Investigating the Efficacy of Modified Lipoaspirate Grafting to Improve the Appearance of Atrophic Acne Scars: A Pilot Study.

BACKGROUND: Processed lipoaspirate grafting describes several techniques theorized to leverage the inflammatory and regenerative capacities of mechanically processed adipocytes to rejuvenate and correct skin pathology. Although lipoaspirate grafting is typically leveraged to fill visible defects such as depressed scars and dermal lines, additional fat processing allows grafts to stimulate mechanisms of wound healing, including the promotion of fibroblast activation, neovascularization, and neocollagenesis. OBJECTIVES: This study intends to assess the efficacy and tolerability of processed lipoaspirate grafting monotherapy to improve the clinical appearance of atrophic acne scars. METHODS: Patients underwent a single autologous processed lipoaspirate grafting procedure at the site of atrophic acne scars. Objective and subjective scar analysis was performed at 3 and 6 months posttreatment. Scars were assessed with standard photography, topographic analysis, and noninvasive skin measurements. In addition, microbiopsies were obtained before and after treatment to assess histological or genetic changes. Clinical improvement was assessed with patient and clinician Global Aesthetic Improvement Scales (GAIS) and blinded photographic evaluation. RESULTS: Ten patients between ages 18 and 60 completed the study. Clinical evaluation demonstrated that fat grafting improved the appearance of atrophic acne scars. Clinician GAIS and patient GAIS scores showed clinical improvement at both 3- and 6-month follow-up compared with baseline (P < .05). Blinded clinician GAIS scores also showed statistically significant improvement when clinicians compared clinical photographs taken at 6-month follow-up to baseline (P < .0001). The attenuation coefficient increased at 6-month follow-up, suggesting collagen remodeling and reorganization over the study period. Patients experienced anticipated posttreatment symptoms including transient erythema and edema; however, no unexpected adverse events were reported. CONCLUSIONS: Micronized lipoaspirate injection is a viable and effective option to improve the appearance of facial acne scarring. Favorable improvements in atrophic acne scarring were captured by objective analysis of skin ultrastructure as well as improvement in subjective assessments of scarring.

Intramuscular Nanofat Injection Promotes Inflammation-Induced Gastrocnemius Regeneration in a Syngeneic Rat Sciatic Nerve Injury Model.

BACKGROUND: Mechanical emulsification of adipose tissue to concentrate protein and stromal cell components (ie, nanofat) has gained considerable interest in clinical practice. Although the regenerative potential of nanofat has largely been used in aesthetic applications, these effects have considerable potential in reconstruction as well. Here, the authors investigated the therapeutic properties of nanofat injected directly into the denervated gastrocnemius after a sciatic nerve injury in Lewis rats. METHODS: Muscle denervation was induced by transecting and immediately repairing the sciatic nerve. Inguinal and subcutaneous adipose was harvested from donor rodents, processed into nanofat, and then injected intramuscularly into the gastrocnemius. Gait analysis was performed weekly. Rodents were euthanized at 9 and 12 weeks, after which tetanic contraction force was measured, and gene expression, histology, and cytokine multiplexing were performed. RESULTS: Intramuscular injection of nanofat significantly increased maximum tetanic force generation at 9 and 12 weeks. The forces of the nanofat-injected gastrocnemii were better correlated to their contralateral gastrocnemii relative to controls. Muscle repair-associated inflammatory gene expressions were significantly up-regulated in nanofat-injected gastrocnemii. Cytokines interleukin (IL)-1ß, IL-18, vascular endothelial growth factor, granulocyte-macrophage colony-stimulating factor, and tissue inhibitor of metalloproteinase-1 were significantly higher in nanofat-injected gastrocnemii relative to control gastrocnemii, and the tetanic force was linearly and significantly correlated to IL-1ß and IL-18 and their interacting effects. CONCLUSIONS: Intramuscular injection of emulsified adipose tissue (nanofat) significantly increased gastrocnemii contraction force after sciatic nerve injury, with prolonged reconstructive inflammation by means of CD68, inducible nitric oxide synthase, IL-1ß, and IL-18 all being potential mechanisms for this recovery. This application could potentially increase the therapeutic breadth of nanofat to include muscular recovery after nerve injury. CLINICAL RELEVANCE STATEMENT: The authors' study investigates a clinically translatable therapy to mitigate muscle atrophy after nerve injury.

