Effect of Facial Feminization Surgery (FFS) on Eyelid Anatomic Features.

Facial feminization surgery (FFS) improves gender dysphoria. The brows and eyes are crucial in perceived gender, yet brow and eyelid surgeries are relatively underutilized. This study aimed to determine rates of brow and eyelid surgeries as part of FFS and characterize pre- and postoperative periocular features. We conducted a retrospective review to identify all patients with the diagnosis of gender dysphoria who underwent FFS at a single academic institution from 2019 to 2022. Thirty-four patients comprising 38 surgical cases were included. Twelve (35%) eyelid surgeries and 27 (79%) brow lifts were performed. Baseline eyelid measurements did not differ between brow lift and nonbrow lift cases. Those undergoing brow lift and eyelid surgery were older in age (p = 0.022), had a higher rate of negative canthal tilt (p = 0.050), and smaller baseline margin-reflex distance 1 (p = 0.014) than patients who had brow lift alone. Brow lift increased tarsal platform show (p ≤ 0.001) and lash-to-brow distance (p ≤ 0.001), and upper blepharoplasty increased tarsal platform show (p = 0.01). Rates of brow lift are high at our institution, and patients are appropriately selected for eyelid surgery in FFS. Brow lift and upper blepharoplasty can feminize anatomical features when using standards described for cisgender cohorts. The impact of periocular features on gender perception in transgender patients warrants further study.

Cardiac implantable electronic devices in female patients: Esthetic, breast implant, and anatomic considerations.

INTRODUCTION: The implantation of a cardiac implantable electronic device (CIED) can have esthetic and psychological consequences on patients. We explore a heart team model for care coordination and discuss esthetic approaches for improved cosmetic outcomes in patients undergoing (CIED)-related procedures or de novo implantation. METHODS: Patients undergoing CIED surgery for approved indications between June 2015 and June 2022 were identified. Patients were included when surgical care was provided by a collaborative relationship between the primary electrophysiologist and the plastic surgeon. Patient demographics, details of the surgical procedure, information on breast implants, complications, and outcomes related to cosmesis were recorded. RESULTS: Twenty-two female patients were included in this study. The mean age was 50.2 ± 18.2 years. The mean follow-up duration was 2.2 ± 5.5 months. The top two indications for the procedure included CIED generator change (n = 9, 41%) and implantable cardioverter-defibrillator (ICD) implantation (n = 7, 32%). The most common reasons for involving plastic surgery in the procedure included surgery near breast implants (n = 10, 45%) and device displacement or discomfort (n = 8, 36%). CIED pocket position was prepectoral in 10 cases (45%), subpectoral in 11 patients (50%), and intramuscular in one patient (4.5%). The majority of the patients (20, 91%) had cosmetically acceptable results postprocedure. One patient (4.5%) had breast asymmetry on the CIED side, and another continued to have skin erosion over the CIED and leads. CONCLUSION: A heart team approach incorporating the expertize of cardiac electrophysiology and plastic surgery is essential for providing optimal care for patients with breast implants and patients requesting esthetic appeal.

Eyelid and Brow Rejuvenation: Technical Pearls and Outcomes of Upper Blepharoplasty with or without Ptosis Correction and Browlift.

BACKGROUND: Eyelid ptosis may present with upper lid dermatochalasis and brow ptosis. When indicated, ptosis correction (PC) is advocated during upper blepharoplasty (UB). Here, we aimed to report our outcomes following UB and PC. METHODS: A retrospective review of patients that underwent UB from November 2018 to March 2020 was performed. Patient demographics, clinical characteristics, and revisions were recorded. Cox regression was performed to assess predictors of revision. RESULTS: Overall, 278 patients with 533 UB were included. Mean age was 67.3 years. Mean follow-up was 8.3 months. In 169 (31.7%) cases, a browlift was performed. UB and PC were performed in 109 (20.5%) cases, of which 60 (55%) involved Müller's muscle conjunctival resection, and 49 (45%) were levator repairs. New dry eye symptoms lasting ≥3 months occurred in 4 (0.8%) cases, all of which resolved. Revision rate was 3.8% after UB (residual skin [n=11], hypertrophic scar [n=4], Herring's law-related ptosis [n=1]); versus 9.2% after UB and PC (overcorrection [n=4], residual skin [n=4], asymmetry [n=2]). Multivariable analysis demonstrated increased revision rates after UB and PC (p-value=0.008). There was no difference in revision rates between different techniques of PC. CONCLUSIONS: In our study of 278 patients presenting for dermatochalasis, up to 21% of cases required ptosis correction in addition to upper blepharoplasty. Ptosis correction is a safe procedure when combined with upper blepharoplasty, regardless of technique used. The revision rate in our series was 9.2% after the combined procedure, which is greater than the revision rate of upper blepharoplasty only, however, comparable to the literature.

