Practice Patterns: An American Society of Plastic Surgeons (ASPS) Member Survey, 2000 and 2020-How Much Has Brow Lifting Changed?

BACKGROUND: In 2001, Elkwood and Matarasso published an American Society of Plastic Surgeons (ASPS) member survey detailing brow lift practice patterns. Interval changes in practice patterns have not been studied. OBJECTIVES: The previous survey was revised to elucidate current trends in brow lift surgery. METHODS: A 34-question descriptive survey was distributed to a random group of 2360 ASPS members. Results were compared to the 2001 survey. RESULTS: A total of 257 responses were collected (11% response rate; ± 6% margin of error at 95% CI). The most frequent technique for the correction of brow ptosis in both surveys was the endoscopic approach. The use of hardware fixation has increased in endoscopic brow lifting, whereas the use of cortical tunnels has decreased. Although coronal brow lifting has decreased in frequency, hairline and isolated temporal lift have increased. Neuromodulators have replaced resurfacing techniques as the most common nonsurgical adjunct. Frequent use of neuromodulators has risen from 11.2% to 88.5%. Nearly 30% of current surgeons feel that neuromodulators have replaced formal brow lifting procedures to a significant degree. CONCLUSIONS: In comparing the 2001 and current ASPS member survey there has been a clear transition to less invasive procedures over time. Although the endoscopic approach was the most popular means of forehead correction in both surveys, coronal brow lifting has decreased in frequency and the hairline and temporal approaches have increased. Neurotoxins have replaced laser resurfacing and chemical peeling methods as an adjunct, and in some cases replaced the invasive procedure entirely. Possible explanations for these findings will be discussed.

Face Lift Practice Patterns: An American Society of Plastic Surgeons Member Survey, 2000 and 2020. How Much Have We Changed?

BACKGROUND: In 2000, Matarasso et al. performed a survey of American Society of Plastic Surgeons members' face lift practice patterns. Since that publication, the aesthetic marketplace has changed dramatically, as have ancillary face lift techniques. In an attempt to detail these changes, we repeated that original survey, adding questions to address more recent technical issues and advances. The goal of this report was to define current face lift practice patterns, compare current patterns to the previous ones, and define recent advances. METHODS: A 38-question survey assessing face lift techniques, perioperative management, complications, and concomitant procedures was electronically distributed to a random cohort of American Society of Plastic Surgeons members. Data were recorded and statistically analyzed utilizing the Pearson chi-square test. RESULTS: A total of 251 forms were returned and analyzed. Details of demographics, face lift techniques, ancillary procedures, perioperative care, and complications are presented. Current results were compared to the previously published society member practice patterns delineated in the 2000 Plastic and Reconstructive Surgery publication. CONCLUSIONS: The basic approach of American Society of Plastic Surgeons members to the face lift operation has not changed dramatically over the past 20 years. The development of operative adjuncts, however, has been positive, including fat grafting techniques, concomitant use of skin resurfacing, and means of minimizing blood loss with tranexamic acid. In certain instances, respondents do not follow evidence-based guidelines for perioperative care. Finally, common complications of practicing members appear to coincide with published retrospective reviews.

Facelift Part II: Surgical Techniques and Complications.

Although previous publications have reviewed face and necklift anatomy and technique from different perspectives, seldom were the most relevant anatomical details and widely practiced techniques comprehensively summarized in a single work. As a result, the beginner is left with a plethora of varied publications that require sorting, rearrangement, and critical reading. A recent survey of US plastic surgery residents and program directors disclosed less facility with facelift surgery compared with aesthetic surgery of the breast and trunk. To this end, 4 of the widely practiced facelift techniques (ie, minimal access cranial suspension-lift, lateral-SMASectomy, extended-SMAS, and composite rhytidectomy) are described in an easy review format. The highlights of each are formatted followed by a summary of complications. Finally, the merits and limitations of these individual techniques are thoroughly compared and discussed.

Evaluating Postoperative Outcomes of Patients Undergoing Elective Procedures in an Ambulatory Surgery Center During the COVID-19 Pandemic.

