The Role of Blood Pressure Control in Prevention of Hematoma After Blepharoplasty.

INTRODUCTION: Hematoma formation after blepharoplasty is serious and potentially vision-threatening, with hypertension being the primary risk factor. The aim of this paper is to assess perioperative blood pressure trends and rates of complication in patients undergoing a strict blood pressure protocol designed to keep perioperative systolic blood pressure below 120 mmHg. METHODS: A retrospective chart review was performed of 32 patients undergoing face lift with conomitant blepharoplasty from January 2015 to July 2018. For each patient blood pressure readings obtained before, during, and after surgery were reviewed. Two-sample one-tail T-tests were performed, and p values less than 0.05 were considered statistically significant. RESULTS: The mean systolic blood pressure (SBP) for all patients was highest intraoperatively. Patients with known hypertension had higher mean SBPs than patients without hypertension across all phases of care, with a statistically significant difference in immediate preoperative SBP (p=0.05). Males had a higher average blood pressure immediately postoperatively (p=0.05). A previous diagnosis of hypertension in females was associated with a higher immediate preoperative SBP (p=0.07) as well as age over 65 (p=0.07). The overall rate of complications was 37.5%. No patients experienced hematoma. CONCLUSION: This study demonstrated that keeping blood pressure below 120 mmHg after surgery was an effective method of preventing hematoma after blepharoplasty, even in patients concurrently on anti-coagulative medications. Special attention to blood pressure control should be shown to patients with known risk factors such as a previous diagnosis of hypertension, male sex, or age greater than 65. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Innovative and Evolving Landscape of Topical Exosome and Peptide Therapies: A Systematic Review of the Available Literature.

Topical antiaging therapies provide noninvasive delivery of active therapeutics. Exosomes, or extracellular nanovesicles, and peptides, small strings of amino acids, have shown promise as topical therapies in early trials, but neither is FDA approved. This review aims to elucidate the current and future landscape of topical exosomes and peptides as therapeutics for skin rejuvenation. A literature search was conducted using the keywords "peptides" OR "exosomes" AND "skin" OR "rejuvenation." Primary endpoints included mechanisms of action in humans or live animals as well as clinical data supporting the use of exosomes or peptides topically for skin rejuvenation or wound healing. Secondary endpoints were safety, side effects, and efficacy. The articles were collected, organized, and sorted using the Covidence software (Melbourne, Australia) for systematic review. Nine articles evaluating topical application of exosomes and 9 of peptides met inclusion criteria. Topical exosomes were found to increase collagen deposition, accelerate wound healing, and improve overall cosmesis. Several clinical trials are currently underway. Topical peptides were found to improve appearance of fine lines and wrinkles, elasticity and viscoelasticity, skin texture, skin thickness, and the potential for accelerated wound healing. Peptides are quite common in "cosmeceutical" products, and several patents have been filed for topical peptide products aimed at increasing skin rejuvenation. This could indicate a movement toward pursuing FDA approval. The future of topical exosome and peptide products for the purpose of skin rejuvenation appears promising. Preliminary data from the studies reviewed here indicates that these products have the potential to be safe and effective.

Defining the Ideal Reduction Mammoplasty: A Crowdsourcing Study.

BACKGROUND: Reduction mammoplasty relieves macromastia symptoms while improving breast aesthetics, though the ideal breast aesthetically has been shown to differ culturally in previous crowdsourcing studies. Better understanding these differences can aid in setting postoperative expectations. OBJECTIVES: The aim of this study was to characterize the ideal reduction mammoplasty according to demographics such as gender, ethnicity, socioeconomic status, and education. METHODS: A crowdsourcing platform was used to collect 10,169 de-identified responses. Users completed one of three surveys, either a preoperative, postoperative, or preoperative and postoperative paired survey. The preoperative and postoperative surveys addressed 10 breast measurements including upper breast slope, projection proportion, nipple position, breast width, and breast fullness. The paired pre- and postoperative survey assessed nipple areolar complex (NAC), chest fit, symmetry improvement, and scarring. RESULTS: Preoperative images were rated more aesthetic than postoperative images. This was consistent across all demographics evaluated. Female, African American, Asian, participants aged 55+, and participants with no high school degree or a graduate degree found the most improvement in breast symmetry (p = 0.001, p = 0.002, p = 0.027, p < 0.001, p = 0.01). Male and Hispanic participants were most likely to see no change in symmetry (p = 0.008, p = 0.04), and South Asian participants found breasts less symmetric postoperative (p < 0.001). There were significant demographic differences in aesthetic ratings of NAC, scarring, and breast fit. CONCLUSIONS: Perceived breast aesthetics after reduction mammoplasty vary significantly across demographics including gender, ethnicity, age, socioeconomic status, and educational achievement. Surgeons should consider demographics when planning each patient's reduction mammoplasty.