Revisiting Breast Reduction Insurance Coverage: How the Schnur Scale Discriminates Against Women Based on Body Habitus.

INTRODUCTION: The Schnur scale utilizes body surface area (BSA) to determine the amount of breast tissue resection in reduction mammoplasty, resulting in a greater requirement of breast weight removal in patients with larger BSA. We aimed to demonstrate BSA variance among women with similar mastectomy weights and the range of mastectomy weights among women with comparable BSAs. METHODS: A retrospective chart review of patients who underwent mastectomy from October 2021 to June 2022 was performed. Patients were included if they underwent skin-sparing or nipple-sparing mastectomy with a minimum specimen weight of 700g. Patient's BSA, body mass index (BMI), mastectomy weight, and Schnur weight requirement (SWR) were collected. RESULTS: A total of 130 patients (194 breasts) were included. There was significant variance in mean BSA, BMI, SWR, and SWR to mastectomy weight ratio among women with similar mastectomy weights. BSA varied by as much as 0.82 units, BMI varied by as much as 32 kg/m 2, and SWR varied by as much as 1365g within the same mastectomy weight group. There was also significant variance in mastectomy weights among women with comparable BSA, especially in BSA groups>2.20, with the greatest range in mastectomy weights being 1684g. CONCLUSION: Analysis of mastectomy patients showed no predictable relationship between BSA and breast weight. There was significant variance in the BSA of patients with similar breast weights, and conversely in breast weights of patients with comparable BSA. Therefore, strict adherence to the Schnur weight requirement can prevent patients suffering with macromastia from receiving breast reductions.

Analysis of Sexual Dimorphic Features of the Jawline and Chin in White Celebrity Faces.

BACKGROUND: The jawline greatly influences facial shape and contributes to facial dimorphism. Analysis of lower facial shape and sexual dimorphic differences in contemporary attractive white faces can advance the goals of lower facial aesthetics and facial gender-affirming surgery (FGAS). METHODS: Full-face, front-view photos of 47 white female and 21 white male celebrities were included from a list generated using GQ magazine's Highest Paid Models issue, People Magazine's Beautiful issue (1991-2022), and celebrities featured on lifestyle websites. Facial landmarks were detected through a facial analysis program using Vision framework and MATLAB. After converting pixel distances to absolute distances, lower face measurements were compared between males and females. RESULTS: The mean lower facial height was 6.08 cm in females and 7.00 cm in males (P value<0.001). The mean bigonial width was 11.21 cm in females and 12.30 cm in males (P value<0.001). The ratio of facial height to lower facial height was 2.98 in females and 2.76 in males (P value<0.001), signifying that symmetry in facial thirds is more prevalent in attractive female faces, while a longer lower face is more common in attractive male faces. The greatest differences in female and male facial contours were at gonial angles and chin. CONCLUSIONS: Analysis of contemporary white celebrity faces demonstrated significantly wider and longer lower facial measurements in males. The overall contour of the female lower face was more tapered at the gonial angles and chin compared to males. These results are important when planning lower facial rejuvenation or FGAS, as lower face size and proportions influence perceived gender and attractiveness.

Analysis of Hairline and Forehead Sexual Dimorphic Aesthetics in 60 Celebrities Using Artificial Intelligence.

