Safety and Adjuncts in Face Lifting.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Classify the commonly performed types of face-lift procedures based on the extent of skin incision and face and neck dissection, and superficial musculoaponeurotic system treatment and perform the appropriate amount of skin undermining in variations of superficial musculoaponeurotic system techniques. 2. Select the optimal placement of skin incisions and list the danger zones encountered in face-lift dissection and their relationship to the fat compartments and retaining ligaments. 3. Use fat grafting as an adjunctive procedure to face lift and apply safe skin resurfacing techniques at the time of rhytidectomy. 4. Institute a preprocedure and postprocedure skin care regimen and use an antihypertensive protocol for postoperative hematoma prevention. 5. List the commonly injured sensory and motor nerves in rhytidectomy, including prevention and treatment strategies. SUMMARY: Today's face lifts can be classified as "traditional," "short-scar," or "mini." Placement of skin incision, extent of dissection in the face and neck, and methods of superficial musculoaponeurotic system treatment are standard components of face-lift techniques. Proper knowledge of facial anatomy and danger zones is crucial for patient safety. Adjunctive fat grafting and skin resurfacing procedures can create superior results without adding to patient morbidity. Management options for more serious yet potentially preventable surgical complications are discussed, including hematoma and sensory and motor nerve injuries.

Achieving Aesthetic Results in the Umbilical Float Mini-Abdominoplasty: Patient Selection and Surgical Technique.

BACKGROUND: The umbilical float mini-abdominoplasty has been criticized for low final umbilicus position and umbilical distortion. The authors believe that in the properly selected patient and with proper technique, the umbilical float can achieve superior aesthetic results in a subset of patients. METHODS: A retrospective review was performed of all umbilical floats performed by two surgeons (B.A.H. and H.S.B.) at the authors' institution. Postoperative photographs were reviewed by 20 blinded evaluators. RESULTS: Thirty-one female patients underwent umbilical float mini-abdominoplasty between 2010 and 2017. All patients had starting umbilicus position at or above the level of the iliac crest. The umbilicus was floated for a distance of 1 to 3.5 cm. Average umbilicus position was slightly above the midpoint between the xiphoid and pubis preoperatively, and slightly below the midpoint postoperatively. Final umbilicus was considered "too low" in five patients (18.5 percent), all of which were positioned at the level of the anterior superior iliac spine. CONCLUSIONS: Optimal candidates for the umbilical float mini-abdominoplasty are postpartum women with normal body mass index, mild to moderate infraumbilical skin excess, and minimal to mild supraumbilical excess. Starting umbilicus position should be at or above the level of iliac crests, or slightly above the mid torso. Final umbilicus position should remain above the anterior superior iliac spine. The umbilical base is reattached with multiple sutures to prevent distortion. At least 10 cm of hairless lower abdominal skin should be maintained between the final scar and navel to prevent a low-appearing umbilicus. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Making Sense of Stem Cells and Fat Grafting in Plastic Surgery: The Hype, Evidence, and Evolving U.S. Food and Drug Administration Regulations.

Autologous fat grafting and adipose-derived stem cells are two distinct entities with two different risk profiles, and should be regulated as such. Autologous fat grafting prepared with the additional step of stromal vascular fraction isolation is considered a form of "stem cell therapy" given the high concentration of stem cells found in stromal vascular fraction. Much ambiguity existed in the distinction between autologous fat grafting and stromal vascular fraction initially, in terms of both their biological properties and how they should be regulated. The market has capitalized on this in the past decade to sell unproven "stem cell" therapies to unknowing consumers while exploiting the regulatory liberties of traditional fat grafting. This led to a Draft Guidance from the U.S. Food and Drug Administration in 2014 proposing stricter regulations on fat grafting in general, which in turn elicited a response from plastic surgeons, who have safely used autologous fat grafting in the clinical setting for over a century. After a series of discussions, the U.S. Food and Drug Administration released its Final Guidance in November of 2017, which established clear distinctions between autologous fat grafting and stromal vascular fraction and their separate regulations. By educating ourselves on the U.S. Food and Drug Administration's final stance on fat grafting and stem cell therapy, we can learn how to navigate the regulatory waters for the two entities and implement their clinical use in a responsible and informed manner.