Reviewing Outcomes and Complications with the Use of Mesh in Breast Reduction Surgery.

INTRODUCTION: Reduction mammoplasty is a common reconstructive and esthetic procedure with variable long-term outcomes regarding breast shape, projection, and nipple-areolar complex. One common complaint is recurrent breast ptosis, which may be mitigated by sufficient support of the inferior pole. This review will look at the effects of mesh in mitigating postoperative ptosis following reduction mammoplasty. METHODS: A comprehensive review of the literature was performed using the PubMed database. Manuscripts that provided data with respect to the effects of mesh on cosmetic outcomes, patient-reported outcomes, complications, and surveillance were utilized. RESULTS: Six studies with a total of 634 patients were included in this review. There is limited evidence to support a cosmetic benefit with the use of mesh in reduction mammoplasty patients. While subjective satisfaction was demonstrated in one paper, few others had objective measurements of the impact of mesh. Complications included infection, skin necrosis, and loss of nipple sensation. Mammography was found to not be affected by mesh placement. DISCUSSION: The use of mesh during reduction mammoplasty is a relatively modern innovation that does not appear to have a significantly different risk profile than that of traditional reduction procedures. There is limited cosmetic value based on currently available data. More objective future analysis is necessary in order to justify the use of mesh in reduction mammoplasty for its claimed cosmetic benefits. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266.

The Mastoid Crevasse and 3-Dimensional Considerations in Deep Plane Neck Lifting.

BACKGROUND: Advances in face and neck lifting involve release of tethering points along the superficial musculoaponeurotic system-platysma complex to freely manipulate the deep natural glide plane in the face and neck. OBJECTIVES: The aim of this article was to determine a combination of deep plane techniques for addressing the face and neck and to elucidate, for the first time, a measurable endpoint for the gonial angle. Analysis of deep plane tethering and decussation zones was also undertaken. METHODS: Extended deep plane surgery performed in 79 patients (158 hemifaces; age, 30-75 years; 95% female), over a 3-month period, was reviewed. Patients were followed for 1 year. Measurements were performed systematically during deep plane face and neck lifting. RESULTS: Before intervention, the mean [standard deviation] gonial depth was 9.4 [3.6] mm on the left and 8.3 [2.7] mm on the right. The mean depth created below the gonial angle when measuring the traditional suspension to the anterior mastoid was 15.8 [3.3] mm on the left and 13.7 [2.5] mm on the right. The distance postoperatively when measuring the gonial depth after performing the crevasse technique was 23.2 [2.2] mm on the left and 22.5 [2.5] mm on the right. This represents a mean increase in the advancement of 7.4 mm on the left and 8.8 mm on the right (average, 8.1 mm) which was demonstrated to be statistically significant bilaterally (P < .0001). CONCLUSIONS: The deep plane techniques described here aid manipulation of the deep plane and deep neck space, while also providing measurable endpoints and more effective modes of fixation by utilizing the mastoid crevasse. The use of techniques that release tension and allow redrape produce the most natural and well-balanced results.

A Clinical Guide to the Treatment of Cellulite and Comprehensive Review of the Etiology, Pathophysiology, and Utility of Intervention.

