The Neo-Pitanguy Ligament: A Three-Flap Technique For Skin Tensioning.

BACKGROUND: Creating a stable, long-lasting supratip break continues to be a challenge, particularly in patients with moderate to severe skin thickness. Multiple techniques have been previously described to address this, including Pitanguy's ligament preservation, re-suturing, and cartilage frame alterations to increase the tip-to-septal angle differential. Each have noteworthy limitations. METHODS: The senior author developed a novel technique which utilizes the native Pitanguy ligament augmented by two bilateral, medially-based superficial musculo-aponeurotic system (SMAS)/soft tissue flaps. This reduces supratip dead space, prevents tissue glide while controlling supratip/tip shape and position. RESULTS: Twenty-six (n=26) primary rhinoplasties in which the supratip and tip skin sleeve was of appropriate thickness were selected and followed for 1-year post operatively. The tri-laminar neo-Pitanguy ligament (NPL) technique was employed in all patients. Every patient maintained a varied degree of supratip break at an average follow up time of 14 months (range: 12-16 months). There was one revision requiring local anesthesia. No patients requested or were indicated for a return to the operating room. No cases of post-operative pollybeak deformity were observed. CONCLUSION: The power of this novel supratip control technique is multidimensional. It allows the surgeon to precisely control the location of supratip break, creating a broad based, diamond-shaped supratip depression. Tri-lamination with the use of the two SMAS/soft tissue flaps provides added strength, control, and long-term stability compared to simple suturing. Soft tissue tensioning above, around, and below the new tip complex prevents dorsal skin tissue glide and further secures the infratip/columella in appropriate position.

Radiofrequency and Electrical Muscle Stimulation: A Synergistic Treatment That Achieves Lipolysis and Circumferential Waist Reduction in Noninvasive Body Contouring.

Background: Surgeons and providers in aesthetic medicine seek noninvasive devices that can be utilized for safe, efficient, and effective body contouring. Patient demand has propelled the development of novel devices that can simultaneously improve skin laxity, adipolysis along with stimulation of muscle hypertrophy. Objectives: To determine the efficacy of body contouring after 3 treatments using the noninvasive Transform (InMode, Lake Forest, CA) device. Methods: A prospective, multicenter study was performed. Outcomes evaluated include: standardized caliper and ultrasound measurements of abdominal skin/soft-tissue thickness, waist circumference, histologic evaluation, patient comfort, and satisfaction assessments. Results: Forty-four patients were successfully enrolled in the study and completed the series of 3 treatments which involved combined electrical muscle stimulation (EMS) and noninvasive bipolar radiofrequency (RF). Abdominal ultrasound measurements reveal a decrease in soft-tissue thickness (average 3.1 mm; P = .001), there was a significant decrease in caliper measurements of periumbilical skin thickness (P < .003), and the average reduction of abdominal circumference was 1.9 cm (P < .0001) 3 months after the treatment series. Histology confirmed subcutaneous adipolysis without damaging the dermal layer. Patients reported a high degree of satisfaction with the overall result (P = .003) and that each of the 3 treatments were progressively more comfortable (P < .005). Conclusions: This study demonstrates that a series of simultaneous noninvasive RF with EMS treatments to the abdomen decreases subcutaneous soft-tissue thickness of the treated area. These comfortable treatments ultimately result in a high degree of patient satisfaction at 3 months.

Correction of age-related changes in the skin at the dermal and subdermal level using radiofrequency macroneedling therapy.

BACKGROUND: The negative effects of skin aging are primarily related to the destruction of dermal architectural structure. More specifically, this includes changes in the spatial arrangement of collagen, elastin fibers, mucopolysaccharides, proteoglycans, and ground substances. AIMS: The purpose of this study is to investigate the histologic effects of dermal and subdermal tissue after a controlled single treatment with radiofrequency (RF) macroneedling. This therapy provides a controlled, localized, thermal effect on the dermis whereby triggering the body's own healing processes of extracellular matrix remodeling. Clinically benefits include skin tightening. METHODS: Biopsies were obtained for histologic evaluation from four patients (n = 4), 4 weeks after completing a single RF macroneedling facial treatment. RESULTS: Age-related changes of the dermal and subdermal architecture were observed at baseline. After treatment, all biopsies demonstrated an increase in epidermal cells, collagen, elastin, fibroblasts, vasculature, and a decrease in inflammatory cells. CONCLUSIONS: The results of this histologic study confirm a significant "subsurfacing" thermal effect from the noncoagulative ascendant thermal injury. The obtained results characterize RF macroneedling therapy as an effective method for correcting age-related changes in facial skin.