Upper facial third morphometrics are an important consideration in aesthetic facial surgery and facial gender-affirming surgery. Although there are generally accepted sexual dimorphic differences, an in-depth analysis of forehead morphometrics in attractive individuals is lacking. Methods: Thirty white female and 30 white male celebrities were included. Three full-face front-view photographs of each celebrity were evaluated by a facial analysis program, using Vision framework and MATLAB. After converting pixel distances to absolute distances, midline and lateral forehead heights were calculated and compared between men and women. Results: Forehead height was similar between attractive men and women, but forehead width was shorter in women. Analysis of forehead height at various points along the hairline demonstrated that forehead measurements above the lateral brow and brow peak were significantly greater in men. Mean forehead height above the lateral eyebrow was 3.51 cm in women and 4.16 cm in men (P = 0.017). Forehead height above the eyebrow peak was 4.34 cm in women and 5.55 cm in men (P < 0.001). Medial forehead height was similar between men and women, indicating that the greatest difference in attractive male and female foreheads is in the lateral forehead and forehead width. Conclusions: Analysis of attractive white celebrities demonstrated no significant differences in central forehead heights between men and women. Forehead width and lateral forehead height were significantly smaller in women, with an overall downward slanting contour. Male hairlines were more horizontal and slanting upward laterally. These results have implications in facial rejuvenation and facial gender-affirming surgery.

Facial Morphometrics in Black Celebrities: Contemporary Facial Analysis Using an Artificial Intelligence Platform.

The diversity of patients pursuing facial aesthetic and facial gender-affirming surgery (FGAS) is increasing, yet there is a paucity of objective guidelines to facilitate surgical decision-making in patients of color. We conducted a quantitative analysis of black celebrities using standardized frontal photos of 21 female and 21 male celebrities. Celebrities were chosen from popular entertainment magazines and websites, including People Magazine, the Internet Movie Database (IMDb), Cosmopolitan, and Essence. For each celebrity, 100 facial landmarks were detected through a facial analysis artificial intelligence (AI) program. Black males had greater facial height, bizygomatic width, lower facial height, and bigonial width than females. However, the facial height to bigonial width ratio was similar between genders and approximated the golden ratio (1.618). Female faces demonstrated a greater mid-face height to total facial height proportion, and males had a greater lower facial height proportion. Females exhibited an upward-slanted medial brow and shorter total eyebrow length, nose height, and alar width. Forehead height above the lateral brow was greater in males, while central forehead height was similar to females. This is the first study that has utilized AI to provide ethnicity-specific facial morphometrics relevant to facial rejuvenation and FGAS in the black population.

Using Artificial Intelligence to Quantify Sexual Dimorphism in Aesthetic Faces: Analysis of 100 Facial Points in 42 Caucasian Celebrities.

Background: Sexual dimorphism has been studied in the faces of average populations and worldwide celebrities; however, a focused analysis of attractive Caucasian faces has not been conducted. Objective: The study harnesses the power of artificial intelligence (AI) to efficiently analyze these facial patterns in attractive Caucasian male and female celebrities. Methods: Twenty-one male and 21 female Caucasian celebrities were selected based on popular editorial rankings, modeling agencies, and casting directors from 2017 to 2022. Frontal photographs of celebrities aged 23 to 42 without facial animation were selected. One hundred facial landmarks were identified using semi-automatic image analysis software consisting of modified Apple Vision (Cupertino, CA) machine-learning algorithms with additional custom landmarks. Measurements were converted to absolute distances by fixing subjects' white-to-white corneal diameters to the validated average in Caucasians. Results: Attractive females had significantly greater upper and middle facial proportions, more uniformly divided facial thirds, and greater canthal tilt compared with males. Attractive males had significantly greater facial height, bizygomatic and bigonial widths, medial and total brow lengths, and alar width than females. The golden ratio (1.618) was observed in the ratio of facial height to bigonial width in females (1.613), and attractive males closely approximated that ratio (1.566). There were no significant differences in interpupillary distances, eyebrow angles, or horizontal palpebral fissure lengths. No faces in either sex exhibited scleral show. Conclusions: The study is the first to utilize AI in quantifying key sexual dimorphisms among Caucasian celebrity faces. Identifying these contemporary patterns may provide valuable considerations in planning facial aesthetic and gender affirmation surgery.

Predictors of Surgical Versus Medical Management of Eyes in the Setting of Orbital Fracture at an Academic Level I Trauma Center.