BACKGROUND: Despite the rapid increase in the number of publications pertaining to COVID-19, there is a lack of data examining patient outcomes following elective procedures performed during this pandemic. OBJECTIVES: The purpose of this investigation was to examine the postoperative outcomes of patients who underwent elective procedures in an ambulatory surgery center during the COVID-19 pandemic, and to share the preoperative screening and patient selection protocol implemented in our center. METHODS: Elective procedures performed in an ambulatory surgery center between March 1, 2020 and April 16, 2020 were retrospectively reviewed. The primary outcomes were occurrence of COVID-19-related postoperative complications. These complications include pneumonia, stroke, myocardial infarction, and clotting disorders. The predictive variables analyzed in this study were age, American Society of Anesthesiologists score, specialty conducting the procedure, operating time, and the type of plastic and reconstructive surgery procedure being performed. RESULTS: A total of 300 consecutive electives cases were included in the study. The most common procedures were pain management (43.0%), gastrointestinal (26.0%), aesthetic (14.0%), orthopedic (10.3%), reconstructive (4.0%), otorhinolaryngology (2.0%), and gynecology (0.67%). The median age of the cohort was 54.6 years (range, 1-90 years) and the median procedure time was 47 minutes (range, 11-304 minutes). COVID-19-related symptoms or complications following the procedures were not observed in any of the patients or in the healthcare care personnel. CONCLUSIONS: In this cohort of 300 elective cases, we found no patients with COVID-19-related symptoms postoperatively. This suggests that with proper preoperative screening and patient selection, elective procedures can be safely performed in an ambulatory surgery center during this pandemic.

Is Breast Implant-Associated Anaplastic Large Cell Lymphoma Better Classified as a Lymphoproliferative Disorder and How Surgeons Reduce Risk?

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is a complex topic with evolving classification and etiology. Commonalities between BIA-ALCL and lymphoproliferative disorders exist, suggesting that BIA-ALCL may be better represented on a spectrum of disease from benign effusion to malignant metastatic lymphoma. Meticulous sterile surgical technique, involving the use of betadine-containing irrigation, should be used to decrease the biological burden introduced into the surgical field and possibly prevent future incidences of BIA-ALCL.

The Muscle-Sparing Descending Branch Latissimus Dorsi Free Flap for Lower Extremity Reconstruction.

BACKGROUND: The muscle-sparing descending branch latissimus dorsi muscle (MSLD) flap is a versatile flap with numerous benefits. It is an often overlooked but useful option when considering free flap donors. In this article, the authors present the largest experience with the MSLD flap, with focus on its use in lower extremity reconstruction. METHODS: Patients undergoing lower extremity reconstruction with the MSLD flap at a single institution from 2012 to 2017 were identified. Patient and wound characteristics, surgical details, complications, and outcomes were examined. Outcomes were compared to a cohort who underwent lower extremity reconstruction with other free muscle flaps during the same period. RESULTS: Thirty-six consecutive patients who underwent MSLD flap surgery were identified. Mean follow-up was 18.8 months. Mean body mass index was 29.2 kg/m and 56 percent were smokers. The most common wound causes were motor vehicle collision (46 percent) and fall (22 percent). The most common anatomical location was the distal third of the tibia (33 percent). Mean operative time was 380 minutes. Complications included three total losses (8 percent) and one partial loss (3 percent). No donor-site seromas were reported. Four patients required subsequent amputation for orthopedic issues (nonunion/pain). Patients receiving MSLD and other flaps had similar rates of amputation, donor- and recipient-site complications, and ambulation status (p > 0.05). CONCLUSIONS: The MSLD flap is a useful and reliable option for free flap reconstruction of the lower extremity. Advantages include an easily contourable flap, low revision rate, low complication rate, and the ability to harvest in supine position. In addition, the MSLD flap preserves donor function useful for rehabilitation and minimizes seroma risk. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Facelift Part I: History, Anatomy, and Clinical Assessment.

In this article, the authors aim to thoroughly describe the critical surgical anatomy of the facial layers, the retaining ligamentous attachments of the face, and the complex three-dimensional course of the pertinent nerves. This is supplemented with clarifying anatomic dissections and artwork figures whenever possible to enable easy, sound, and safe navigation during surgery. The historic milestones that led the evolution of cervicofacial rejuvenation to the art we know today are summarized at the beginning, and the pearls of the relevant facial analysis that permit accurate clinical judgment and hence individualized treatment strategies are highlighted at the end. The facelift operation remains the cornerstone of face and neck rejuvenation. Despite the emergence of numerous less invasive modalities, surgery continues to be the most powerful and more durable technique to modify facial appearance. All other procedures designed to ameliorate facial aging are either built around or serve as adjuncts to this formidable craft.

Local Infiltration of Tranexamic Acid With Local Anesthetic Reduces Intraoperative Facelift Bleeding: A Preliminary Report.