INTRODUCTION: Cellulite is a common esthetic concern affecting most women. Despite its prevalence, there is no consensus on the optimal treatment approach for cellulite, partly due to the complex and multifactorial nature of its pathophysiology. Understanding the underlying biological processes along with available treatment options is important to be able to effectively counsel patients on effective management of this condition. This review aims to focus on high-quality evidence behind pathophysiology of cellulite, severity and grading, and its available treatment options. METHODS: A comprehensive review of the literature was performed using PubMed and Embase databases. Manuscripts that provided objective data with respect to pathophysiology, grading scales, and applications of treatment options were utilized. RESULTS: Using the existing CSS classification, an evidence-based algorithm is proposed for treatment of cellulite. Mild cellulite is best served with lifestyle modifications such as healthy diet, hydration, and exercise. Use of topicals in mild cellulite patients as adjuncts to lifestyle modifications have the highest efficacy, although there are inconsistent data on topical treatments. Moderate cellulite is best targeted with noninvasive treatment options including laser therapy, radiofrequency, and ultrasound. Radiofrequency demonstrates the strongest efficacy in the current peer-reviewed literature. Severe cellulite is recommended to be treated with minimally invasive approaches such as subcision and injectables. CONCLUSION: Cellulite is a challenging cosmetic problem to treat, and thus multimodal treatment options should be considered in an attempt to achieve optimal outcomes and patient satisfaction. As the pathophysiology of cellulite is further elucidated, more targeted treatments may be developed in the future. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Reflecting upon the Long-term Impact of COVID-19 on Cosmetic Plastic Surgery and Education.

As we enter a new year, this article serves as an opportunity to ponder on the impact of a worldwide pandemic on physicians and the field of plastic surgery, which began 4 years ago in January 2020. When looking at the data in the general-surgery and reconstructive literature, the surgical treatment of patients with COVID-19 appears safest 8 weeks after infection. It was also found that the so-called Zoom-boom crush of cosmetic surgery cases following pandemic lockdown appeared to be largely due to a backlog of cases. Cosmetic surgery, particularly facial cosmetic surgery, continues to increase in popularity year over year. However, the effects on plastic surgery training remain unclear. Even so, those affected by the pandemic seem more driven than ever to find job stability and security.

Lower Eyelid Blepharoplasty With Volume Preservation Using the Skin Flap.

Lower blepharoplasty is one of the most commonly performed facial plastic surgeries and can be approached through many different techniques to improve perceived aging and fatigue due to prominent eyelid fat pads, deep tear troughs, loose eyelid skin, and global periorbital deflation. The technique discussed herein is a personal approach to lower eyelid rejuvenation surgery by the senior author, focusing on volume preservation with conservative resection and transposition of lower eyelid fat pads, muscle preservation, and microfat grafting. The authors discuss a series of 80 patients with case examples and a technique video.

Direct-to-implant versus autologous tissue transfer: A meta-analysis of patient-reported outcomes after immediate breast reconstruction.

BACKGROUND: The effect of immediate implant and autologous breast reconstruction on complication rates has been studied extensively; however, the patient-reported outcomes for these procedures during immediate, one-stage reconstruction has yet to be comprehensively investigated. OBJECTIVE: This study compared the patient-reported outcomes for immediate implant reconstruction with those associated with immediate autologous reconstruction to determine the advantages and disadvantages for each modality from the patient's perspective. METHODS: A literature search of PubMed between 2010 and 2021 was performed, and 21 studies containing patient-reported outcomes were selected for the analysis. A meta-analysis of patient-reported outcome scores was performed separately for immediate breast reconstruction using autologous tissue transfer and synthetic implants. RESULTS: Nineteen manuscripts were included, representing data on a total of 1342 patients across all studies. The pooled mean of patients' satisfaction with their breasts was 70.7 (95% CI, 69.4-72.0) after immediate autologous reconstruction and 68.5 (95% CI, 67.1-69.9) after immediate implant reconstruction, showing a statistically significant difference in outcomes (p < 0.05). The pooled mean of patients' sexual well-being was 59.3 (95% CI, 57.8-60.8) after immediate autologous reconstruction and 62.8 (95% CI, 60.7-64.8) after immediate implant reconstruction (p < 0.01). The pooled mean of patients' satisfaction with their outcome was 78.8 (95% CI, 76.2-81.3) after immediate autologous reconstruction and 82.3 (95% CI, 80.4-84.1) after immediate implant reconstruction (p < 0.05). The results of each meta-analysis were summarized on forest plots depicting the distribution of patient-reported outcome scores from each study. CONCLUSIONS: Immediate reconstruction with implants may have a similar or greater capacity to achieve patient satisfaction and improve patients' QoL compared to those associated with immediate reconstruction with autologous tissue transfer when both procedures are available.

The New Era of Marketing in Plastic Surgery: A Systematic Review and Algorithm of Social Media and Digital Marketing.

