Seroma After Breast Reconstruction With Tissue Expanders: Outcomes and Management.

BACKGROUND: Seroma is a relatively common complication after breast reconstruction with tissue expanders. The main risk in the presence of seroma is development of periprosthetic infection, which can lead to implant loss. Our goals were to identify risk factors for seroma, and to describe our protocol for managing fluid accumulation. PATIENTS AND METHODS: An IRB approved breast reconstruction database was reviewed to identify patients who underwent tissue expander reconstruction. Patient characteristics, details of surgery, outcomes and treatment were recorded. RESULTS: Two hundred nineteen tissue expander reconstructions were performed in 138 patients. Twenty-eight reconstructions developed seroma (12.8%), and 75 were identified to have prolonged drains (34.2%). Seroma was more common in patients with lymph node surgery ( P = 0.043), delayed reconstruction ( P = 0.049), and prepectoral reconstruction ( P = 0.002). Seroma and/or prolonged drains were more commonly noted in patients with higher body mass index ( P = 0.044) and larger breast size ( P = 0.001). Aspiration was the most common intervention (85.7%), which was performed in the clinic utilizing the expander port site. There was no difference in infection or explantation rate between seroma and no-seroma patients ( P = 0.546 and 0.167), whereas patients with any fluid concern (seroma and/or prolonged drains) were more prone to developing infection and undergoing explantation ( P = 0.041 and P < 0.005). CONCLUSION: We recommend that prolonged drain placement longer than 3 weeks should be avoided, and patients should be screened for fluid accumulation after drain removal. Serial aspiration via expander port site and continuation of expansion provide a safe and effective method to manage seromas to avoid infection and expander loss.

Broad-Spectrum Antibiotics for Breast Expander/Implant Infection: Treatment-Related Adverse Events and Outcomes.

BACKGROUND: Despite best practices, infection remains the most common complication after breast reconstruction with expanders and implants, ranging from 2% to 29%. Empiric broad-spectrum antibiotics are frequently used in nonsurgical treatment of implant-associated infections in an effort to salvage the reconstruction. Pitfalls of antibiotherapy include adverse events, vascular access site complications, and drug resistance. Our goals were to describe management of implant infections with broad-spectrum antibiotics, review treatment related adverse events, and report on outcomes of therapy. PATIENTS AND METHODS: A retrospective review was carried out to identify patients who were treated with intravenous (IV) antibiotics for periprosthetic infection. Patient characteristics, surgical details, and antibiotic therapy-related adverse events were collected. Eventual outcome related to expander/implant salvage was noted. RESULTS: A total of 101 patients (111 treatment episodes) were identified. Mean duration of antibiotic treatment was 18 days (range, 1-40 days). The most commonly used parenteral treatment was a combination of daptomycin with piperacillin-tazobactam (65%) or an alternative agent (16%). Fifty-nine percent of treatment episodes resulted in salvage of the expander or implant. Thirty-five percent treatment episodes were associated with 1 or more adverse events: diarrhea (12.6%), rash (10%), vaginal candidiasis (3.6%), agranulocytosis/neutropenic fever (3.6%), nausea (3.6%), urinary complaint (0.9%), myositis (0.9%), headache (0.9%), vascular line occlusion (1.8%), deep vein thrombosis (1.8%), and finger numbness (0.9%). No patients developed Clostridium difficile colitis. Five episodes (4%) needed discontinuation of antibiotics because of severe adverse events. The prosthesis was explanted in 3 of the cases of discontinued treatment. CONCLUSIONS: Our findings show favorable outcomes and well-tolerated adverse effects with broad-spectrum parenteral antibiotherapy for periprosthetic infection. However, every effort should be made to deescalate therapy by narrowing the spectrum or limiting the duration, to minimize adverse events and development of bacterial resistance. Treating surgeons need to carefully weigh benefits of therapy and be aware of potential complications that might necessitate discontinuation of treatment.

Bilateral immediate two-stage breast reconstruction in patients with unilateral breast cancer: Outcomes analysis and risk assessment.