Patient Pre-operative Planning of Gluteal Augmentation.

Demand for autologous gluteal augmentation with fat transfer continues to rise paralleling the increasingly complex nature of the operation. Improved overall aesthetic outcomes are a result of: (1) donor site fat harvest has evolved to circumferential torso high-definition lipo-sculpting; (2) a shift from indiscriminate buttock augmentation to precise gluteal re-shaping. Discussing complex operations with patients, particularly ones of artistic nature, can be challenging. The senior author has developed a gluteal re-shaping graphic to focus a patient's attention to the four most important areas. It also serves as a foundation for surgeons to create operative plans and track outcomes for professional development.

The S-Curve®: Clinical Importance of the Gluteal Ligaments in Efficacious Fat Transfer.

Liposuction cannulas are versatile tools in a plastic surgeon's armamentarium useful for dissection, deep subcutaneous ligamentous release, fat extraction, and lipofilling. Experienced surgeons develop the ability to navigate subcutaneous anatomy through real-time tactile feedback of the cannula's depth, angulation, excursion, and resistance. Peripheral gluteal ligaments acting as anatomic boundaries must be understood and protected. However, central ligaments tether the dermis to deeper structures precluding expansion. Appropriate, targeted ligamentous weakening improves focal capacitance allowing precise gluteal contouring while staying in safe planes. This maneuver is critical during subcutaneous lipofilling of the S-Curve® procedure to create an aesthetically pleasing, convex gluteal silhouette.

Gluteal Augmentation in Men.

The shape and definition of the male buttock have been emphasized throughout time, as it represents masculinity, strength, health, and beauty across various cultures. Aesthetic Plastic Surgery in general has become more acceptable for men; thus, the demand for gluteal enhancement parallels this shift in social norms. Surgeons interested in such cases must first understand the aesthetic ideals and principles of gluteal shaping as it pertains to men. By using gluteal implants, fat transfer techniques, local tissue rearrangement principles, or a combination thereof, one can sculpt an aesthetically pleasing male buttock with a high degree of patient satisfaction.

Productivity and Efficiency of a Department Resident Aesthetic Plastic Surgery Clinic.

Background: There has been increasing demand for aesthetic surgery procedures in the United States, highlighting the critical importance of the competence of plastic surgery residents and rigorous methods of aesthetic surgery training. Objectives: The objective of this study was to review procedures and outcomes from our plastic surgery resident aesthetic clinic. Outcomes and costs were compared to national averages and reports from the literature. Methods: A retrospective chart review identified all adult patients who presented to the Resident Aesthetic Surgery Clinic at NYU Langone Health in 2021. Patient demographics, comorbidities, procedural data, postoperative complications, revisions, and surgeon fees were compiled. A brief confidence survey was distributed to participating residents before and after their clinic rotation. Data were analyzed using IBM SPSS software (Armonk, NY). Results: In 2021, 144/379 consultations led to an operation (38.0% conversion rate), resulting in 420 distinct surgical procedures. The majority (53.3%) of procedures involved the head and neck. Complication and revision rates were 5.5% and 1.0%, respectively, with surgeon fees consistently below the national average. Residents reported being significantly more confident performing face lifts, rhinoplasties, and aesthetic surgery in general following their clinic rotation. Conclusions: These data represent the largest annual reported study of plastic surgery resident aesthetic procedures and outcomes, demonstrating the high volume and productivity of the NYU Resident Aesthetic Surgery Clinic. These results further support resident aesthetic clinics as a robust training modality.

A Comparative Analysis of Nonthumb Metacarpal Fracture Treatments in New York City Civilians and Incarcerated Individuals.

Nonthumb metacarpal (NTMC) fractures are common in the incarcerated and the underinsured civilian populations. However, certain social challenges contribute to high rates of follow-up noncompliance and complications in these unique populations. We conducted a retrospective review of the treatments, outcomes, and complications in the incarcerated and civilian patient population who were treated at a tertiary public hospital for NTMC fractures. Even though incarcerated patients were more likely than their civilian counterparts to undergo operative interventions, both populations showed similar complication profiles as well as low rates of treatment compliance and follow-up. This article affirms that incarcerated individuals do not receive inferior care compared with civilians, and both the incarcerated and underinsured civilians would benefit from careful consideration of treatment algorithms and additional access to hand therapy.

Robotic deep inferior epigastric perforator flap harvest in breast reconstruction.