Modern Primary Breast Augmentation: Best Recommendations for Best Results.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Develop a practical method for preoperative implant size selection. 2. List characteristics and examples of fourth- and fifth-generation silicone implants. 3. Recognize the differences in "profile" designations across implant manufacturers. 4. Recall updated statistics on breast implant-associated anaplastic large cell lymphoma and describe current guidelines on disease diagnosis and treatment. 5. Apply atraumatic and aseptic surgical techniques in primary breast augmentation. SUMMARY: Modern primary breast augmentation requires an intimate knowledge of the expanding breast implant market, including characteristics of current generation silicone implants and "profile" types. Optimal implant size selection requires balancing patient desires with tissue qualities. Evidence and awareness of breast implant-associated anaplastic large cell lymphoma continue to grow, and patients and surgeons alike should be informed on the most updated facts of the disease entity. Atraumatic surgical technique and aseptic adjuncts are critical in reducing periprosthetic inflammation and contamination, both of which are known instigators of capsular contracture and potentially breast implant-associated anaplastic large cell lymphoma.

Clinical Implications of Gluteal Fat Graft Migration: A Dynamic Anatomical Study.

BACKGROUND: The intraoperative mortality and overall complication rate for gluteal augmentation with fat transplantation is unacceptably high. The current controversy among experts regarding safety is whether fat should be placed within the gluteus muscle or limited to only the subcutaneous space. The purpose of the present study was to test the hypothesis that under certain pressures, fat injected within the gluteal muscle can actually migrate out of the muscle and into a deeper plane containing critical neurovascular structures, by means of the process of deep intramuscular migration. METHODS: A total of eight human cadaver dissections were performed. Four hemibuttocks were selected for intramuscular fat injection. The patterns of subfascial fat migration were evaluated in three of these hemibuttocks by direct visual inspection and in one hemibuttock by endoscopic evaluation. Four other hemibuttocks were selected for subcutaneous or suprafascial fat injection. RESULTS: Proxy fat was found to migrate through the muscle and into the deep submuscular space with each intramuscular injection. With subcutaneous injection, no proxy fat was found during dissection in the intramuscular septae or submuscular space. CONCLUSIONS: The intramuscular insertion of fat, which up to this point has been considered reasonable to perform in the superficial muscle and even recommended in the literature, is now deemed to be an inexact and risky surgical technique. This technique, because of the migratory nature of injected fat, should be avoided from further use in fat transplantation to the gluteal region.

Making Sense of Implant "Profile" in Breast Augmentation.

The increasing variety of breast implants has led to their classification into "profile" types to guide implant cataloguing and selection. Implant "profile" describes the overall silhouette of the implant. It represents a permutation of all 3 dimensions of the implant: base diameter, projection, and volume. Implant "profile" is not the same as implant projection. Implant projection is a quantifiable linear measurement of the anterior-posterior dimension of the implant, whereas implant "profile" is a vendor-driven assessment that currently lacks universal standardization. Until "profile" assessments are standardized across vendors, it behooves us to be cognizant of their limitations as primary variables used to guide implant selection.

Facial Nerve Axonal Analysis and Anatomical Localization in Donor Nerve: Optimizing Axonal Load for Cross-Facial Nerve Grafting in Facial Reanimation.

BACKGROUND: Donor nerve axonal count over 900 in two-stage reconstructions using cross-facial nerve grafts is possibly associated with improved outcomes in facial reanimation. Facial nerve axonal analysis was performed to determine the ideal location for optimizing axonal load. Correlation of axonal number, branch diameter, and age was also assessed. METHODS: Twenty-eight fresh unpreserved cadaveric hemifaces were dissected exposing the extracranial facial nerve branches. Axonal counts at 2-cm intervals from the pes anserinus along branches inserting into the zygomaticus major muscle were taken, noting position relative to the zygomatic arch, posterior ramus border, lateral border of the zygomaticus muscle, and anterior parotid gland border. Nerves were fixed, sectioned, and stained with SMI-31 antineurofilament stain for digital axonal analysis. RESULTS: All specimens had one or more intraparotid zygomatic branches with over 900 axons, and 96 percent had an extraparotid branch with over 900 axons. The likelihood that a zygomatic branch would have over 900 axons at its last intraparotid point (mean, 6 mm posterior to the parotid border) was 92 percent (range, 67 to 100 percent) in contrast to 61 percent (range, 25 to 100 percent) when sampled at the first extraparotid point (mean, 14 mm anterior to the parotid border). Nerve cross-sectional area was positively correlated to its axonal count (R° = 78 percent; p < 0.0001), with nerve diameter over 0.6 mm predicting over 900 axons. Age did not correlate with axonal counts. CONCLUSIONS: Branches with adequate axonal load were found in all specimens. The likelihood of adequate branch selection improved from 61 percent to 92 percent with short retrograde intraparotid dissection. Nerve diameter correlated with axonal load.