INTRODUCTION: Contralateral prophylactic mastectomy has the potential to decrease the occurrence of cancer and reduce psychological burden. However, it is known that complications after bilateral mastectomy are higher compared with unilateral mastectomy. Our goal was to evaluate outcomes of immediate breast reconstruction in patients undergoing bilateral mastectomy and to compare complication rates between therapeutic and prophylactic sides. PATIENTS AND METHODS: Electronic medical records of patients with unilateral breast cancer who underwent bilateral mastectomy and immediate reconstruction with expanders were reviewed. Postoperative complications were compared between therapeutic and prophylactic mastectomy sides. RESULTS: Sixty-two patients were analyzed. The overall complication rate after both stages was 23.9% on the therapeutic side and 16.5% on the prophylactic side. Infection was the most common complication on both sides. All infections on the prophylactic mastectomy side were successfully treated with intravenous (IV) antibiotics (salvage rate of 100%), whereas 35.7% of infected tissue expander/implants on the therapeutic mastectomy side were explanted despite treatment. CONCLUSION: Careful counselling of patients undergoing elective contralateral prophylactic mastectomy is essential as complications can develop in either breast after reconstruction.

Plastic Surgery and the COVID-19 Pandemic: A Review of Clinical Guidelines.

BACKGROUND: A novel coronavirus disease (COVID-19) was first reported in December 2019 in China and was soon declared a pandemic by the World Health Organization. Many elective and nonessential surgeries were postponed worldwide in an effort to minimize spread of disease, as well as to conserve resources. Our goal with this article is to review current practice guidelines in setting of the COVID-19 pandemic, based on available data and literature. METHODS: Websites pertaining to surgical and medical societies, and government agencies were reviewed, along with recently published literature to identify recommendations related to COVID-19 and plastic surgery procedures. RESULTS: Clinical practice modifications are recommended during the pandemic in outpatient and perioperative settings. Use of personal protective equipment is critical for aerosol-generating procedures, such as surgery in the head and neck area. Care for trauma and malignancy should continue during the pandemic; however, definitive reconstruction could be delayed for select cases. Specific recommendations were made for surgical treatment of cancer, trauma, and semiurgent reconstructive procedures based on available data and literature. CONCLUSIONS: The risk and benefit of each reconstructive procedure should be carefully analyzed in relation to necessary patient care, minimized COVID-19 spread, protection of health care personnel, and utilization of resources. Recommendations in this article should be taken in the context of each institute's resources and prevalance of COVID-19 in the region. It should be emphasized that the guidelines provided are a snapshot of current practices and are subject to change as the pandemic continues to evolve.

Expander/Implant Removal After Breast Reconstruction: Analysis of Risk Factors and Timeline.

INTRODUCTION: Removal of tissue expanders (TE) or implants is a dire consequence of breast reconstruction, and has the potential to halt the reconstructive efforts. Our goals were to characterize a cohort of patients with TE/implant removal, to perform a time-based analysis, and to review the bacteriology associated with explanted devices. MATERIALS AND METHODS: Review of a prospectively maintained database was performed to identify patients who underwent TE/implant removal. Patient characteristics, surgical technique, adjuvant therapies, indications, complications, culture results were obtained. Data were analyzed according to timing of explantation. RESULTS: A total of 55 TE and implants were removed in 43 patients. Reasons for explantation were infection (58%), patient request (22%), and wound-related complications (20%). The majority of explantations occurred after 30 days (62%), and after Stage I (81%). Median days to explantation was 62. Patients of older age (p = 0.01) and higher BMI (p = 0.02) were more likely to undergo explantation after Stage I. The most commonly cultured organisms were S. epidermidis (10.9%), S. aureus (10.9%) and P. aeruginosa (10.9%). Antibiotic resistance was commonly encountered for ampicillin, cefazolin, penicillin, and erythromycin. CONCLUSION: Infection is the most common reason for explantation after prosthetic breast reconstruction. Patients should be carefully monitored for a prolonged period of time after Stage I, as the majority of explantations occur in this stage but beyond 30 days. For oral treatment, fluoroquinolones and trimethoprim-sulfamethoxazole and for IV treatment a combination of vancomycin or daptomycin with piperacillin-tazobactam or imipenems/carbapenems appear to be appropriate choices according to our culture results. 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 .

Role of tissue expansion in abdominal wall reconstruction: A systematic evidence-based review.

