Direct Sub-Scarpal Lipectomy Combined With Liposuction in Abdominoplasty: An Analysis of Safety & Efficacy in 200 Consecutive Patients.

BACKGROUND: Abdominoplasty procedures continue to evolve as combining techniques such as suction-assisted lipectomy or direct sub-scarpal lipectomy have proven to be powerful adjuncts to achieve optimal aesthetic results. However, there is apprehension in combining techniques simultaneously given the potential to affect the vascularity of the abdominoplasty flap. OBJECTIVES: To assess the safety and efficacy of simultaneous direct sub-scarpal lipectomy combined with liposuction in abdominoplasty patients. METHODS: A 4-year retrospective review of consecutive abdominoplasties (n = 200) performed by a single surgeon was conducted. Liposuction of the abdominal flap and flanks was performed in all patients. After raising the abdominoplasty flap, undermining was performed to just beyond the xyphoid, lower rib margins superiorly, and to the anterior axillary line laterally. Fat deep to Scarpa's fascia was then removed by direct tangential excision in all zones of the abdominal flap. RESULTS: Average values included: Age, 42.19; BMI, 28.10 kg/m2; follow up, 7 months. Seroma occurred in 13 patients (6.5%), superficial wound dehiscence treated with local wound care in 16 patients (8%), hypertrophic scarring in 16 patients (8%), partial umbilical necrosis in one patient (0.5%), and partial umbilical epidermolysis in six patients (3%). No patients experienced major or minor full-thickness tissue loss. No patients needed reoperation. CONCLUSIONS: Simultaneous direct excision of sub-scarpal fat with liposuction of the abdomen and flanks does not appear to subject any zone of the abdominoplasty flap to increased risks of vascular compromise. No flap necroses were observed. The use of our technique is safe and may provide superior abdominoplasty results.

The Influence of Sagittal Head Tilt on Periorbital Appearance: Implications for Clinical Photography and the Evaluation of Postoperative Results.

BACKGROUND: Consistency in standardized periorbital photography-specifically, controlling for sagittal head tilt-is challenging yet critical for accurate assessment of preoperative and postoperative images. OBJECTIVES: To systematically assess differences in topographic measurements and perceived periorbital attractiveness at varying degrees of sagittal head tilt. METHODS: Standardized frontal photographs were obtained from 12 female volunteers (mean age 27.5 years) with the Frankfort plane between -15° and +15°. Unilateral periorbital areas were cropped, and topographic measurements were obtained. The images of each individual eye, at varying head tilt, were ranked in order of attractiveness by 11 blinded evaluators. RESULTS: Inter-rater and intra-rater reliability was excellent (intraclass correlation > 0.9). Downward sagittal head tilt was linearly associated with an improved aesthetic rating (Spearman's correlation; ρ = 0.901, P < 0.001). However, on subgroup analysis, eyes with lower lid bags received the highest aesthetic score at neutral head tilt. Pretarsal show and upper lid fold heights progressively decreased (P < 0.001), positive intercanthal tilt became more pronounced (P < 0.001), and the apex of the brow (P < 0.001) and lid crease (P = 0.036) arcs lateralized with downward sagittal head tilt, contributing to a more angular appearance of the eye. Marginal reflex distance (MRD) 1 was maintained, while MRD2 progressively increased (P < 0.001) with downward head tilt. CONCLUSIONS: Negative sagittal head tilt significantly improves periorbital aesthetics; however, in the presence of lower eyelid bags, this also increases demarcation of the eyelid cheek junction which may be aesthetically detrimental. Controlling for sagittal head tilt is critical to reliably compare preoperative and postoperative clinical photographs.

Acellular Dermal Matrix-Associated Contracture: A Clinical and Histologic Analysis of Patients Undergoing Prosthetic Breast Reconstruction.