We present clinical and imaging predictors of ocular injuries that required medical management versus surgical intervention in cases of orbital fractures. From 2014 to 2020, a retrospective review of patients with orbital fractures who received ophthalmologic consultation and computed scan (CT) analysis at a level I trauma center was performed. Inclusion criteria were patients with confirmed orbital fracture on CT and ophthalmology consultation. Patient demographics, associated injuries, comorbidities, management, and outcomes were collected. Two hundred and one patients and 224 eyes (11.4% bilateral orbital fractures) were included. Overall, 21.9% of orbital fractures presented with a significant concomitant ocular injury. Associated facial fractures were present in 68.8% of eyes. Management included surgical treatment in 33.5% of eyes and ophthalmology-directed medical treatment in 17.4%. On multivariate analysis, clinical predictors of surgical intervention were retinal hemorrhage (OR=4.7 (1.0-21.0), P =0.0437), motor vehicle accident injury (OR=2.7 (1.4-5.1), P =0.0030) and diplopia (OR=2.8 (1.5-5.3), P =0.0011). Imaging predictors of surgical intervention were herniation of orbital contents (OR=2.1 (1.1-4.0), P =0.0281) and multiple wall fractures (OR=1.9 (1.01-3.6), P =0.0450). Predictors of medical management were corneal abrasion (OR=7.7 (1.9-31.4), P =0.0041), periorbital laceration (OR=5.7 (2.1-15.6), P =0.0006), and traumatic iritis (OR=4.7 (1.1-20.3), P =0.0444). We demonstrated a 22% incidence of concomitant ocular trauma in orbital fracture patients at our level I trauma center. Predictors of the surgical intervention included multiple wall fractures, herniation of orbital contents, retinal hemorrhage, diplopia, and motor vehicle accident injury. These findings emphasize the importance of a multidisciplinary team in managing ocular and facial trauma.

Surgical and Patient-Reported Outcomes of Open Perforator-Preserving Anterior Component Separation for Ventral Hernia Repair.

BACKGROUND: Abdominal wall reconstruction is challenging for surgeons and may be life altering for patients. There are scant high-quality studies on patient-reported outcomes following abdominal wall reconstruction. We assess long-term surgical and patient-reported outcomes of perforator-preserving open anterior component separation (OPP-ACS) following large ventral hernia repair. METHODS: A retrospective review of patients with large ventral hernia defects who underwent OPP-ACS performed by the authors (B.A.S., M.J.T.) was conducted between 2015 and 2019. Demographics, surgical history, operative details, outcomes, and complications were extracted. A validated questionnaire, Carolinas Comfort Scale (CCS), was used to assess postoperative quality of life. RESULTS: Twenty-two patients (12 males and 10 females) with a mean age and BMI of 60.9 ± 10 years and 28.9 ± 4.8 kg/m2, respectively, were included. Mean follow-up was 28.5 ± 16.3 months. All had prior abdominal surgery; 15 (68%) for abdominopelvic malignancy, 3 (14%) for previous failed hernia repair, and 8 (36%) had history of abdominopelvic radiation. Overall, 16 (73%) hernias were in the midline, 4 (18%) in the right lower quadrant, 1 (4.5%) in the right upper quadrant, and 1 (4.5%) in the left lower quadrant. Mean hernia defect surface area was 145 ± 112 cm2. A total of 9 patients (40.9%) underwent bilateral component separation, whereas 13 (59.1%) had unilateral. Bioprosthetic mesh was used in all patients as underlay. Mean mesh size and thickness were 545.6 ± 207.7 cm2 and 3.4 ± 0.5 mm, respectively. One patient presented with a minor wound dehiscence, and two presented with seromas not requiring aspiration/evacuation. One patient had hernia recurrence 22 months after surgery. One patient was readmitted for partial small bowel obstruction and one required wound revision. A total of 14 (65%) patients responded to the CCS questionnaire. At 12 months, mean score for all 23 items was 0.29 ± 0.21 (0.08-0.62), which corresponds to absence or minimal symptoms. CONCLUSION: The OPP-ACS is a safe surgical option for large, complex ventral hernias. Our cases showed minimal complication rate and hernia recurrence, and our patients reported significant improvement in life quality.