BACKGROUND: Tissue expanders (TEs) can be used to assist primary closure of complicated hernias and large abdominal wall defects. However, there is no consensus regarding the optimal technique, use, or associated risk of TE in abdominal wall reconstruction. METHODS: A systematic search of PubMed and Embase databases was conducted to identify articles reporting abdominal wall reconstruction with TE techniques. English articles published between 1980 and 2016 were included on the basis of the following inclusion criteria: two-stage TE surgical technique, >3 cases, reporting of postoperative complications, hernia recurrence, and patient-based clinical data. RESULTS: Fourteen studies containing 103 patients (85 adults and 18 children) were identified for analysis. Most patients presented with a skin-grafted ventral hernia (n = 86). The etiology of the hernia was from trauma or prior abdominal surgery. The remaining patients had TE placed before organ transplantation (n = 12) or for congenital abdominal wall defects (n = 5). The location for expander placement was subcutaneous (n = 74), between the internal and external obliques (n = 26), posterior to the rectus sheath (n = 2), and intra-peritoneal (n = 1). Postoperative infections and implant-related problems were the most commonly reported complications after Stage I. The most common complication after Stage II was recurrent hernia, which was observed in 12 patients (11.7%). Five patients with TE died. Complications and mortality were more prevalent in children, immunosuppressed patients, and those with chronic illnesses. CONCLUSIONS: Tissue expansion for abdominal wall reconstruction can be successfully used for a variety of carefully selected patients with an acceptable complication and risk profile.

Combined submuscular tissue expansion and anterior component separation technique for abdominal wall reconstruction: Long-term outcome analysis.

BACKGROUND: We report the long-term outcome analysis of 12 patients who underwent two-stage abdominal wall reconstruction using combined submuscular tissue expansion and anterior components separation (CS) technique. METHODS: Outcome measures were (1) the patients were assessed for the presence or absence of recurrence; (2) patient-reported outcomes on physical functioning in relation with the abdominal wall reconstruction were evaluated using the SF 36-item health survey. RESULTS: The mean age, average expansion volume, and mean time expansion were 37.5 years, 1250 cc, and 9.5 weeks, respectively. The average soft tissue deficiency size was 15.5 (width) × 19.5 (length) cm2. The average fascial defect was 17 (width) × 21.5 (length) cm2. No mesh-assisted technique was required. Primary closure was obtained in all. The average follow-up was 39.6 months. Hernia recurrence was noted in one patient (8.3%). All 12 patients completed the SF 36-item health survey. Moreover, 75% of the patients reported 100%, indicating "Not limited in vigorous activities," and 25% indicated "limited a little." All patients reported 100% "not limited at all" in lifting or carrying groceries, climbing several flights of stairs, climbing one flight of stairs, bending, kneeling, stooping, walking more than a mile, walking several blocks, walking one block, bathing, or dressing. CONCLUSIONS: Parietal laxity obtained with tissue expansion increases the possibility of direct closure of the fascial layer, skin, and subcutaneous tissue components. Combined use of tissue expansion and CS may result in favorable long-term outcomes as evidenced by patient-reported physical functioning data and low rate of hernia recurrence.

Free vascularized lymph node transfer for treatment of lymphedema: A systematic evidence based review.

BACKGROUND: Free vascularized lymph node transfer (VLNT) is a relatively novel technique for treatment of lymphedema. The purpose of this systematic review was to evaluate the current evidence on VLNT and to determine if there is objective data concerning improved outcomes. METHODS: A literature search of PubMed, EMBASE and CENTRAL electronic databases was conducted to identify articles written in the English language on VLNT for treatment of lymphedema. Publications were selected according to inclusion criteria. Papers reporting adjunct techniques and those that did not describe outcomes were excluded. Data including patient demographics, surgical technique, complications and outcomes were extracted. A quality score was calculated for each article. RESULTS: Eighteen studies were included with an overall study population of 305 patients. Mean quality score of articles was 5.3 with levels of evidence range from II to IV. Among 182 patients who underwent limb circumference assessment, 165 (91%) showed postoperative improvement. Reduction of limb volume was noted in 98 of 114 (86%) patients. Ninety two patients underwent lymphoscintigraphy/lymphangiography and 55 (60%) demonstrated moderate or significant improvement of flow. Patient satisfaction was questioned in 105 patients and with exception of 7 patients, all reported a high satisfaction level with significant relief in symptoms and improved quality of life. Publications also reported a reduction in infectious episodes. CONCLUSION: VLNT appears to provide improvement in lymphedema. More studies with standardized methods for reporting outcomes and uniform patient selection are needed to evaluate this technique thoroughly.