Light-Guided Percutaneous Neck Rejuvenation With Division of Platysma Bands and Suture Suspension: A Multicenter Retrospective Study.

BACKGROUND: Traditional invasive suture suspension techniques have proven efficacy and durability. A previously described percutaneous placement of a neck suspension suture with light guidance has transformed this into a minimally invasive technique. This novel technique provides a major advance for minimally invasive neck rejuvenation. OBJECTIVES: The authors sought to describe their experience with light-guided percutaneous neck rejuvenation over the past 4.5 years, including technique, patient selection, safety profile, and expected outcomes. METHODS: Data were retrospectively reviewed for all patients who underwent the procedure with 5 surgeons across 4 aesthetic plastic surgery practices from January 2018 through May 2022. Inclusion criteria were mild to moderate neck laxity, prominent anterior platysma bands, and desire to improve neck contour. Patients undergoing concurrent skin incision >5 mm (ie, open rhytidectomy or platysmaplasty) were excluded. RESULTS: A total of 391 patients meeting criteria were identified during the study period. No hematomas were documented. Four patients (1%) developed infection at the suture site, 1 resolving on antibiotics and 3 requiring suture removal. Eighteen (4.6%) developed recurrent platysmal bands, and 7 (1.8%) had residual loose skin. Four (1%) experienced transient marginal mandibular neuropraxia. Mean length of follow-up time was 240 days. CONCLUSIONS: Light-guided percutaneous suture suspension is a safe and viable option for improving neck contours. Although it does not address extensive skin laxity or excess submental fat, it can be combined with energy-based tissue tightening, submental liposuction, or skin excision. In selected patients, this minimally invasive procedure provides predictable results with a low risk of complications.

Seromas: How to Prevent and Treat Them-a 20-Year Experience.

Seromas are a common complication in plastic surgery. In this article, the authors describe their approach to the prevention and treatment of seromas and include a discussion of the evolution of their techniques. They provide specific technical details for many body contouring operations, including abdominoplasty, belt lipectomy, brachioplasty, and thighplasty. Many of the authors' techniques question the traditional dictums of plastic surgery, and they hope to encourage others to consider novel techniques for the treatment and prevention of seromas.

A Single-Center Pilot Study to Classify Signs of Dorsal Hand Aging Using 3 Grading Scales.

BACKGROUND: While validated scales must be created in order to systemically evaluate patients and quantify outcomes of aesthetic hand treatments, scales currently available are limited to the analysis of volume loss alone. OBJECTIVES: The purpose of this study was to develop 3 validated scales for the assessment of dorsal hand aging that also take into consideration wrinkling and pigmentation. METHODS: Fifty (50) healthy volunteers (40 females and 10 males) with Fitzpatrick skin types I-IV were recruited, and standard photographs of their left and right dorsal hands were taken with a Nikon D7100 (Nikon; Minato, Tokyo, Japan) camera. Using 25 randomized photographs, 11 plastic surgery physicians (3 chief residents, 6 senior residents, and 2 aesthetic surgery fellows) were trained on the 3 scales under investigation as well as the already-validated Merz Hand Grading Scale (MHGS). The evaluators then viewed the remaining 75 photographs independently and assigned a grade for each of the 4 scales to each photograph. Inter-rater variability was calculated for each scale. RESULTS: The Kappa score for the MHGS was 0.25, indicating fair agreement; 0.40 for wrinkle scale, indicating fair agreement; and 0.48 and 0.46 for the pigmentation density and intensity scales, respectively, indicating moderate agreement (P < 0.001). CONCLUSIONS: The results show that after receiving training, the inter-rater agreement for the 3 scales under investigation was similar or slightly higher than that for the MHGS. These 3 photographic classification systems can be used consistently and reliably to characterize multiple signs of dorsal hand aging.

Roundtable Discussion: Making Sense of Current Liposuction Technologies.

Suction-assisted lipectomy (or "liposuction") is a fundamental technique for all plastic surgeons, and like many procedures in aesthetic surgery, its applications are continuing to evolve. With the rapid introduction of new technologies, many plastic surgeons are left with questions about how these new devices work, what results to expect, and how to best apply these technologies in their practice. We recognized that there is a need for unbiased recommendations to guide surgeons on how to approach current liposuction devices (as well as their adjuncts) and how to use them effectively for their patients. Using available literature and personal experience, we answer the most common questions that we hear from our plastic surgery colleagues.