Craniomaxillofacial Trauma: The Past, Present and the Future.

Reconstruction of facial trauma has seen a significant evolutionary leap in the last 100 years. The current surgical management of facial fractures was made possible by the efforts and creativity of pioneer surgeons, advances in anatomic understanding, and the continued development of biomaterials and imaging technologies. Virtual surgical planning (VSP) and 3-dimensional printing (3DP) are being incorporated into the management of acute facial trauma. The integration of this technology at the point of care is rapidly expanding globally. This article reviews the history of the management of craniomaxillofacial trauma, current practices, and future directions. The use of VSP and 3DP in facial trauma care is highlighted with a description of EPPOCRATIS, a rapid point-of-care process incorporating VSP and 3DP at the trauma center.

Editorial: A Tribute to Mediterranean Pioneers in Facial Plastic and Craniomaxillofacial Surgery.

BACKGROUND: Physicians from the Mediterranean civilization were profoundly instrumental in the early development and contemporary advancement of the craniomaxillofacial field. These feats are scarcely studied or acclaimed. In this editorial, the authors explore the contributions of these major Mediterranean pioneers. METHODS: A literature review on the subject was performed using PubMed, Scopus, Embase, and Mayo Clinic Libraries. RESULTS: Mediterranean medicine has recognized and managed craniomaxillofacial pathologies from as early as the 10th century. The first inscriptions were authored by Abu Alkasem al-Zahrawi and Serefeddin Sabuncuoglu. Starting in the 15th century, Leonardo da Vinci shed light on anatomy and esthetics at a time where Gasparo Tagliacozzi spearheaded maxillofacial techniques. The field during the Renaissance was dominated by Hippocrates Asclepiades. Varaztad Kazanjian revolutionized the armamentarium necessitated by mass emergencies during the World War. In the 20th century, Paul Tessier redefined the limits of craniomaxillofacial treatment by using facial osteotomies and developing refined surgical instruments. Modern day Sam Hamra, Enrico Robotti, and Daniel Labbé continue to lead educational and innovative fronts of the field. CONCLUSIONS: This essay highlights some important historical contributions to the fields of craniomaxillofacial and facial plastic surgery by pioneer surgeons from around the Mediterranean.

Brow and Eyelid Rejuvenation: Trends from the 100 Most Cited Articles over 30 Years.

Background and Objective: Various periorbital rejuvenation techniques have been introduced over the last 3 decades. This study highlights important milestones in the evolution of periorbital rejuvenation surgery by identifying the 100 most-cited articles in this field. Material and Methods: The Web of Science citation index was used to identify the 100 most-cited articles concerning periorbital rejuvenation. Articles published in English from January 1989-April 2020 describing periorbital rejuvenation-related surgical techniques, facial aging, and anatomy were included. The terms "lower blepharoplasty", "upper blepharoplasty", "browlift", "browplasty", "endobrow lift", "endoscopic brow", "Foreheadplasty", "lower eyelid anatomy", "upper eyelid anatomy", "forehead lift", "eyelid rejuvenation", "canthopexy", "canthoplasty", "eyelid fat pad", "orbital fat pad", "tear trough", and "eyelid bags" were entered into the citation search. Web of Science Core Collection was the database used for the search. A manual review of the initial 159 studies was performed. Articles describing reconstructive or non-invasive techniques, injectable fillers, lasers, and neurotoxins were excluded. Of the 100 most-cited articles, the publication year, specialty journal, the corresponding author's primary specialty, the focus of the article, the corresponding author's country of residence, the type of study, and the level of evidence were analyzed. Results: The mean number of citations per article was 75 ± 42. There were more articles published from 1989-1999 (n = 53) than later decades. Most articles originated from the USA (n = 82) and were published in plastic surgery journals (n = 81). Plastic surgery was the primary specialty of the corresponding authors (n = 71), followed by oculoplastic surgery (n = 22). Most articles (n = 69) reported on surgical techniques. Of the clinical studies (n = 69), 45 (79%) provided level IV evidence. Conclusions: Of the 100 most-cited studies on periorbital rejuvenation, studies focusing on periorbital anatomy, aging, and surgical techniques comprised the most-cited publications. An anatomically based approach accounting for age-related changes in the periorbital structures is paramount in the field of contemporary periorbital rejuvenation.