Treatment of Foot Degloving Injury With Aid of Negative Pressure Wound Therapy and Dermal Regeneration Template.

Degloving injury of the foot continues to be a challenging condition to treat. Despite current advancements in reconstructive options, most of these injuries can result in amputations, causing physical and emotional impairment. Few reports have been published on the management of these complex traumatic injuries. Typical reconstruction options have included skin grafting and reattachment of the avulsed skin. Many treating physicians have encountered challenging issues in predicting tissue viability, knowing the extent of the injury, and making a logical decision for limb salvage procedures. The present report provides an algorithm of our approach in managing degloving injuries. A case of foot degloving injury, treated by serial surgical operations with the dominant aim of salvaging the avulsed tissue, is presented. The avulsed portion of the foot, with no identifiable vessels for microsurgical reattachment, was defatted and used as a full-thickness skin graft. Negative pressure wound therapy and a dermal regeneration template were used as adjunct techniques to help obtain good soft tissue coverage. The traditional treatment methods for degloving injuries and the applications of new wound care technologies are discussed.

An Analysis of Current Techniques Used for Intraoperative Flap Evaluation.

BACKGROUND: Over the last decade, microsurgeons have used a greater variety of more complex flaps. At the same time, microsurgeons have also become more interested in technology, such as indocyanine green (ICG) angiography, dynamic infrared thermography (DIRT), and photospectrometry, for preoperative planning and postoperative monitoring. These technologies are now migrating into the operating room, and are used to optimize flap design and to identify areas of hypoperfusion or problems with the anastomoses. Although relatively more has been published about ICG angiography, information is generally lacking about the intraoperative role of these techniques. METHODS: A systematic analysis of articles discussing intraoperative ICG angiography, DIRT, and photospectrometry was performed to better define the sensitivity, specificity, expected outcomes, and potential complications associated with these techniques. RESULTS: For intraoperative ICG angiography, the sensitivity was 90.9% (95% CI: 77.5-100) and the accuracy was 98.6% (95% CI: 97.6-99.7). The sensitivity of DIRT was 33% (95% CI: 11.3-64.6), the specificity was 100% (95% CI: 84.9-100), and the accuracy was 80% (95% CI: 71.2-89.7). The sensitivity of intraoperative photospectrometry was 92% (95% CI: 72.4-98.6), the specificity was 100% (95% CI: 98.8-100), and the accuracy was also 100% (95% CI: 98.7-100). CONCLUSION: These technologies for intraoperative perfusion assessment have the potential to provide objective data that may improve decisions about flap design and the quality of microvascular anastomoses. However, more work is needed to clearly document their value.

Variables affecting postoperative tissue perfusion monitoring in free flap breast reconstruction.

Postoperative flap monitoring is a key component for successful free tissue transfer. Tissue oxygen saturation measurement (TOx) with near-infrared spectrophotometry (NIRS) is a method used for this purpose. The aim of this study was to identify external variables that can affect TOx. Patients who had breast reconstruction with free flaps were monitored prospectively and intra-operative details were recorded. Flap TOx was recorded with NIRS pre-extubation, postextubation, and then every four hours for 36 hours. At each of these time points, blood oxygen saturation (SO2), amount of supplemental oxygen, and blood pressure were recorded. Thirty flaps were monitored. Initially, a significant trend over time was detected such that for every increase of 24 hours, TOx decreased on average by 2.1% (P = 0.025). However, when accounting for SO2 levels, this decrease was no longer significant (P = 0.19). An increase by 1% in SO2 produced an increase in TOx reading of 0.36 (P = 0.007). The amount of supplemental O2, systolic blood pressure, and diastolic blood pressure did not have a significant impact on TOx (P > 0.05). The TOx values were highest in the free TRAM flaps and were lower in decreasing order in the muscle-sparing TRAM, DIEP, and SIEA flaps (P > 0.05). The TOx values did not significantly correlate with vessel size, perforator number, or perforator row. Postoperative flap TOx was found to correlate with SO2 and was not significantly dependent on blood pressure, supplemental O2, or surgical variables. Careful interpretation of oximetry values is essential in decision making during postoperative flap monitoring.