INTRODUCTION: Reducing donor site morbidity after deep inferior epigastric artery perforator (DIEP) flap harvest relies mainly upon maintaining integrity of the anterior rectus sheath fascia. The purpose of this study is to describe our minimally-invasive technique for robotic DIEP flap harvest. METHODS: A retrospective review of four patients undergoing seven robotic-assisted DIEP flaps from 2019 to 2020 was conducted. Average patient age and BMI were 52 years (range: 45-60 years) and 26.7 kg/m2 (range: 20.6-32.4 kg/m2 ), respectively. Average follow-up was 6.31 months (range: 5.73-7.27 months). Robotic flap harvest was performed with intramuscular perforator dissection in standard fashion, followed by the transabdominal preperitoneal (TAPP) approach to DIEP pedicle harvest using the da Vinci Xi robot. Data was collected on demographic information, perioperative characteristics. Primary outcomes included successful flap harvest as well as donor site morbidity (e.g., abdominal bulge, hernia, bowel obstruction, etc.). RESULTS: All four patients underwent bilateral abdominally-based free flap reconstruction. Three patients received bilateral robotic DIEP flaps, and one patient underwent unilateral robotic DIEP flap reconstruction. The da Vinci Xi robot was used in all cases. Average flap weight and pedicle length were 522 g (range: 110-809 g) and 11.2 cm (range: 10-12 cm), respectively. There were no flap failures, and no patient experienced abdominal wall donor site morbidity on physical exam. CONCLUSION: While further studies are needed to validate its use, this report represents the largest series of robotic DIEP flap harvests to date and is a valuable addition to the literature.

Clinical Outcomes of 2019 COVID-19 Positive Patients Who Underwent Surgery: A New York City Experience.

BACKGROUND: The coronavirus disease 2019 (COVID-19) global pandemic has led to a halt in elective surgeries throughout the United States and many other countries throughout the world. Early reports suggest that COVID-19 patients undergoing surgery have an increased risk of requiring intensive care unit (ICU) admission and overall mortality. MATERIALS AND METHODS: A retrospective review was performed of all COVID-19, positive with polymerase chain reaction confirmation, patients who had surgery between February 17, 2020 and April 26, 2020 at a major New York City hospital. Clinical characteristics and outcomes including ICU admission, ventilator requirement, and mortality were analyzed. RESULTS: Thirty-nine COVID-19 surgical patients were identified. Mean age was 53.9 y, and there were more men than women in the cohort (56.4% versus 43.6%). Twenty-two patients (56.4%) had a confirmed positive COVID-19 test preoperatively, and the remainder tested positive after their procedure. The majority (59%) of patients had an American Society of Anesthesiologists (ASA) class of 3 or higher. Postoperatively, 7 patients (17.9%) required ICU level care with a mean length of stay of 7.7 d. There were 4 deaths (10.3%) in this patient population, all of which occurred in patients who were ASA class 3 or 4. CONCLUSIONS: This study represents the largest study to date, that objectively analyzes the outcomes of COVID-19 positive patients who underwent surgery. Overall, ICU admission rates and mortality are similar to reported rates in the literature for nonsurgical COVID-19 patients. Notably, in COVID-19 patients with ASA 1 or 2, there was a 0% mortality rate in the postoperative period.

Propeller Flap Perineal Urethrostomy Revision.

OBJECTIVE: To describe a technique for perineal urethrostomy (PU) revision using a posterior thigh propeller flap for a complex repair at high risk for stenosis. METHODS: Our technique utilizes the consistent posterior thigh perforators for a local flap with ideal length and thickness for repair. The stenotic PU is incised. Potential flaps are marked around a perforator blood supply closest to the defect. The flap is then elevated and rotated on its pedicle with its apex placed directly in the defect. Absorbable sutures partially tubularize the flap apex at the level of the urethrotomy which is calibrated to 30 Fr. We subsequently monitored the patient's clinical progress. RESULTS: With 17 months of follow-up the patient is voiding well without complaint, reports improved quality of life with a patent PU. Post void residuals have been less than 100cc. The patient, who has had a long history of urinary tract infections requiring hospitalization, has only reported one infection during follow up which was treated as an out-patient. CONCLUSION: For challenging PU revisions a distant local propeller flap of healthy tissue outside the zone of injury is the ideal choice for length, thickness, and minimal morbidity resulting in excellent clinical results for our patient.

Management and Complications of Non-Thumb Metacarpal Fractures in the Incarcerated Population.

We reviewed the patient demographics, injury mechanisms, fracture characteristics, treatment modalities, and outcomes of incarcerated patients who were referred for metacarpal fracture evaluation and treatment to our high-volume tertiary care center from a New York City Department of Correction infirmary facility. There is a scarcity of information in the orthopedic and plastic surgery literature on treating these common fractures in this vulnerable population. We conducted a basic statistical analysis and discuss the potential implications of these findings. We found a high incidence of stiffness that may relate to the high rates of follow-up noncompliance coupled with prolonged immobilization. Awareness of these findings may influence treating hand specialists to use less restrictive immobilization devices such as functional bracing, elastic bandage, or neighbor strapping as an effort to promote bony union without the risk of developing stiffness and the potential to compromise general hand function when treating non-thumb metacarpal fractures.