Social media has been demonstrated to serve as a critical tool for plastic surgeons, facilitating patient engagement, peer-to-peer education and learning, and outreach to the broader public community. This study aims to perform a meta-analysis of data to determine the most valuable and useful social media platforms for practicing plastic surgeons developing their practice by assessing the perceived value to the practice and quantifying return on investment. A systematic review was performed using PubMed (National Institutes of Health, Bethesda, MD). The initial search yielded 3592 articles. Sixteen articles met inclusion and exclusion criteria. It was found that patients are more likely to engage with aesthetic content rather than scientific content. Younger generations are more likely to utilize Instagram (Meta, Menlo Park, CA), Snapchat (Santa Monica, CA), and TikTok (Culver City, CA), while older generations may be more likely to utilize Facebook (Meta, Menlo Park, CA) and YouTube (San Bruno, CA). Age-specific recommendations include utilizing Instagram, Snapchat, and TikTok with emphasis on breast augmentation for patients aged 17 and 35 given this is the most common procedure performed for this age group. Patients between the ages of 36 and 70 are most likely to be engaged on Facebook, Instagram, and Facebook with liposuction being the most common procedure in this age group. For ages 70+, patients are most likely to utilize Facebook with the most common procedure performed as blepharoplasty. Effective social media marketing for the plastic surgeon considers delivering the right content and choosing the right platform. The right content and platform are critically dependent on the specific age of the audience.

The Utility of Lymphatic Massage in Cosmetic Procedures.

Lymphedema is a severe debilitating disease characterized by the accumulation of excessive protein-rich fluid in the interstitial space. Given the severe morbidity associated with this disease process, various surgical and nonsurgical treatment modalities have been developed to attempt to reduce the incidence and symptoms associated with lymphedema. Manual lymphatic drainage (MLD) is a component of complete decongestive therapy on-surgical treatment which has demonstrated benefit in reducing the development of lymphedema following surgery. Here we provide a review of literature on MLD and its potential mechanism of action. This paper aims to educate patients, physicians, and surgeons about MLD regarding its efficacy and utility in the treatment paradigm for lymphedema and to translate concepts from the treatment of lymphedema to cosmetic procedures.

The Safety of Same-day Discharge after Immediate Alloplastic Breast Reconstruction: A Systematic Review.

Background: Implant-based breast reconstruction can be accomplished in a variety of ways and can result in vastly different postoperative experiences for patients. The COVID-19 pandemic and recent trends have resulted in a shift toward outpatient management of these patients. Methods: A systematic review of PubMed and Embase databases was conducted. A total of 1328 articles were identified on initial search, and after several rounds of review, a total of four met inclusion and exclusion criteria. Manuscripts were included if postmastectomy alloplastic breast reconstruction was performed, and there was documentation of same-day discharge. This cohort of patients was compared with traditional, planned overnight admission cohorts found in the literature. Objective data compared between groups included preoperative patient factors and postoperative complication rates. Results: Four studies representing data on a total of 574 patients were included: 289 were same-day discharge and 285 were overnight admission. Patient characteristics of body mass index, radiation, smoking, and bilateral procedures were comparable. Tissue expanders were used more frequently than implants in both cohorts. The rate of overall complications was 33% for same-day discharge and 34% for overnight admission. Rates of major and minor complications, including infection, seroma, and hematoma, were similar. There was no increase in reoperations or readmissions reported in any of the studies. Conclusions: Same-day discharge after mastectomy with immediate alloplastic reconstruction is a safe approach to treatment in both the ambulatory and hospital setting. There are comparable rates of common complications such as infection, seroma, and hematoma, with no increase in readmission or reoperation.

Painless, Drainless Lipoabdominoplasty: A Retrospective Study of Pain Following Lipoabdominoplasty Utilizing Liposomal Bupivacaine and a Modified Enhanced Recovery After Surgery Protocol.