Comparison of a Novel Silicone Gel Wound Dressing vs Bacitracin After Follicular Unit Extraction Hair Transplantation.

BACKGROUND: Follicular unit extraction (FUE) hair transplantation subjects are excellent candidates to assess wound dressings. The wound surface area is large and adequately delineated to allow randomization, while in-patient split scalp designs allow patients to serve as their own controls. OBJECTIVES: This randomized, single-blinded, split-scalp comparison trial compares a novel, film-forming silicone gel-Stratamed (SM; Stratpharma AG, Basel, Switzerland)-to Bacitracin (Bac; McKesson Medical-Surgical Inc., Richmond, VA) in subjects undergoing FUE. METHODS: Twenty subjects were randomized to receive SM and Bac on alternating sides of the scalp. Primary outcome measures included blinded clinician assessments of edema, erythema, crusting, healing response and outcome preference. Secondary measures included subject-reported assessments of pain and pruritis as well as FaceQ scores taken at post-FUE days two through six. RESULTS: Twenty subjects were enrolled. Nineteen completed the trial. All subjects were non-smokers, and none had medical comorbidities expected to impact wound healing. An average of 1778 follicles per subject were harvested. No adverse events were reported, and all subjects healed by day 7. Healing response and outcome preference were significantly higher at day 1 in the SM group and by day 7, both groups were similar. There were no significant differences between groups for edema, erythema, or crusting. There were no significant differences between groups for subject-reported outcomes of pain, pruritis, or FACE-Q scores. When asked which product they preferred using, 44% of subjects preferred using SM versus 22% who preferred Bac. CONCLUSIONS: The SM wound dressing was well-tolerated in patients undergoing FUE. SM may speed the healing response in the early phase of wound healing.

Seromas: How to Prevent and Treat Them-a 20-Year Experience.

Seromas are a common complication in plastic surgery. In this article, the authors describe their approach to the prevention and treatment of seromas and include a discussion of the evolution of their techniques. They provide specific technical details for many body contouring operations, including abdominoplasty, belt lipectomy, brachioplasty, and thighplasty. Many of the authors' techniques question the traditional dictums of plastic surgery, and they hope to encourage others to consider novel techniques for the treatment and prevention of seromas.

Temperature-Controlled Monopolar Radiofrequency in the Treatment of Submental Skin Laxity: A Prospective Study.

BACKGROUND: Laxity of the submental area is a common cosmetic complaint of the aging population. OBJECTIVES: The aim of this study was to determine the safety and effectiveness of a temperature-controlled, minimally invasive percutaneous monopolar radiofrequency device to improve dermal laxity and achieve lift. METHODS: A total of 72 subjects (35-65 years old) with mild to moderate skin laxity in the submental area were included in this single-center prospective study. All subjects received 1 treatment at baseline with an average subdermal temperature of 63°C. The primary endpoint was the proportion of subjects with at least a 20-mm2 decrease in surface area at Day 90 based on 3-dimensional photography. Secondary endpoints included skin elasticity measured by Cutometer, assessment by a blinded physician panel from 2-dimensional photographs, and physician- and subject-reported outcomes. RESULTS: At Day 90, 72.1% (95% CI: 62.2%-84.0%; P < 0.001) of subjects achieved at least a 20-mm2 lift of the submental area. All Cutometer-measured skin elasticity values (R2, R5, R7) showed significant improvement by 180 days. The independent panel graded 74.2% of subjects as "improved" at 90 days (95% CI: 62.0%-84.2%; P < 0.001). The treatment was well tolerated, and only 1 possibly related serious adverse event was reported (pharyngeal inflammation). CONCLUSIONS: Treatment with temperature-controlled monopolar radiofrequency alone is a safe and effective treatment to achieve submental lift for at least 6 months.

Improved Testing and Design of Intubation Boxes During the COVID-19 Pandemic.