BACKGROUND: Capsular contracture is a well-recognized complication following prosthetic breast reconstruction. It has been the authors' observation that some patients undergoing breast reconstruction experience contracture specifically of the acellular dermal matrix placed at the time of their tissue expander insertion. The goal of the authors' study was to identify clinical and histologic findings associated with the development of acellular dermal matrix-associated contracture. METHODS: The authors performed a retrospective cohort study of all patients undergoing bilateral implant-based breast reconstruction performed by the senior author (M.S.A.). Patients were excluded if they had radiation therapy to the breast. Patients with suspected acellular dermal matrix-associated contracture were identified by clinical photographs and review of operative notes. Histologic analysis was performed on specimens taken from two patients with acellular dermal matrix contracture. RESULTS: The authors included a total of 46 patients (92 breasts), of which 19 breasts had suspected acellular dermal matrix-associated contracture. Acellular dermal matrix contracture was less common in direct-to-implant reconstruction (4.2 percent versus 26.5 percent; p = 0.020) and more common in breasts that had seromas (0 percent versus 15.8 percent; p = 0.001) or complications requiring early expander replacement. Contracted acellular dermal matrix had less vascularity and a lower collagen I-to-collagen III ratio, and was twice as thick as noncontracted acellular dermal matrix. CONCLUSIONS: The authors have described a distinct phenomenon of acellular dermal matrix-associated contracture that occurs in a small subset of breasts where acellular dermal matrix is used. This merits further investigation. Future work will be required to better characterize the clinical factors that make acellular dermal matrix-associated contracture more likely to occur. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Repair of Lower Eyelid Cicatricial Entropion With Midface Lift, Spacer Graft, and Drill-Hole Canthoplasty.

Postoperative cicatricial lower lid retraction is a challenging surgical problem that often disfigures the shape of the eye and has functional consequences. Depending on the severity, more than one surgical procedure may be needed to achieve the desired lower lid shape and position given the recurrent nature of scarring. Concepts of scar release, establishing lower lid vertical height, soft tissue replacement, and midcheek support are discussed in this video.

Current Upper Blepharoplasty and Ptosis Management Practice Patterns Among The Aesthetic Society Members.

BACKGROUND: Patients presenting for upper blepharoplasty can exhibit different aging patterns and we have anecdotally observed wide variability in upper blepharoplasty approaches among surgeons. However, upper blepharoplasty practice patterns have not been systematically analyzed among members of The Aesthetic Society. OBJECTIVES: The aim of this study was to report upper blepharoplasty practice patterns, the recognition of different patient presenting features, and to assess the incidence and management of ptosis as reported by members of The Aesthetic Society. METHODS: A 29-item electronic questionnaire was distributed to 1729 Aesthetic Society members with available email addresses. RESULTS: In total, 214 Aesthetic Society members submitted the questionnaire, for a response rate of 12.4%. There was a significantly increased rate of volume preservation among surgeons with greater experience (≥10 years in practice) and a high-volume (≥100 cases in past 12 months) of upper blepharoplasty cases. Furthermore, high-volume upper blepharoplasty surgeons were significantly more likely to perform concomitant upper lid fat grafting (P = 0.03), browlift (P = 0.02), and ptosis repair (P = 0.01). Ninety-five percent of respondents reported a mild/moderate ptosis (MRD1 2 to <4mm) incidence of <25%. Among surgeons who perform ptosis repair, 97.4% utilize levator advancement or plication as their most commonly used technique. CONCLUSIONS: High-volume upper blepharoplasty surgeons are more likely to preserve upper lid volume and perform concomitant browlift and ptosis repair. Our data suggest that different upper eyelid aging patterns and mild/moderate ptosis are underrecognized.

Enhancing the Lateral Orbital "C-Angle" With Calcium Hydroxylapatite: An Anatomic and Clinical Study.

BACKGROUND: Deliberate injection of specific facial subunits may improve aesthetic outcomes in facial rejuvenation. We contend that the lateral orbital area (LOA) is a key anatomic subunit in the perception of eye attractiveness, with a C-shaped distribution of fat contributing to the formation of a distinct angle in the lateral orbit. OBJECTIVES: The aim of this study was to describe the anatomy of the LOA that constitutes the C-shaped angle and to investigate the safety and cosmetic outcomes of nonsurgical enhancement of that area with calcium hydroxylapatite (CaHA). METHODS: Four injected fresh-frozen cadaver heads were dissected. Twenty patients were enrolled in a prospective clinical study. Participants were seen on the day of injection, and at 2 weeks and 3 months postinjection. Two-dimensional and 3D photographs were analyzed to quantify the volumetric changes between pretreatment and postinjection time points. Secondary outcomes included Global Aesthetic Improvement Scale score and subject satisfaction at 3 months. RESULTS: Cadaver dissections revealed distinct fat compartments and a zone of adhesion forming the C-shaped area around the lateral orbit. In the clinical study, a mean of 1.88 mL of CaHA was injected into each lateral periorbital region. There was 97% and 76% volume retention at 2 weeks and 3 months, respectively, with 70% of patients being "very satisfied" at 3 months. The average Global Aesthetic Improvement Scale rating at 3 months was 3.95. There were no complications. CONCLUSIONS: The LOA is a distinct facial subunit that can be enhanced safely by CaHA injection with good cosmetic outcomes. Focusing on the C-angle can improve periorbital aesthetics.