BACKGROUND: Rebound bleeding as a result of loss of epinephrine effect is a common problem encountered during facelift surgery. Tranexamic acid (TXA) is an anti-fibrinolytic agent whose safety and efficacy in reducing bleeding are well documented. We have found that local infiltration of TXA combined with a lidocaine with epinephrine solution during facelift surgery has been effective in decreasing rebound bleeding and the time required to gain hemostasis. OBJECTIVES: The authors sought to share their local infiltration protocol of TXA combined with epinephrine solution in facelift. METHODS: Patients who underwent facelift received subcutaneous injection of TXA-lidocaine 0.5% solution following the authors' protocol. After completing both sides of the facelift and the submental platysmaplasty, the first and second sides were sequentially closed. The time to gain hemostasis on each side prior to closure was prospectively measured. RESULTS: Twenty-seven consecutive patients who underwent facelift surgery received local infiltration of TXA-lidocaine solution. In 23 of the 27 patients, the time required for hemostasis was prospectively recorded. The mean age was 62.1 years (±9.3) and all were females. The average time spent achieving hemostasis on the right, left, and both sides of the face was 6.5 (±2.7), 6.3 (±2.1), and 12.9 (±4.2) minutes, respectively. The total surgical time saving is approximately 25 to 60 minutes. Although primary facelift [13.6 (± 4.3)] exhibited a longer time of hemostasis compared with the secondary group [10.2 (± 2.8)], this was not statistically significant (P = 0.09). CONCLUSIONS: Local infiltration of TXA with local anesthetic prior to a facelift appears to decrease bleeding, operative time, and postoperative facelift drainage output.Level of Evidence: 4.

Facelift in Patients with Massive Weight Loss.

Significant volume deflation and redundant inelastic skin is seen after massive weight loss (MWL). These changes parallel those found with natural aging; thus, patients exhibit accelerated facial aging appearance. A facelift procedure may enhance the cervicofacial contour and reduce the apparent age in MWL patients; nonetheless, fully correcting this facial deformity is challenging. Extensive skin undermining is the most critical aspect of the MWL facelift, as it allows the resection of the excess skin and adequate redraping. This article describes the surgical and medical modifications that need to be considered in the MWL facelift to ensure a successful outcome.

Neck Rejuvenation: Anatomy and Technique.

An aesthetically pleasing neck contour remains the cornerstone for facial rejuvenation. In this article a detailed description of the anatomy pertaining to the necklift surgery is provided, with supplemental cadaver video dissections going over the most common and novel necklift techniques.

Indocyanine Green Fluorescence Imaging with Lymphoscintigraphy for Sentinel Node Biopsy in Melanoma: Increasing the Sentinel Lymph Node-Positive Rate.

INTRODUCTION: The goal of this study was to analyze patients who underwent a sentinel lymph node biopsy (SLNB) in melanoma with the combination of radioisotope lymphoscintigraphy and indocyanine green (ICG) fluorescence imaging to compare our true positive (TP) rate, a means to perform immediate analysis of the SLNB, with that of the literature. METHODS: Consecutive cutaneous melanoma patients who underwent SLNB with lymphoscintigraphy and ICG-based fluorescence imaging by the senior author (BG) from 2012 to 2018 were prospectively enrolled. The average expected SLN-positive rate per T stage was calculated based on three studies and compared with our SLN-positive rate. RESULTS: Overall, 574 consecutive patients were analyzed. Average Breslow thickness was 1.9 mm. A total of 1754 sentinel nodes were sampled; 1497 were identified by gamma probe signaling and ICG, 241 were identified by gamma probe signaling only, and 16 were identified by ICG only. There were 123 (21.4%) patients with at least one positive SLN; 113 (91.9%) had at least one positive node identified with both gamma probe signaling and ICG, 8 (6.5%) had positive node(s) identified with gamma probe signaling only, and 2 (1.6%) had positive node(s) identified with ICG only. There was an overall 21.4% SLN-positive rate, with 8% T1, 18.5% T2, 41.1% T3, and 52.4% T4, which is higher than the predicted rates for each stage. CONCLUSIONS: With the largest cohort of patients reported who underwent a melanoma SLNB with lymphoscintigraphy and ICG, we demonstrated that this technique results in higher SLN-positive rates than predicted. Patients are being followed but, given the TP data, knowledge of our results may foster the use of this modality to improve staging and treatment options.

Challenges in Microsurgical Reconstruction for Craniofacial Osteomyelitis With Resultant Osteonecrosis.