STUDY OBJECTIVE: Throughout the coronavirus disease 2019 pandemic, many emergency departments have been using passive protective enclosures ("intubation boxes") during intubation. The effectiveness of these enclosures remains uncertain. We sought to quantify their ability to contain aerosols using industry standard test protocols. METHODS: We tested a commercially available passive protective enclosure representing the most common design and compared this with a modified enclosure that incorporated a vacuum system for active air filtration during simulated intubations and negative-pressure isolation. We evaluated the enclosures by using the same 3 tests air filtration experts use to certify class I biosafety cabinets: visual smoke pattern analysis using neutrally buoyant smoke, aerosol leak testing using a test aerosol that mimics the size of virus-containing particulates, and air velocity measurements. RESULTS: Qualitative evaluation revealed smoke escaping from all passive enclosure openings. Aerosol leak testing demonstrated elevated particle concentrations outside the enclosure during simulated intubations. In contrast, vacuum-filter-equipped enclosures fully contained the visible smoke and test aerosol to standards consistent with class I biosafety cabinet certification. CONCLUSION: Passive enclosures for intubation failed to contain aerosols, but the addition of a vacuum and active air filtration reduced aerosol spread during simulated intubation and patient isolation.

Surgical Management of Hand Deformity in Epidermolysis Bullosa: Initial Experience and Technique.

Epidermolysis bullosa describes a rare group of genetic mucocutaneous disorders characterized by excessive epithelial fragility resulting in mechanically induced blistering and abnormal wound healing.1,2 Its prevalence and incidence are 8.2 and 19.6 per 1,000,000 live births, respectively.2 Gene therapy, protein replacement, and cell therapy strategies have been investigated, but there is currently no cure.2.

A Smart Sensing Cannula for Fat Grafting.

Gluteal fat grafting has been highlighted as a significant safety issue in plastic surgery, with a mortality rate as high as one in 3000 cases. Injury to the gluteal veins resulting in fat emboli has been identified as the cause of these mortalities. The gluteal veins lie deep to the gluteal musculature in the buttocks, and it has been suggested that avoiding intramuscular injection of fat may prevent these complications. The authors present a novel injection cannula design that uses impedance sensing to determine the location of the cannula tip. Specifically, the system can determine when the tip of the cannula leaves the subcutaneous plane and enters muscle. The use of this system may prevent inadvertent injury to the gluteal veins and subsequent embolic complications. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.

In search of a resident-centered handoff tool: Discovering the complexity of transitions of care.

INTRODUCTION: Transfer of a patient's care between providers is a significant potential for medical errors. Given the potential for patient safety breeches we sought to investigate residents' perceptions of handoffs at our institution. METHODS: Residents completed an online survey assessing the effectiveness of handoffs and what they thought was necessary for safe and informative transition communication. Thematic analysis was used to identify critical themes. RESULTS: 78% of residents reported formal training in handoff delivery. 90% stated they were effective in delivering handoffs; however they scored 41% of handoffs they received as less than effective. 11 themes emerged, the most commonly described requirement was "important events" from the previous shift. Only 16% of residents used an established formal handoff tool. CONCLUSIONS: In a survey of surgical residents they view themselves as very effective at delivering handoffs, but judge nearly half of handoffs they receive as ineffective. Multiple handoff tools exist but residents rarely use them. In an era of increasing transitions of care, efforts targeting improvement of handoff effectiveness will require education beyond checklists and mnemonics.

Comparing the Effectiveness of an Axial and a Centrifugal Left Ventricular Assist Device in Ventricular Unloading.

Centrifugal (CFG) and axial flow (AX) left ventricular assist devices have different hydrodynamic properties that may impact the effectiveness of left ventricular unloading. We sought to determine whether patients implanted with the HeartWare HVAD (CFG) and HeartMate II (AX) had a similar degree of hemodynamic support by comparing parameters measured using echocardiography and right heart catheterization. Using our prospectively collected database, we identified 268 patients implanted with the AX and 93 with the CFG. Demographic characteristics were similar between groups. AX patients had a significantly lower INTERMACS score. Baseline ventricular dimension, mitral regurgitation, right ventricular systolic pressure, right atrial pressure, mean pulmonary artery pressure, cardiac output, and pulmonary vascular resistance were similar. Wedge pressure was higher, and left ventricular ejection fraction was lower at baseline in the AX. After implantation, there was a greater reduction of right atrial pressure, pulmonary capillary wedge pressure, mean pulmonary artery pressure, and left ventricular internal diameter during diastole in the AX cohort. After implantation, cardiac output by Fick calculation showed a greater improvement in the AX group. These results demonstrate that both AX and CFG devices resulted in left ventricular unloading; however, AX devices may offer advantages in the magnitude of left ventricular unloading, which could have implications in myocardial recovery or reduction in pulmonary vascular resistance before transplantation.