Background: There are many functional and aesthetic benefits to lipoabdominoplasty (combination of liposuction with abdominoplasty), including increase in core strength, reduction in urinary incontinence, and improvement in lower back pain. However, patients are still hesitant to undergo surgery due to the perceived fears of postsurgical drains, and postoperative pain. Objectives: To propose a standardized multimodal pain protocol for patients undergoing lipoabdominoplasty procedures that aims to improve postoperative pain control. Methods: A total of 80 patients operated on between July 2020 and December 2021 were evaluated in this study. Patients all underwent lipoabdominoplasty and were administered a standardized preoperative, intraoperative, and postoperative pain regimen. Pain scores were measured across all patients in the immediate postoperative period, and postoperative days (PODs) 1, 7, 28, and 90. Results: Mean pain scores in the postanesthesia recovery unit were 0.46/10 (+/- 0.18). Subsequent reassessment in the postop recovery suite yielded mean pain scores of 0.34 (+/- 0.15). Mean pain scores on POD1 were 1.23 (+/- 0.15) and consistent through to POD7 at 1.24 (+/- 0.11) with patients taking an average of 6.65 total Percocet 5 mg (Endo Pharmaceuticals Inc., Malvern, PA) during the week. After POD7, 95% (76/80) of patients were only taking nonsteroidal anti-inflammatory drugs. A total of 75/80 patients (93.75%) reported zero pain at 4 to 6 weeks after surgery (mean pain score 0.10 +/- 0.08). Conclusions: The multimodal analgesia protocol consisting of preoperative or immediate induction intravenous Tylenol (Johnson & Johnson, New Brunswick, NJ), precut local analgesia with Marcaine (Pfizer Inc., New York, NY) and lidocaine, and intraoperative use of liposomal bupivacaine can improve perioperative pain control in patients undergoing lipoabdominoplasty.

Oncoplastic breast reconstruction: Principles, current techniques, and future directions.

Oncoplastic breast reconstruction has improved esthetic results after breast-conserving surgery with low complication rates and stable oncologic outcomes. Basic principles can be applied across different volume displacement and replacement techniques including restoration of breast shape and symmetry through esthetic incisions while eliminating dead space. Technique selection is guided by several factors including breast size, resection-to-breast ratio, and patient desires. A surgeon familiar with all techniques will allow individualization of treatment and optimization of outcomes.

Fat Grafting: Basic Science, Techniques, and Patient Management.

In this review, a summary of the rich history of autologous fat grafting is provided, and a comprehensive summary of the science and theory behind autologous adipocyte transplantation, as well as the techniques commonly used is described. These include recipient site preparation, harvesting, processing, and engraftment. In addition, important considerations for preoperative and postoperative management are discussed to maximize graft retention. Special considerations in grafting to the breast, face, and buttocks are also summarized.

Validation of Ideal Breast Characteristics With Breast Augmentation Patients.

Background: Breast augmentation procedures are one of the most commonly performed aesthetic procedures in the United States. Little work has focused on the general public's overall perception of the ideal breast or has validated them with patient photographs. Objectives: To validate crowdsourced perceptions of breasts with their alignment to the aesthetics of breast augmentation patients. Methods: A prospective cross-sectional study was performed using participants enrolled through the AmazonMechanical Turk crowdsourcing platform (Amazon Web Services, Amazon, Seattle, WA) to obtain participant opinions ofhow closely patient breasts aligned with previously obtained results of 4 ideal breast characteristics. Outcomes were reported based on the correlation between breast attractiveness and alignment to ideal breast characteristics, both before and after breast implant procedures. Results: 2306 responses from 737 participants reported patient photograph alignment with ideal breast projection proportion (1.0) as having the highest correlation to opinions of heightened aesthetic beauty (R = 0.98, P < 0.001), and ideal nipple direction (front) as having the lowest correlation to aesthetic beauty (R = 0.90, P < 0.001). Younger age groups (18-24) and participants with a high school diploma or less rated patients as less attractive, while married and wealthy individuals reported higher attraction levels. Conclusions: Crowdsourcing can be a useful tool for aesthetic surgery preferences and has helped reveal key takeaways. The importance of the 4 breast characteristics has been validated, with alignment to all 4 characteristics tested having a high correlation to preferences. Differences in preference across demographic groups are a topic to further investigate.

Public Perception of Ideal Breast Shape.