Cosmetic considerations for placement of deep brain stimulation pulse generator: the submammary subfascial approach.

INTRODUCTION: Deep brain stimulation (DBS) is an effective treatment for a number of debilitating neurological diseases. However, the placement of an implantable pulse generator (IPG) can lead to significant cosmetic concerns for some patients. METHODS: We present a subfascial technique of DBS IPG implantation under the breast using a more concealed scar location. The technique is illustrated in a female patient who favored a more aesthetic placement of the DBS to treat essential tremor. Relevant literature of this approach from both breast augmentation and cardiac pacemaker implantation was reviewed. RESULTS: An excellent cosmetic outcome was demonstrated, and reviewing the literature, implanting under the pectoralis major fascia has the potential benefit of reducing complication rates associated with silicone implant placement in the plastic surgery literature when compared to other planes. CONCLUSIONS: The subfascial implantation of IPG was described. This plane, which is used routinely in breast augmentation, has the potential to decrease complication rates compared to placement in the subglandular plane. An inframammary incision provides patients with concerns about the scar and stigmata associated with an infraclavicular location of DBS generator a better cosmetic outcome.

Virtual Surgical Planning and 3D-Printed Surgical Guides in Facial Allotransplantation.

The complex three-dimensional (3D) anatomy in facial allotransplantation creates a unique challenge for surgical reconstruction. Evolution of virtual surgical planning (VSP) through computer-aided design and computer-aided manufacturing has advanced reconstructive outcomes for many craniomaxillofacial indications. Surgeons use VSP, 3D models, and surgical guides to analyze and to trial surgical approaches even prior to entering the operating room. This workflow allows the surgeon to plan osteotomies and to anticipate challenges, which improves surgical precision and accuracy, optimizes outcomes, and should reduce operating room time. We present the development, evolution, and utilization of VSP and 3D-printed guides in facial allotransplantation at our institution, from guide conception to first clinical case.

Breast Resection Weight Prediction and Insurance Reimbursement in Reduction Mammaplasty: Which Scale Is Reliable?

BACKGROUND: Many insurance companies in the United States rely on the Schnur sliding scale to predict resection weights to determine medical necessity for breast reduction surgery. Accurate methods to predict resection weights are needed to avoid insurance denials. The authors compared the accuracy of formulas such as the Schnur, Appel, Descamps, and Galveston scales in predicting resection weights, and assessed whether they influence insurance coverage decision. METHODS: A retrospective review of bilateral reduction mammaplasty procedures from June of 2017 to June of 2019 was performed at the Mayo Clinic, Rochester. Oncoplastic reduction operations were excluded. The accuracy of each formula-based estimate was evaluated with linear regression analysis. RESULTS: One hundred fifty-four patients (308 breasts) were reviewed. The Schnur scale had low correlation with actual resection weight ( r2 = 0.381; b1 = 1.153; p < 0.001). The Appel scale was the most accurate ( r2 = 0.642; b1 = 1.01; p < 0.001), followed by the Descamps ( r2 = 0.572, b1 = 0.934, p < 0.001) and Galveston ( r2 = 0.672; b 1 = 0.654; p < 0.001) scales. The Appel, Descamps, and Galveston scales were more accurate for resection weights of 500 g or greater, body mass index greater than 30 kg/m², and patients younger than 50 years. For resection weights of 500 g or greater, the median difference between the estimated and actual resection weight for the Schnur, Appel, Descamps, and Galveston scales was -211.4 ± 272.3, -17.5 ± 272.3, -9.6 ± 229.5, and -99.2 ± 238.5 g, respectively. No scale was accurate for resection weights less than 500 g. Insurance reimbursement was denied in 15.56 percent of patients; of these, 23 percent had resection weights less than 500 g. The Schnur scale overestimated the resection weights in 28.9 percent of patients. CONCLUSIONS: The Schnur scale is a poor predictor of breast resection weight. The Appel scale is the most accurate estimator, especially in the young and obese population with larger resections. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, I.

Efficacy of Tranexamic Acid in Reducing Seroma and Hematoma Formation Following Reduction Mammaplasty.