INTRODUCTION: Chronic osteomyelitis is characterized by compromised blood supply and eventual osteonecrosis. Definitive treatment requires aggressive resection of affected bone. The resultant defect poses a unique challenge to reconstructive surgeons. Much of the literature on craniofacial osteomyelitis focuses on infection eradication, rather than subsequent reconstruction. This article reports representative cases from our experience with free flap reconstruction for defects secondary to chronic osteomyelitis of the craniofacial skeleton. METHODS/RESULTS: The authors selected 5 of the most difficult reconstructive cases of craniofacial osteomyelitis from our experience in a single tertiary referral institution with a follow-up of at least 6 months. Three of the 5 cases arose in the setting of previous head and neck cancer treated with resection and radiation therapy. One case had a previous surgical craniotomy complicated by osteomyelitis and multiple failed alloplastic reconstructions. The final case was due to multiple gunshots to the head, with subsequent cerebral and cranial abscess (>1000cc). In each case, the defect was successfully treated with free tissue transfer. Two cases required creation of recipient vessels with an arteriovenous loop. CONCLUSIONS: Free tissue transfer provides a versatile and effective tool in the reconstruction of extensive craniofacial osteomyelitis defects. Furthermore, the addition of vascularized tissue can protect against further episodes of osteomyelitis. Finally, arteriovenous loops can be employed successfully when prior radiation and infection of the wound bed precludes the use of local recipient target vessels.

Face and Neck Lifting After Weight Loss.

After massive weight loss, deflation of the tissues and loss of skin elasticity in the face and neck can result in the appearance of accelerated facial aging. Surgical facial rejuvenation can be successfully performed with several modifications. Proper preoperative counseling and expectation management regarding staged or ancillary procedures is recommended. Wide undermining of the face and neck, and extended postauricular incisions are required to allow for mobilization of excess skin and access to the mobile superficial musculoaponeurotic system (SMAS). Fat transfer into the deep malar compartment for midface volumizing is helpful. Treatment of the SMAS and platysma are universally necessary.

Long-term Outcomes of Cranioplasty: Titanium Mesh Is Not a Long-term Solution in High-risk Patients.

BACKGROUND: Titanium mesh is a popular material for cranioplasty. However, long-term outcomes of these reconstructions remain unknown. We aimed to compare long-term outcomes between patients undergoing both (1) skull reconstruction with titanium mesh and other commonly used cranioplasty materials and (2) scalp reconstructions with locoregional flaps and free tissue transfers. METHODS: A retrospective review of patients treated with 466 cranioplasties (401 patients) between 2002 and 2014 was performed. RESULTS: Materials used for reconstructions included nontitanium alloplast (52.0%), titanium mesh (38%), and autologous bone (10%). Median cranial defect size was 58.4 cm. Eighty-three reconstructions (18%) included full-thickness scalp defect with a median area of 155.4 cm. Median follow-up was 3.9 years. Retention rate for isolated cranioplasty was 90%, 89.9%, and 77.1% for titanium mesh, nontitanium alloplast, and autologous bone, respectively (P > 0.05). In composite defect cases, retention rate for autologous bone was comparable, 81.8% (P > 0.05), whereas for titanium mesh and nontitanium alloplast it was significantly lower, 46.8% and 72.0%, respectively (P < 0.05). The retention rate of titanium mesh cranioplasty with free fascio- and myocutaneous flaps was higher when compared with locoregional and free muscle flaps (P < 0.05). CONCLUSIONS: Titanium mesh offers a durable repair of isolated bone defects. However, in high-risk patients with soft-tissue defect, the outcomes are significantly worse. In these cases, free tissue transfer for soft-tissue coverage tends to be more successful, especially when using a myocutaneous or fasciocutaneous free flap. This is the first study to identify a high complication rate of this popular material, especially when it is combined with a locoregional scalp flap or free muscle flap. Therefore, in these cases, titanium mesh should be used with caution.

Indocyanine green fluorescence imaging with lymphoscintigraphy for sentinel node biopsy in head and neck melanoma.

BACKGROUND: Head and neck melanoma is associated with a high false negative (FN) sentinel lymph node biopsy (SLNB) rate. If techniques are developed that can decrease FN SLNBs, better prognostic information will be obtained, and it may be possible to improve overall survival as patients are assigned to the appropriate adjuvant management. Our group previously demonstrated that the combination of lymphoscintigraphy and indocyanine green (ICG) fluorescence-based technology was feasible for SLNB in primary melanoma. METHODS: Consecutive head and neck cutaneous melanoma patients who underwent radioisotope lymphoscintigraphy and ICG-based fluorescence imaging by the senior author (B.G.) from 2012 to 2015 were prospectively enrolled for analysis. Patients were followed postoperatively by the multidisciplinary melanoma team. Main outcome variables were FN rate of SLNB. Length of follow-up was date of surgery to the date of last follow-up/death. RESULTS: There were 10 positive SLNBs, 51 true negative SLNBs, and one FN SLNB. False negative rate was 9.1%, false negative incidence was 1.6%, sensitivity was 91%, and specificity was 100%. Mean follow-up was 27.6, 17.6, and 16.5 mo for true negative, true positive, and FN patients, respectively. CONCLUSIONS: We report the largest cohort of patients with head and neck cutaneous melanoma undergoing SLNB using both a combination of radioactive tracer, gamma probe, and ICG-based fluorescence identification. Our results demonstrate that using concomitant gamma probe-based radioactivity detection and ICG-based fluorescence for SLN identification in head and neck melanoma is reliable, reproducible and, thus far, has produced a low rate of FN SLNB.