Predicting skin flap viability using a new intraoperative tissue oximetry sensor: a feasibility study in pigs.

BACKGROUND: Operations for soft-tissue reconstruction, orthopedic, vascular, and other types of surgery can be complicated by unexpected skin flap necrosis. At present, surgeons utilize subjective clinical judgment and physical findings to estimate the potential for tissue compromise. As the validity of these subjective methods is questionable, there is a need for objective, quantitative tools to determine the risk of flap necrosis during surgery. METHODS: Three 9-month-old Yorkshire pigs were used for the study. Four laterally based random pattern fasciocutaneous flaps were dissected on each animal. After the flaps were elevated, a prototype oximeter (ViOptix Inc., Fremont, CA), was used to measure tissue oxygenation (StO2) at 2 cm intervals along the flaps. Measurements were performed immediately after the flaps were dissected, and again at the same points after they were sutured. The animals were reevaluated 4 days later, and assessed for areas of tissue necrosis. RESULTS: For each flap, StO2 at the base was compared with StO2 at the more distal points. The median delta StO2, as measured immediately after dissection, was -3.9% points for tissue that remained viable and -34.0% points for tissue that became necrotic (p = 0.039). After the flaps were sutured back to the chest wall, the median delta StO2 for tissue that remained viable was -1.7% points versus -24.7% points for tissue that became necrotic (p = 0.006). CONCLUSIONS: This new handheld surface sensor can be used to measure StO2 of skin flaps and may potentially reduce complications associated with unexpected tissue necrosis.

Defining the fat compartments in the neck: a cadaver study.

BACKGROUND: Cervicoplasty is an important component of aesthetic facial and neck surgery, but the fat content in this area has not been described. OBJECTIVES: The authors identify anatomic compartments of fat in the neck (specifically the areas relevant to surgical management), quantify the fat in each compartment, and describe the relationships between each compartment and the submandibular glands. METHODS: The skin was removed from 10 fresh cadaver heads. Each compartment of fat was weighed, along with the submandibular gland. Supraplatysmal fat was found between the skin and the platysma muscle, and it was compartmentalized into suprahyoid and infrahyoid fat. Subplatysmal fat was found deep to the platysma and between the medial edges of the anterior digastric in the midline; this fat also fell into suprahyoid and infrahyoid compartments. The "very deep" fat was deep to the anterior digastric muscles and submandibular gland, and adherent to the strap muscles. RESULTS: On average, supraplatysmal fat represented 44.7% of the fat in the neck, the subplatysmal fat represented 30.7%, and the submandibular gland represented 24.5%. The very deep fat was scant, representing less than 1% of the fat in the neck. CONCLUSIONS: This anatomic study provides a comprehensive review of fat in the neck, and the results should serve as an additional guide as surgeons approach this challenging area in surgical rejuvenation.

Feasibility of using external jugular vein and its branches as Y- and X-shaped vein grafts for bridging of arterial defects and providing additional arterial sources for free flap applications in rat model.

BACKGROUND: Venous grafting has been widely used in microsurgical training. Different types of vascular grafts have been described in experimental models. In this study we describe for the first time the Y- and X-shaped vein grafts (YVG, XVG) with accompanying drain-out branches as a new tool for the microsurgical training and free flap applications in rats. METHODS: Twelve adult male Lewis rats were used in this study. The dissections were performed to determine the average diameter and harvestable length of vein grafts in eight rats. In four rats vein grafts were applied for bridging of the common carotid artery gap, whereas the drain-out branches were used as the arterial source for single and bilateral free groin flap applications. The venous anastomoses of groin flaps were performed in end-to-end fashion to the external jugular vein and its branches. The patency of anastomoses was checked 72 hours after repair. RESULTS: The average length of the harvestable vein branches ranged between 5.2 to 11.8 mm. The average surgery time for repair of the arterial gap with the vein grafts was 40 minutes. The ischemia time for single and bilateral groin flap transfer using YVG and XVG was 30 and 70 minutes, respectively. The patency of the interpositional vein graft was 100%. Flap survival rates were 50%. CONCLUSIONS: These vein grafts can be used as an alternative technique for reconstruction of tissue defects that require arterial gap repair with single or multiple free flap applications and also as a new microsurgical training model.