BACKGROUND: Tranexamic acid (TXA) has gained increasing recognition as a valuable pharmacologic agent within plastic surgery. OBJECTIVES: The aim of this study was to investigate the value and safety profile of both intravenous and topically administered TXA in the setting of bilateral reduction mammaplasty. METHODS: A retrospective review was performed to identify consecutive patients who underwent bilateral reduction mammaplasty for symptomatic macromastia (January 2016-July 2021). Pertinent preoperative, intraoperative, and postoperative details were collected/reviewed. Primary outcome measures included hematoma requiring surgical evacuation and clinically significant/symptomatic seroma formation mandating percutaneous aspiration. Patients taking anticoagulation/antiplatelet medication or those with a history of thromboembolic diseases were excluded. Patients who had received TXA were compared to a historical control group who did not receive TXA within the same consecutive cohort. RESULTS: A total of 385 consecutive patients (770 breasts) were included. TXA was used in 514 (66.8%) cases (topical, 318 [61.9%]; intravenous, 170 [33.1%]; intravenous and topical, 26 [5.1%]). Neither seroma nor hematoma were impacted/reduced with TXA (P > 0.05). Increased age (hazards ratio, 1.06 per 1-year increase; 95% CI, 1.004-1.118) significantly increased the risk of hematoma (P = 0.032). The use of drains significantly decreased the risk of seroma (P < 0.0001). Increased BMI increased the risk of seroma (hazards ratio, 1.16 per 1-kg/m2 increase; 95% CI, 1.06-1.26; P = 0.0013). The use of TXA did not impact drain duration. CONCLUSIONS: This study, the largest to date on the use of IV and topical TXA, did not find any reduction in risk when using TXA in breast reduction surgery.

EPPOCRATIS: A Point-of-Care Utilization of Virtual Surgical Planning and Three-Dimensional Printing for the Management of Acute Craniomaxillofacial Trauma.

While virtual surgical planning (VSP) and three-dimensional planning (3DP) have become important tools in acute craniomaxillofacial surgery, the incorporation of point of care VSP and 3DP is crucial to allow for acute facial trauma care. In this article, we review our approach to acute craniomaxillofacial trauma management, EPPOCRATIS, and discuss current challenges and future directions in acute facial trauma management.

Inferior pedicle breast reduction and long nipple-to-inframammary fold distance: How long is safe?

BACKGROUND: Free nipple grafting indications in breast reduction surgery are outdated. Safety of inferior pedicle technique for large resections and long pedicles has not been clearly defined. We evaluated patients who underwent inferior pedicle reduction mammoplasty to define the safety constraints of the inferior pedicle. METHODS: A retrospective review of patients who underwent inferior pedicle reduction mammoplasty due to symptomatic macromastia at Mayo Clinic over a six-year period was conducted. Patients with prior breast surgeries were excluded. Demographics, breast measurements, and surgical outcomes were collected. Univariate and multivariate analyses were performed to assess for predictors of necrosis. RESULTS: Overall, 288 patients (576 breasts) underwent inferior pedicle breast reduction from 2014 to 2019. The mean sternal notch-to-nipple (SNN) distance was 31.5 cm (standard deviation[SD]:4.2; range[r]:16-48), and the mean nipple-to-inframammary fold (N-IMF) distance was 14.8 cm (SD:4.0; r:7.5-27). The mean resection weight was 699.6 g (SD:310.4; r:125-2,385). The median follow-up was 3.9 months (interquartile range[IQR]:2.8-9.0). The overall skin or nipple areolar complex necrosis rate was 2.1%; the overall complication rate was 14.8%. On multivariate analysis, overall necrosis was not found to be associated with the N-IMF distance (adjusted odds ratio[aOR]:1.05, 95%-CI 0.88-1.16). Resection weight was statistically associated with an increased risk of overall necrosis (aOR:1.003, 95%-CI 1.001-1.005), adjusting for N-IMF and SNN distances. CONCLUSION: Inferior pedicle breast reduction offers low risk of necrosis and can be safely performed in patients regardless of the N-IMF distance. No association was found between N-IMF distance and overall necrosis in our cohort, including lengths >15 cm. However, large resections could increase the risk of necrosis.