Determining the False-Negative Rate Using Fluorescence Image-Assisted Sentinel Lymph Node Biopsy in Cutaneous Melanoma.

INTRODUCTION: Despite the advances in cutaneous melanoma management, the false-negative rates (FNRs) of sentinel lymph node biopsy (SLNB) are still high. These rates are dependent not only on the technique but also on definitional terms and percentage of head/neck melanoma (highest false-negative SLNB). Fluorescence imaging technology is well acquainted in plastic surgery and other specialties. Having demonstrated that fluorescence-assisted SLNB is effective in melanoma, we are interested in determining its FNR. METHODS: We obtained institutional review board approval to follow up prospectively all patients with cutaneous melanoma who underwent radioisotope/fluorescence-assisted SLNB with the intent to capture 100 negative SLNB patients. Inclusion criteria were as follows: (1) National Comprehensive Cancer Network criteria; (2) an SLNB report; (3) at least 24 months of follow-up in the negative SLNB group. The outcome variables were FNR and adjusted FNR of SLNB, considering the criterion standard of assessing the accuracy of SNLB. The FNR was defined as the proportion of patients with false-negative SLNB to patients with true-positive and false-negative SLNB [false negative/(false negative + true positive)]. Adjusted FNR refers to the previously described false-negative SLNB, but in the absence of local/in-transit recurrence or distant metastases. Furthermore, false-negative incidence (false-negative/negative SLNB patients) was also calculated. Length of follow-up was date of surgery to the date of last follow-up/death. RESULTS: A total of 125 participants, with 52.0% being male and 48.0% being female, were included. One hundred patients had an SLNB negative for metastases, whereas the rest had positive SLNB results. Median follow-up time of the cohort and that of the negative SLNB group were 36.7 (2.6-58.5) and 37.9 (24.0-58.5) months, respectively. A relatively high number (24.8%) of head/neck melanoma were included. We identified 2 cases of false-negative SLNB, with one having in-transit metastases. Thus, the FNR and adjusted FNR were 7.4% and 3.7%, respectively. The false-negative incidence and adjusted false-negative incidence were 2.0% and 1.0%, respectively. CONCLUSIONS: This is the first prospective study examining the FNR of fluorescence-assisted SLNB for patients with cutaneous melanoma. Our study reveals that this technique has one of the lowest FNRs published, especially considering the large percentage of participants with head/neck melanoma involved.

Large orbital defect reconstruction in the setting of globe-sparing maxillectomy: The titanium hammock and layered fibula technique.

INTRODUCTION: The purpose of our study was to describe a novel technique for reconstruction of orbital defects after maxillectomy using a non-anatomic titanium mesh suspension of orbital contents for both support and volume correction. This construct is then articulated with a layered fibula osteocutaneous free flap that restores orbital rim, zygoma, and maxillary alveolus. We herein present our application of this technique, including refinements over time and long-term outcomes. METHODS: A retrospective review was performed on 12 patients who underwent reconstruction of Brown class III orbitopalatomaxillary defects with extensive orbital involvement (at minimum complete orbital floor and rim absent) with titanium mesh sling and a layered fibula free flap. RESULTS: Primary reconstruction was accomplished in all 12 patients. The mean postoperative length of stay was 8 days (6-14 days). There were no free flap failures or perioperative re-explorations. Patients were routinely extubated on postoperative day #1 and began oral intake by postoperative day #3. At a mean follow-up length of 48 months, unrestricted eye function was accomplished in all patients. Midfacial symmetry was accomplished in 10 of 12 patients; 2 patients had moderate asymmetry due to extirpation of facial musculature and/or soft tissue. Minor revisions were necessary for lower lid ectropion and exposure of the titanium plate. Two patients required adipofascial free flap coverage of exposed intraoral bone after radiation therapy. CONCLUSIONS: This technique provides excellent restoration of eye position and function and also allows for implant-based prosthetic rehabilitation. It has become our procedure of choice for orbitomaxillary reconstruction.