Rethinking Upper Blepharoplasty: The Impact of Pretarsal Show.

BACKGROUND: Conventional upper blepharoplasty relies on skin, muscle, and fat excision to restore ideal pretarsal space-to-upper lid fold ratios. The purpose of this study was to identify presenting topographic features of upper blepharoplasty patients and their effect on cosmetic outcomes. METHODS: This is a retrospective review of patients who underwent upper blepharoplasty at the authors' institution from 1997 to 2017. Preoperative and postoperative photographs were standardized using Adobe Illustrator to an iris diameter of 11.5 mm. Pretarsal and upper lid fold heights were measured at five locations. Patients were classified into three groups based on preoperative pretarsal show: none, partial, or complete. Photographs were randomized in PowerPoint and given a cosmetic score of 0 to 5 by four independent reviewers. RESULTS: Three hundred sixteen patients were included, 42 men (13 percent) and 274 women (87 percent). Group 1 included 101 eyes (16 percent), group 2 had 159 eyes (25 percent), and group 3 had 372 eyes (59 percent). Mean cosmetic score increased from 1.75 to 2.38 postoperatively (p < 0.001), with a significantly lower improvement in scores in group 3 compared to groups 2 and 1 for both sexes (p < 0.01). For group 3, those with midpupil pretarsal heights greater than 4 mm had a significantly lower postoperative aesthetic score (1.95) compared with those less than or equal to 4 mm (2.50) (p < 0.001). CONCLUSIONS: Many patients presenting for upper blepharoplasty have complete pretarsal show and are at risk for worse cosmetic outcomes using conventional skin excision techniques. Adjunctive procedures such as fat grafting and ptosis repair should be considered in this group. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Pushing the Limits in Cheek Reconstruction: The Sub-Superficial Musculo-Aponeurotic System "Deep Plane" Cervicofacial Flap for Reconstruction of Large Eyelid-Cheek Junction Defects.

The cervicofacial flap is a workhorse flap for reconstruction of moderate to large sized defects of the cheek. Defects that involve the eyelid-cheek junction are often the most challenging of these. While the ideal plane of dissection has been debated, it is our belief that dissection in the sub-superficial musculo-aponeurotic system (SMAS) plane provides better aesthetic and functional outcomes due to enhanced vascularity, fascial support, and additional bulk of the flap itself. The authors present a series of 9 patients who presented with heterogeneous defects of the eyelid-cheek junction after cancer resection and underwent reconstruction using a sub-SMAS cervicofacial flap. At a mean follow-up time of 20 months, the cohort had 2 patients who developed lower lid retraction requiring revision and 2 other minor complications. This series lends support to the versatility and reliability of the sub-SMAS cervicofacial flap for large defects of the eyelid-cheek junction.

Allograft Alone vs. Allograft with Intramedullary Vascularized Fibular Graft for Lower Extremity Bone Cancer: A Systematic Review and Meta-Analysis.