Trends in Proximal Interphalangeal and Metacarpophalangeal Joint Arthroplasty Utilization Using Statewide Databases.

Background: Arthritis can have profound debilitating effects on the hand secondary to finger deformities and pain. Arthroplasty of the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) can be performed to reduce pain while maintaining joint range of motion. Methods: We used outpatient surgery registries from the states of California and Florida to assess the trends of arthroplasty across several recent years and to determine if the outcomes differ based on disease etiology. Results: We found that there has been a steady decline in number of MCP arthroplasty procedures performed annually between 2005 and 2011 while PIP arthroplasty procedures peaked in 2007 and have since also declined. There was an overall complication rate of 2.4% and no difference in cardiac, respiratory, deep venous thrombosis and infection between patients with osteoarthritis and other arthritic etiologies. However, the risk of device failure in patients with rheumatoid arthritis is found to be significantly higher than for patients with osteoarthritis (p < 0.01). Conclusions: PIP and MCP arthroplasty are safe procedures with an overall low complication rate. The increased risk of device related complications observed in patients with rheumatoid arthritis can be used to appropriately counsel this patient population regarding post-operative expectations and prognosis.

Posterior "Open Book" approach for type 1 internal hemipelvectomy.

INTRODUCTION: Internal limb-sparing hemipelvectomy is currently the preferred surgical option for resection of pelvic tumours. Obtaining an acceptable functional outcome through the standard ilioinguinal or iliofemoral incisions, only compounds the already challenging dissection, resection and reconstruction of these extensive en-bloc extirpative oncologic operations. SURGICAL TECHNIQUE: We describe a novel surgical approach to the lateral pelvis that minimises injury to the gluteal muscles, spares the gluteal vessels and provides a broad yet shallow operative field conducive to microsurgery with sizeable vasculature in close proximity to facilitate any microsurgical reconstruction. Access to the ilium and sacrum for Enneking Type 1 and Type 4 resections respectively is obtained by reflecting a skin and soft tissue flap anteriorly while the gluteal muscles are reflected posteriorly and inferiorly. This technique minimises the amount of tissue reflected in any particular direction, therefore, providing a broad and shallow operative field which benefits the orthopaedic oncologic surgeon and the plastic reconstructive surgeon. CONCLUSION: The "posterior open-book" approach offers a promising alternative to the standard ilioinguinal or iliofemoral incisions for internal limb-sparing Type 1 hemipelvectomies while also optimising the exposure for subsequent reconstructive procedures.

Extracapsular Mandibular Condyle Fractures Are Associated with Severe Blunt Internal Carotid Artery Injury: Analysis of 605 Patients.

BACKGROUND: Mandibular condyle fractures are common following facial trauma and carry an increased risk for concomitant blunt carotid artery injuries. Further elucidation of this relationship may improve vascular injury screening and management. METHODS: A retrospective cohort study was performed for all patients sustaining condylar fractures presenting to a large trauma center over twelve years. Fracture locations were classified according to the Strasbourg Osteosynthesis Research Group (1, condylar head; 2, condylar neck; and 3, extracapsular condylar base). Carotid artery injury severity was based on the Biffl scale. Severe vascular injury was defined as a Biffl score greater than I. RESULTS: 605 patients were identified with mandibular condyle fractures consisting of 21.0 percent (n = 127) condylar head; 26.8 percent (n = 162) condylar neck; and 52.2 percent (n = 316) extracapsular condylar base. The incidence of vascular injuries in this population was 5.5 percent (n = 33), of which 75.8 percent (n = 25) were severe. Severe vascular injuries occurred in 1.6 percent (n = 2) of condylar head, 2.5 percent (n = 4) of condylar neck, and 6.0 percent (n = 19) of extracapsular condylar base fractures (p < 0.05). Extracapsular condylar base fractures were independently associated with a 2.94-fold increased risk of a severe blunt carotid artery injury compared with other condyle fractures on multivariable analysis (p < 0.05). CONCLUSIONS: Extracapsular subcondylar fractures should heighten suspicion for concomitant blunt carotid artery injury. The data support a force transmission mechanism of injury in addition to direct injury from bony fragments. CLINICAL QUESTIONS/LEVEL OF EVIDENCE: Risk, II.