BACKGROUND: In the past decade, there has been a dramatic increase in trends related to body-shaping procedures. According to the American Society of Plastic Surgeons, nearly 300,000 breast augmentation procedures were conducted in 2019. Learning the ideal shape of a breast and which esthetics lead to public perception of the most attractive breast is beneficial to properly performing these procedures. OBJECTIVES: The authors aimed to quantify the public's perception of attraction to breast shape by measuring public opinion for various esthetic elements of breast anatomy and linking this to various demographic factors. METHODS: Survey responses were collected from 1000 users of Amazon Mechanical Turk to collect demographic data and ask users to rank preferences for randomized image panels of breast proportions. RESULTS: 960 responses were used for analysis. A majority of respondents were male (60%), with a plurality being 25 to 34 years old (49.3%). The most notable preferences between all groups were breast projection proportion and nipple direction, with preferences of 1.0 and frontal nipple direction, respectively. Breast width to shoulder width ratio also had a clear preference among the crowd, with 105% being the preferred percentage, and the 25 to 34 age group having a very strong preference for this. CONCLUSIONS: The authors used a crowdsourcing survey technique with randomized image panels to analyze ideal breast preference using images of various anatomical traits of the female breast. It was concluded that crowdsourcing can be a favorable technique for learning ideal overall preferences for specific anatomy.

Evaluating Facelift Complications and the Effectiveness of the SMASectomy Technique: A Single Center's 15-Year Experience.

BACKGROUND: Facelift continues to be one of the most common aesthetic procedures performed in the United States. Although there exist many techniques and variations, superficial musculoaponeurotic system (SMAS) manipulation, by way of plication, overlap, or SMASectomy, is common and has been shown to result in favorable cosmesis and durability. However, there is a lack of current complications data in the discussion of this technique. OBJECTIVES: To assess the benefits and risks of the SMASectomy technique. METHODS: The records of all patients who underwent a facelift procedure between December 2004 and March 2019 were reviewed for this study. All procedures were performed at an American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)-accredited outpatient facility in Marina Del Rey, California. This represents data on 241 total patients. Retrospective chart review was performed to include data on patient characteristics, operative technique, and complications. RESULTS: Average operative time of 152.68 ± 51.50 minutes and anesthesia time of 175.00 ± 54.07 minutes were observed among those patients who underwent SMASectomy. This was significantly lower (P < 0.000001) than those who did not undergo SMASectomy (average operative time of 265.25 ± 85.25 minutes and anesthesia time of 294.22 ± 85.31 minutes). There were no observed facial nerve injuries among patients who underwent SMASectomy. No deep vein thrombosis (DVT) events were observed in this patient population. CONCLUSIONS: In the hands of an experienced surgeon, the SMASectomy facelift technique offers the unique advantage of significantly reducing operating time and anesthesia time and can provide extremely favorable and long-lasting aesthetic results.

Platelet Rich Plasma Hybridized Adipose Transplant (PHAT) for the Treatment of Hair Loss: A Case Series.

BACKGROUND: Platelet-rich plasma (PRP) has long been used for the restoration of hair in conjunction with microneedling or on its own. Fat grafting to the scalp has also been utilized in the past to improve the quality of hair and the possibility of successful hair transplant. The novel therapy reported in this case series combines the natural progression of these two techniques and utilizes synergistic effects to improve the quality of hair, either in preparation for micrografting or without hair transplant. OBJECTIVES: To demonstrate the principles behind the novel approach to restoration of hair and the rationale for its use. METHODS: A review of the evidence for PRP and fat transfer for non-scarring alopecia serves as the foundation for the combination treatment reported herein. Through presentation of three cases in this series, we provide examples of the utility of this approach for non-scarring alopecia. This report includes a female who suffered non-scarring alopecia following COVID-19 hospitalization and intensive care stay where she lost a large percentage of her hair, in addition to two male patients suffering from androgenic alopecia. RESULTS: Platelet-rich plasma-hybridized adipose transplant hair was shown in these three cases to improve both the quality and density of hair. It improved the density of hair in all patients and was characterized first by a short period of transient hair loss followed by new hair growth which develops starting at 4 weeks and was readily apparent at 12-week follow-up. Results were maintained at 6-month and 1-year follow-up. CONCLUSIONS: PHAT hair offers a combination of beneficial effects-namely the unique healing properties and growth signaling provided by PRP, along with adipocyte angiogenic and growth signaling, which both work to improve scalp quality. The combination of these effects is better than previously characterized PRP injections alone in the hands of these individual practices. This may be due to synergistic interactions at a cellular level, but additional clinical studies are needed to better understand this novel treatment and the observed effects. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .