion when administered intravenously or topically, but remains underutilized in plastic surgery. This study aims to investigate whether topical administration of topical TXA reduces postoperative hematoma following BRM. METHODS: A double-blinded, randomized controlled trial of 98 patients (196 breasts) undergoing bilateral primary reduction mammoplasty at a single academic institution was performed. Patients were used as internal matched controls, with one breast randomized to receive 1000mg of topical TXA before closure, and the other receiving saline. All members of the surgical team and patient were blinded as to which breast received the study drug. Postoperative complications, including hematoma, within 30 days of surgery, drain outputs, and duration of drain use, were compared between treatment and placebo breasts. RESULTS: The overall hematoma rate was 1.5%. There was no significant association between application of TXA and development of a hematoma (p=0.56) or other complications. The hematoma rate of patients enrolled in the trial was similar to the overall rate of hematoma during the study time period (1.5% versus 2.4%, p=0.511). In a multivariate model, TXA was not significantly associated with differences in drain output after controlling for resection weight, age, and duration of drain use (p=0.799). No adverse effects or thromboembolic events from TXA were observed. CONCLUSION: Topical application of TXA does not decrease the incidence of hematoma following reduction mammoplasty.

Analysis of Body Contouring and Sustained Weight Loss in a Diverse, Urban Population: A 7-Year Retrospective Review.

BACKGROUND: Studies demonstrating the positive impact of body contouring on sustained weight loss in bariatric patients describe a narrow cohort. The authors sought to evaluate the impact of postbariatric body contouring procedures on sustained weight loss in minority race patients. METHODS: A retrospective review of bariatric surgery patients at a single institution was performed. Patients were grouped as follows: (1) those who underwent body contouring, (2) those who had consultation but did not undergo body contouring, and (3) those without consultation. Body mass index (BMI) and excess body weight loss (EBWL) over 7 years were the primary outcomes. RESULTS A TOTAL OF: 2531 patients were analyzed: 350 in group 1, 364 in group 2, and 1817 in group 3. At postoperative year 7, groups 1 and 2 had average BMIs 4.71 and 2.31 kg/m 2 lower than group 3, respectively, while adjusting for covariates. After exclusion of 105 patients in group 2 who were not offered body contouring because of inadequate weight loss, however, group 2 had an average BMI 4.07 kg/m 2 lower than group 3 at postoperative year 7. During postoperative year 1, group 1 had an average EBWL of 74.38%, which declined 1.51% yearly, and group 2 had an average EBWL of 70.12%, which declined 1.86% yearly. After exclusion of the aforementioned patients, group 2 had an average EBWL of 74.9% at postoperative year 1, which declined 1.88% yearly. CONCLUSIONS: Body contouring after bariatric surgery did not impart a clinically significant, long-term sustained weight loss benefit in the authors' cohort. In the authors' study population, patients identifying as black had significantly worse sustained weight loss. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Current Trends in Ideal Nasal Aesthetics Show Younger Patients Have a Preference Toward Longer Augmented Noses.

Background: Aesthetic norms fluctuate over time and often result in generational differences in preferred ideal nasal aesthetics. While some traditional concepts of the ideal nasal aesthetic have been suggested in our literature, there has been no study to date that has identified contemporary preferences across different age groups. Objectives: To understand the general population's current perception of ideal nasal profiles. Methods: Two-dimensional images of female noses (n = 10) of varying ethnicities were simulated to alter either the radix height or nasolabial angle (NLA) independently. Radix height was manipulated by increasing or decreasing the height by 5 mm relative to baseline. For NLA, 3 images were created with the following measurements: (1) 90°, (2) 100°, and (3) 110°. Groups were categorized by generation and age at the time of completing the study: Generation Z (Gen Z; age 18-23), Millennial 20s (age 24-30), Millennial 30s (age 31-39), and Generation X (Gen X; age 40-55). Each figure consisted of either 3 variations in radix height (n = 10) or 3 variations in NLA (n = 10). Within each figure, volunteers were asked to choose their preferred nose. Results: The younger generations, Gen Z and Millennial 20s and 30s, preferred a more augmented radix compared to Gen X which preferred a baseline radix height. Gen Z, Millennial 20s, and Gen X preferred a 90° NLA, while Millennial 30s preferred an NLA of 100°. Conclusions: The authors found that younger populations (Gen Z, Millennial 20s, and Millennial 30s) preferred a more augmented appearance to the nasal radix and, on average, a more acute NLA than published data suggest.

Intraoperative Navigation in Plastic Surgery with Augmented Reality: A Preclinical Validation Study.

BACKGROUND: Augmented reality allows users to visualize and interact with digital images including three-dimensional holograms in the real world. This technology may have value intraoperatively by improving surgical decision-making and precision but relies on the ability to accurately align a hologram to a patient. This study aims to quantify the accuracy with which a hologram of soft tissue can be aligned to a patient and used to guide intervention. METHODS: A mannequin's face was marked in a standardized fashion with 14 incision patterns in red and nine reference points in blue. A three-dimensional photograph was then taken, converted into a hologram, and uploaded to HoloLens (Verto Studio LLC, San Diego, Calif.), a wearable augmented reality device. The red markings were then erased, leaving only the blue points. The hologram was then viewed through the HoloLens in augmented reality and aligned onto the mannequin. The user then traced the overlaid red markings present on the hologram. Three-dimensional photographs of the newly marked mannequin were then taken and compared with the baseline three-dimensional photographs of the mannequin for accuracy of the red markings. This process was repeated for 15 trials (n = 15). RESULTS: The accuracy of the augmented reality-guided intervention, when considering all trials, was 1.35 ± 0.24 mm. Markings that were positioned laterally on the face were significantly more difficult to reproduce than those centered around the facial midline. CONCLUSIONS: Holographic markings can be accurately translated onto a mannequin with an average error of less than 1.4 mm. These data support the notion that augmented reality navigation may be practical and reliable for clinical integration in plastic surgery.