Breast reconstruction with abdominal-based free flaps in high body mass index population: postoperative complications and impact of weight loss.

Obesity, which is becoming endemic in the United States, causes a significant challenge for reconstructive surgeons. This study evaluates postoperative complications and impact of weight loss in the high body mass index (BMI) population undergoing breast reconstruction with abdominal free flaps. A retrospective review of 182 consecutive patients was performed. Patients were divided into groups according to their BMI at the time of surgery (preoperative BMI) and presence of weight loss, and data were compared among groups. Multivariate analysis of effect of preoperative BMI on complications revealed that overall flap (P = 0.008) and donor (P = 0.016) complication rates were significantly higher in the obese group. Analysis of preoperative weight loss did not yield a statistically significant reduction in flap (P = 0.5161) or donor (P = 0.8034) complication rates. Univariate analysis showed that higher preoperative BMI is associated with higher risk of systemic complications (P = 0.027). It is important to inform patients preoperatively that weight loss, although beneficial for ease of procedure and quality of life, does not diminish their increased risk of complications. Body mass index during surgery is the most important predictor of complications.

A failsafe method to avoid injury to the great auricular nerve.

BACKGROUND: The great auricular nerve (GAN) is the most commonly injured nerve during facelift surgery. Although rare, injury can result in long-term sequelae. OBJECTIVES: Previous reports have described the nerve's location at the midbelly of the sternocleidomastoid muscle (SCM) or at its emergence from underneath the SCM. The purpose of our study was to identify the superior course of the great auricular nerve as it applies to facelift. METHODS: Thirteen fresh cadavers were dissected. A vertical line through the midlobule was drawn perpendicular to the Frankfort's horizontal, acting as a reference to the course of the GAN. Transparent paper overlay tracings were then done to record each nerve's location. The distance from the bony external auditory canal (EAC) to the nerve was measured at the anterior muscle border, at the midbelly of the SCM, and as the nerve emerged from under the SCM. Branching patterns of the nerve and its relation to the external jugular vein were identified. RESULTS: In 100% of the dissections, the superior course of the GAN fell within a 30-degree angle constructed using the vertical limb perpendicular to the Frankfurt horizontal and a second limb drawn posteriorly from the midlobule. The distance from the EAC to the nerve was 4.9 ± 1.1 cm at the anterior muscle border, 7.3 ± 1.0 cm at the midbelly of the SCM, and 9.8 ± 1.2 cm at the GAN's emergence from under the SCM. Four types of branching patterns were identified. CONCLUSIONS: The 30-degree angle described above rapidly and accurately identifies the nerve's location.

Achieving patient satisfaction in abdominally based free flap breast reconstruction: correlation with body mass index subgroups and weight loss.

BACKGROUND: The goal of this study was to evaluate the relationship between body mass index, preoperative weight loss, and patient satisfaction in breast reconstruction with abdominally based free flaps. METHODS: A custom survey with overall, breast, and abdomen questions was sent to patients who underwent abdominally based free flap breast reconstruction over the past 4 years. Clinical data were collected for patients who returned surveys. Data analysis was performed based on body mass index and percentage weight loss before surgery. RESULTS: One hundred seventy-nine surveys were sent. Ninety-two patients (51.4 percent) responded. Normal weight patients versus overweight patients did not have statistically significant differences in any satisfaction scores. Overweight patients had higher overall satisfaction (p = 0.01), breast-specific satisfaction (p = 0.01), and abdomen-specific satisfaction (p = 0.02) compared with obese patients. Normal weight patients had higher breast-specific satisfaction (p = 0.05) and abdomen-specific satisfaction (p = 0.03) scores compared with obese patients. Patients with significant preoperative weight loss were more satisfied with feeling of breasts in clothes (p = 0.01), social appearance (p = 0.05), and current abdominal appearance (p = 0.01) compared with patients with moderate preoperative weight loss. Overall, breast- and abdomen-specific satisfaction scores decreased with increase in pannus thickness. CONCLUSIONS: Patient satisfaction with abdominally based free flap breast reconstruction was highest in patients with normal body mass index and lowest in obese patients. Overweight or obese patients should be encouraged to participate in healthy weight loss programs to achieve improved postoperative satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Outcomes assessment of combination face lift and perioral phenol-croton oil peel.