Revisiting the Management of Capsular Contracture in Breast Augmentation: A Systematic Review.

BACKGROUND: Capsular contracture is a complication of breast augmentation that frequently requires revision surgery. "Capsulectomy, site change, and implant exchange" has been referred to as the gold standard treatment of clinically significant contractures. However, the actual clinical evidence behind this algorithm remains elusive at best. A systematic review of the literature was performed to clarify the true evidence behind the surgical management of capsular contracture. METHODS: A search of the MEDLINE database was performed for clinical studies involving the surgical treatment of capsular contracture following breast augmentation. Resulting articles were reviewed using a priori criteria. RESULTS: The systematic review was performed in April of 2015. The primary search for "breast augmentation" yielded 9490 articles. When filtered for "treatment of capsular contracture," 461 articles resulted. Review of these articles and pertinent references using a priori criteria yielded 24 final articles. No controlled trials met final inclusion criteria. CONCLUSIONS: There is limited clinical evidence behind the surgical management of capsular contracture. Site change and implant exchange are associated with reduced contracture recurrence rates and likely play a beneficial role in treating capsular contracture. The data on capsulectomy are less conclusive. Acellular dermal matrix may be a useful adjunct but still requires long-term data.

Face Lift.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Identify the essential anatomy of the aging face and its relationship to face-lift surgery. 2. Understand the common operative approaches to the aging face and a historical perspective. 3. Understand and describe the common complications following face lifting and treatment options. SUMMARY: Surgical rejuvenation of the aging face remains one of the most commonly performed plastic surgery procedures. This article reviews the anatomy of the face and its impact on surgical correction. In addition, this review discusses the evolution of various face-lift techniques and the current surgical approach to the aging face. Finally, this article discusses potential postoperative complications after rhytidectomy and management solutions.

The differing adipocyte morphologies of deep versus superficial midfacial fat compartments: a cadaveric study.

BACKGROUND: Anatomical studies show that facial fat is partitioned into distinct compartments, with the nasolabial fat pad in a superficial compartment and the deep medial cheek fat in a deep compartment. Gross morphologic differences may exist between these fat depots, but this has never been established at the cellular level. METHODS: Adipose tissue specimens from nasolabial fat and deep medial cheek fat pads were obtained from 63 cadaveric specimens (38 female and 25 male cadavers) aged 47 to 101 years (mean, 71 years). Thirty-seven cadavers had a normal body mass index (≤25 kg/m) and 26 cadavers had a high body mass index (>25 kg/m). Cross-sectional areas of individual adipocytes were calculated digitally and averaged from histologic sections of the adipose tissue samples. RESULTS: The average adipocyte size of nasolabial fat is significantly (p < 0.0001) larger than that of deep medial cheek fat. The average adipocyte size in both nasolabial and deep medial cheek fat is significantly (p < 0.0001) larger in subjects with high compared with low body mass index. Although the overall average adipocyte size is significantly (p < 0.0001) larger in female than in male subjects, this sexual dimorphism is lost in the nasolabial fat depots of overweight subjects and in the deep medial cheek depots of normal-weight subjects. CONCLUSIONS: The significantly smaller adipocyte size in deep medial cheek fat relative to nasolabial fat in elderly subjects supports the theory that deep and superficial facial fat pads are morphologically different. Future investigation of the metabolic and structural properties of these fat compartments will help us understand the different patterns of volumetric facial aging.

Outcomes analysis of the role of plastic surgery in extremity sarcoma treatment.

Over the past 5 years we have developed a multidisciplinary service for the treatment of extremity sarcoma. This service includes orthopedic oncology, neurosurgery, medical and radiation oncology, and plastic surgery. Prior to 2007, the role of plastic surgery in this multidisciplinary team was limited. After 2007, plastic surgery at our institution played an increasingly integral role in multidisciplinary care. Based on the development of the plastic surgery service at our institution, we were able to evaluate the role of plastic surgery in the outcomes following extremity reconstruction after sarcoma resection. We hypothesize that plastic surgery involvement would reduce the amputation rate without altering recurrence rates. We found a decrease in lower-extremity amputation of approximately 20% without any significant change in recurrence rates. The incidence of infectious complications requiring IV antibiotics decreased by about 20%. The incidence of skin graft loss decreased by 75%. We do report a significant increase in partial flap necrosis. Overall, plastic surgery is an essential component of the multidisciplinary team in the care of extremity sarcoma.

The clinical importance of the fat compartments in midfacial aging.

