Surgical Management of Polymethylmethacrylate-Collagen Gel Complications in the Lower Eyelid: A Case Series.

BACKGROUND: As nonsurgical rejuvenation with fillers continues to grow in popularity, patients are increasingly interested in more durable results. Polymethylmethacrylate (PMMA)-collagen gel is unique among fillers in that the PMMA microspheres are not completely absorbed and phagocytosed by the body. This durability coupled with the biophysical properties of PMMA makes it a poor choice for periorbital rejuvenation, an unforgiving and highly complex anatomic area. METHODS: Between 2011 and 2018, 14 patients with PMMA granulomas in various facial areas self-referred to the senior author's practice. Of these patients, 11 were managed nonsurgically; however, all 3 patients who presented with granulomas in the infraorbital area required surgery to remove the filler and restore a natural aesthetic. RESULTS: The 3 patients with significant swelling and PMMA filler nodules in the infraorbital area with unacceptable cosmetic appearance were females between the ages of 50 and 55 years. Nonsurgical protocols were unsuccessful, and surgical removal was required. All subjects have been followed for a minimum of 2 years with no immediate- or long-term postoperative complications secondary to PMMA removal. Patients remain satisfied with the outcome of the surgery. CONCLUSIONS: Despite the evidence that the periorbital area is prone to adverse events when injected with particulate fillers, misguided enthusiasm for PMMA-collagen gel as a durable treatment continues to lead to unnecessary and severe complications in patients. The case studies presented here highlight that this product should not be introduced into the periorbital area. We also describe a surgical treatment approach for its removal if complications arise.

Smoking as a risk factor for breast reduction: An analysis of 13,503 cases.

BACKGROUND: Reduction mammaplasty is one of the most common reconstructive procedures performed by plastic surgeons. Over 100,000 procedures are performed annually. Although important for relieving the painful symptoms associated with macromastia, complication rates of this procedure are not insignificant. They are reported in up to half the cases. Reported risk factors for adverse outcomes include obesity, preoperative wound infection, and advanced American Society of Anesthesiologists status. Smoking has been described as a risk factor for breast reduction. There is disagreement in the literature regarding the effect of smoking on patient outcomes. To further describe and investigate smoking as a risk factor, we undertook the largest multicenter retrospective study on this subject. METHODS: Data on 13,984 patients was identified from the 2009-2014 American College of Surgeons National Surgical Quality Improvement Program. Smoker and nonsmoker cohorts were compared to assess unadjusted differences in demographics, comorbidities, intraoperative details, 30-day outcomes, and readmission rates. Univariate analysis was performed using chi-square or Fisher's exact and Wilcoxon signed-rank tests. A multivariate logistic regression model was created to identify independent risk factors for complications and readmission. Odds ratios were computed at the 95% confidence interval. RESULTS: After adjusting for potential confounders, smokers had a higher likelihood of any wound complication (OR 1.72; p = 0.001) following reduction mammaplasty compared to nonsmokers. CONCLUSION: Smoking has been shown to be a significant risk factor for wound complications following reduction mammaplasty. Comprehensive preoperative counseling and documentation should be performed with patients who smoke regarding the potential for increased risk of adverse outcomes.

Urban Myths in Plastic Surgery: Postoperative Management of Surgical Drains.

BACKGROUND: Surgical patients are frequently discharged with surgical drains to assist in wound closure that could be disrupted by postoperative hematomas, lymphoceles, or seromas. In clinical practice, duration of drain use is typically dependent on daily output. OBJECTIVE: The aim of this paper was to examine the origins and justifications of drain removal criteria. The authors considered factors that may influence recommendations such as duration, area of surgical site, and risk of infection. METHODS: A literature review was performed regarding the indications for drain removal in patients undergoing reconstructive and breast surgeries. PubMed was queried for publications up to May 2015 with the following search terms: drain removal, hematomas, lymphoceles, seroma, volume, reconstruction, and mastectomy. Clinical trials, retrospective reviews, meta-analyses, and literature reviews were included. RESULTS: Most plastic surgeons remove drains based on volume criteria; however, some evidence supports early, fixed-duration drain removal. Patients who produce large volumes of fluid from the surgical site are more likely to continue to do so after drain removal and may require increased duration of drain use. Surgical site surface area may also be a factor to consider when pulling a drain. CONCLUSION: Though drain-associated infection rates are low and appear unaffected by duration, poor outcomes such as implant loss and need for reoperation may be mitigated by antisepsis strategies.

An Updated View of the Integrated Plastic Surgery Match.

BACKGROUND: Plastic surgery is one the most competitive residency programs. Data on match trends for plastic surgery residencies and traits of successful applicants are necessary for individuals applying into this highly desirable specialty. AIM: Analyze recent trends in the independent and integrated match as well as to describe attributes of successful applicants. METHODS: Data from National Resident Matching Program and San Francisco Match Program for 2007 to 2014 were compiled and analyzed. Statistical analysis and figure creation were performed using the R software package. For bivariate associations, χ or Fisher's exact test was used. RESULTS: The number of available integrated plastic surgery positions through National Resident Matching Program has increased since 2007, whereas the number of independent residencies offered through the SF Match has steadily decreased. The average Step 2 scores, The number of research presentations, publications, abstracts, and the percent of students ranking plastic surgery only have increased. In a break from previous trends, percent of applicants with Alpha Omega Alpha (AOA) membership and mean Step 1 board scores decreased. United States medical school applicants who matched were more likely to be AOA members and graduates from a top 40 medical school. There was no significant association between having an additional academic degree and successfully matching into integrated plastic surgery. CONCLUSIONS: Integrated plastic surgery residency programs continue to be highly competitive, with overall increasing research experience, but slightly lower Step 1 scores and AOA membership than that in previous years. If the trend of decreasing independent and increasing integrated positions continues, the applicant only interested in plastic surgery may find the integrated pathway a more feasible option.