BACKGROUND: Face-lift surgery when combined with perioral phenol-croton oil peel is an underappreciated tool for face rejuvenation. The procedure results in significant central face skin tightening and wrinkle reduction. METHODS: A retrospective review of 47 consecutive patients who underwent simultaneous face lift and perioral peel was performed. The objective measures used to evaluate the change in appearance of the patients included (1) a validated patient satisfaction questionnaire, (2) an evaluation of apparent age, and (3) an evaluation of perioral wrinkles by independent reviewers using a validated model. The assessment of apparent age was performed as follows: preoperative and postoperative photographs were shown randomly to six reviewers, who were asked to estimate the patient's age. The apparent age was compared with the patient's actual age, and the reduction in apparent age was calculated. Improvement in perioral rhytides was evaluated by using the Glogau classification system (range, 1 to 4). RESULTS: Survey results documented overall patient satisfaction, which was rated as 6.5 on a scale of 1 to 7 (with higher scores indicating greater satisfaction). Patients' postoperative apparent age estimate was 8.2 years younger than their real age (p=0.0002). The Glogau classification system score demonstrated a mean reduction of 1.15 (3.3 preoperatively as compared with 2.15 postoperatively, p<0.0001). CONCLUSION: Outcomes measurements, including patient satisfaction, objective evaluation of wrinkle improvement, and significant reduction in apparent age, document the power of this technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Dentition, bone loss, and the aging of the mandible.

BACKGROUND: Facial aging is a dynamic process with impact on both the soft tissues and the bones. Despite a growing body of evidence, controversy still exists regarding absolute characteristics of the aging facial skeleton. OBJECTIVE: The purpose of this study was to investigate various mandibular measurements in different age groups and to delineate the relation of the dentition to these parameters. METHODS: Ninety Caucasian mandibles were assessed for the following distance landmarks: gonion-gonion, infradentale-gnathion, mental foramen-mandibular crest, mental foramen-inferior mandibular border, gnathion-gonion, condyle-gonion, and gonial angle. The measurements were compared according to age, sex, and dentition. RESULTS: The number of teeth decreased significantly with increasing age in males (P = .002) and females (P < .001). There were no other statistically significant differences between age groups for the rest of the parameters. The infradentale-gnathion distance (P = .005) and the mental foramen-mandibular crest distance (P < .001) was found to increase with total number of teeth. Other parameters did not show a significant relation to dentition. All parameters were significantly larger in the male subgroups with the exception of gnathion-gonion distance and gonial angle. Bilateral mandibular measurements were symmetric except for the gonial angle, which was more obtuse on the right side in males (P = .007) and females (P = .018). CONCLUSIONS: Our findings support previous evidence that dentition is the main determinant of the morphology of the mandible. The skeletal characteristics are variable among individuals, and a longitudinal study is required to better understand age-related changes of the mandible.

Complications following injection of soft-tissue fillers.

BACKGROUND: Soft-tissue filler injection is a very common procedure in the United States. Although the safety profile is favorable, adverse events (AE) can occur, ranging from mild to severe in intensity. OBJECTIVES: The authors performed a literature search to identify the facial sites most prone to severe complications. They review the course of these complications and discuss preventive measures. METHODS: The National Library of Medicine, the Cochrane Library, and Ovid MEDLINE were searched, and relevant articles (published through August 2012) were retrieved based on prespecified inclusion criteria. The complications reviewed were limited to "severe" events, such as soft-tissue necrosis, filler embolization, visual impairment, and anaphylaxis. The filler materials included were those approved by the US Food and Drug Administration at the time of this study. RESULTS: Forty-one articles, representing 61 patients with severe complications, were identified. Data collected from these case reports included filler type, injection site, complication site, symptom interval, symptom of complication, time to therapy, modality of treatment, and outcome. The most common injection site for necrosis was the nose (33.3%), followed by the nasolabial fold (31.2%). Blindness was most often associated with injection of the glabella (50%). An estimated incidence of 0.0001% for developing a severe complication was calculated by reviewing society-based filler data and case reports within same time period. CONCLUSIONS: Although soft-tissue fillers are a popular choice for minimally invasive rejuvenation of the face, physicians should be aware of the serious potential adverse effects, recognize their presentations, and have appropriate treatments readily available.