BACKGROUND: Limb salvage surgery has become a first-line treatment in the setting of lower extremity cancer. Despite a multitude of techniques, the most effective modality for osseous reconstruction has not been described. We aim to examine outcomes of allograft reconstruction alone compared to an allograft combined with a vascularized fibula graft (VFG) (Capanna Technique) through a meta-analysis of the literature. METHODS: A systematic review of the literature was conducted through the online databases PubMed, Embase, and Web of Science, examining articles utilizing an allograft with or without an intramedullary VFG for the reconstruction of lower extremity osseous defects following oncological resection. A meta-analysis examined outcomes, including nonunion, infection, fractures, explantation, and functional limb status, that were evaluated dependent upon reconstructive modality. RESULTS: Twenty-five articles were deemed appropriate for inclusion. The allograft with VFG group had considerably lower rates of nonunion (13%) in comparison to the allograft alone group (21.4%) (p < .001). Rates of infection (7.9% vs. 9%, respectively) and fracture (19.6% vs. 19.1%) were not statistically different. The allograft with VFG group also had significantly lower rates of explantation (6.57%) compared to the allograft alone cohort (18.11%) (p < .001). Functional outcomes were similar across groups as measured by Musculoskeletal Tumor Society scores (88.22% vs. 87.77%). CONCLUSIONS: Allograft reconstruction with a supplementary inlay VFG decreases the risk of nonunion and explantation compared to allograft alone reconstruction in the setting of oncological resection of the osseous lower extremity. This technique warrants increased consideration in the operative planning of lower limb reconstruction following tumor extirpation.

Lower Eyelid Reconstruction: A New Classification Incorporating the Vertical Dimension.

BACKGROUND: Lower eyelid defects are traditionally classified based on depth and 25 percent increments in defect width. The authors propose a new classification system that includes the vertical defect component to predict functional and aesthetic outcomes. METHODS: A retrospective review of patients who underwent lower lid reconstruction performed by a single surgeon was performed. Defects were classified into four categories based on the vertical component: (1) pretarsal; (2) preseptal; (3) eyelid-cheek junction; and (4) complex pretarsal/preseptal. Preoperative and postoperative central and lateral marginal reflex distance-2 values were obtained. Aesthetic outcomes were evaluated by three blinded reviewers. Outcomes were compared using one-way analysis of variance and analysis of covariance with Bonferroni corrected post hoc comparisons to control for defect area and width. RESULTS: Thirty-four patients underwent reconstruction of lower eyelid defects. There were 12 pretarsal defects (type I), nine preseptal defects (type II), nine eyelid-cheek defects (type III), and four complex pretarsal/preseptal defects (type IV). Postoperative retraction was highest in the complex pretarsal/preseptal group at 75 percent, with a significantly greater change from preoperative to postoperative central and lateral marginal reflex distance-2 compared with the other groups (p < 0.01) and worse postoperative mean aesthetic scores (p < 0.001). Type IV patients had significantly more revision operations (mean, 5.5) compared with the other groups (p < 0.001). CONCLUSIONS: The vertical dimension of lower eyelid defects is an important variable. A new classification system is proposed that supplements width-based methods for improved surgical planning and prediction of postoperative outcomes in lower eyelid reconstruction. CLINICAL QUESTION/LEEVL OF EVIDENCE: Therapeutic, IV.

Identifying Aesthetically Appealing Upper Eyelid Topographic Proportions.

BACKGROUND: The goal of upper eyelid procedures is to restore or create the ideal proportions between the pretarsal space and the upper lid fold. OBJECTIVES: The aim of this study was to define the topographic features of the attractive upper lid. METHODS: Caucasian female frontal facial photographs were obtained from public media and periorbital areas were cropped. A total of 294 photographs of eyes were rated by 6 evaluators using a 4-point Likert scale. Eyes rating an average ≥3.5 were defined as "attractive," whereas those rated ≤2.0 were defined as "unattractive" and analyzed using Adobe Illustrator. RESULTS: Fifty-one and 19 eyes were included in the attractive and unattractive cohorts, respectively. (Upper lid foldPretarsal) shows ratios averaged between 1.8 and 3.0 among attractive eyes, and larger ratios were observed laterally. These ratios were significantly larger laterally among attractive vs unattractive eyes (P ≤ 0.003). The lash line peak (P < 10-4), lid crease peak (P < 10-3), and brow peak (P < 0.05) were significantly more lateralized in attractive eyes. CONCLUSIONS: Attractive eyes tend to exhibit decreased pretarsal show. However, there is pronounced variability in these ratios among attractive eyes, suggesting the importance of other features. Interestingly, progressive lateralization of the lash line, lid crease, and brow peaks appears to be an undescribed feature common to attractive eyes. Knowledge of attractive eyelid features may be an important consideration for planning and optimization of upper lid rejuvenation procedures.