SUMMARY: The recent identification of the facial fat compartments has greatly affected our understanding of midfacial aging. This article chronicles the discovery of these fat compartments including the shift of attention from a purely gravitational to a volumetric approach to facial aging and the series of methodologies attempted to ultimately define the anatomy of these compartments. The revived interest in volumetric facial rejuvenation including compartment-guided augmentation techniques is discussed. Lastly, the article discusses interesting distributional patterns noted in these fat compartments likely related to the different mechanical and biologic environments of the deep and superficial facial fat pads.

Training and simulation in otolaryngology.

This article focuses on key issues surrounding the needs and application of simulation technologies for technical skills training in otolaryngology. The discussion includes an overview of key topics in training and learning, the application of these issues in simulation environments, and the subsequent applications of these simulation environments to otolaryngology. Examples of past applications are presented, with discussion of how the interplay of cultural changes in surgical training in general along with the rapid advancements in technology have shaped and influenced their adoption and adaptation. The authors conclude with emerging trends and potential influences advanced simulation and training will have on technical skills training in otolaryngology.

Creating a cross-institutional grading scale for temporal bone dissection.

OBJECTIVES/HYPOTHESIS: There is increasing interest in objective assessment of surgeon competence. In the field of otolaryngology, several surgical training programs, including The Ohio State University, the University of Toronto, and Stanford University, have pursued standardized criteria to rate their trainees' performance in the initial steps of temporal bone dissection (complete mastoidectomy with facial recess approach). Although these assessment metrics require the completion of similar basic components integral to successful temporal bone dissection, certain listed criteria are unique to each institution. Our aim was to establish a more standardized set of criteria that can be used across different institutions to objectively assess temporal bone dissection. We translated these new criteria into automated metrics in our temporal bone dissection simulator to achieve even more objective grading of temporal bone dissections. STUDY DESIGN: Cross-sectional study/survey. METHODS: The temporal bone assessment criteria developed by each of the three aforementioned institutions were compiled into an all-encompassing scale. This compilation was sent out as an online survey to members of the American Neurotology Society and American Otological Society with instructions to rate the importance of each criterion. RESULTS: Criteria that were ranked by >70% of respondents as either "very important" or "important" were used to create the new, cross-institutional scale for the objective assessment of temporal bone dissection. CONCLUSIONS: The new assessment scale and its eventual incorporation into the temporal bone surgical simulator will enhance the objectivity of currently existing methods to evaluate surgical performance across different institutions.

Pathological changes in the brains of rabbits experimentally infected with Angiostrongylus cantonensis after albendazole treatment: histopathological and magnetic resonance imaging studies.

OBJECTIVES: To determine the effects of albendazole on rabbits infected with larvae of Angiostrongylus cantonensis by histopathological and magnetic resonance imaging (MRI) techniques. METHODS: Male rabbits were infected with 400 A. cantonensis larvae and treated with albendazole (5 mg/kg/day) for 2-14 days on day 5, 10, 15 or 20 post-infection. RESULTS: Although there were pathological changes in the brains, MRI revealed unremarkable findings in the untreated group. However, the treated rabbits exhibited eosinophilic meningitis, choroid plexus inflammation, meningeal congestion, encephalitis, perivascular cuffing and meningitis, and were also found to have abnormal signal intensities on brain MR images in the 20 day post-infection treated group. CONCLUSIONS: Pathological changes in the brains of the treated rabbits are more severe than those without albendazole treatment, suggesting that the drug may not be very suitable for the treatment of cerebral angiostrongyliasis.

Magnetic resonance imaging findings in the brains of rabbits infected with Angiostrongylus cantonensis: a long-term investigation.

Because magnetic resonance (MRI) imaging is a superior technique in delineating pathological changes in cerebral angiostrongyliasis, it should also be an optimal imaging modality in monitoring long-term changes in the brains of animals infected with Angiostrongylus cantonensis. In this study, MRI and histological techniques were used to observe the changes in the brains of 7 rabbits infected with the third-stage larvae of A. canronensis. Changes were monitored by MRI from day 0 to day 207 postinfection (PI). Hyperintense lesions on T2-weighted MR brain images were first observed on day 22 PI and hallmarks of abnormalities were noted on day 35 PI. Hyperintensities on brain MR images remained up to day 207 PI. Histological examination from days 108 to 207 PI revealed meningeal congestion, choroid plexus inflammation, infarction, granuloma with embedded larva, gliosis, and hemorrhage in the brain tissues. These findings suggest that hosts infected with A. cantonensis may undergo pathological changes in the brain tissues for more than 200 days PI. Moreover, severe abnormalities may occur as early as the fifth week PI.