Turning Back the Clock: Artificial Intelligence Recognition of Age Reduction after Face-Lift Surgery Correlates with Patient Satisfaction.

BACKGROUND: Patients desire face-lifting procedures primarily to appear younger, more refreshed, and attractive. Because there are few objective studies assessing the success of face-lift surgery, the authors used artificial intelligence, in the form of convolutional neural network algorithms alongside FACE-Q patient-reported outcomes, to evaluate perceived age reduction and patient satisfaction following face-lift surgery. METHODS: Standardized preoperative and postoperative (1 year) images of 50 consecutive patients who underwent face-lift procedures (platysmaplasty, superficial musculoaponeurotic system-ectomy, cheek minimal access cranial suspension malar lift, or fat grafting) were used by four neural networks (trained to identify age based on facial features) to estimate age reduction after surgery. In addition, FACE-Q surveys were used to measure patient-reported facial aesthetic outcome. Patient satisfaction was compared to age reduction. RESULTS: The neural network preoperative age accuracy score demonstrated that all four neural networks were accurate in identifying ages (mean score, 100.8). Patient self-appraisal age reduction reported a greater age reduction than neural network age reduction after a face lift (-6.7 years versus -4.3 years). FACE-Q scores demonstrated a high level of patient satisfaction for facial appearance (75.1 ± 8.1), quality of life (82.4 ± 8.3), and satisfaction with outcome (79.0 ± 6.3). Finally, there was a positive correlation between neural network age reduction and patient satisfaction. CONCLUSION: Artificial intelligence algorithms can reliably estimate the reduction in apparent age after face-lift surgery; this estimated age reduction correlates with patient satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Facelift Surgery Turns Back the Clock: Artificial Intelligence and Patient Satisfaction Quantitate Value of Procedure Type and Specific Techniques.

BACKGROUND: Patients desire facelifting procedures to look younger, refreshed, and attractive. Unfortunately, there are few objective studies assessing the success of types of facelift procedures and ancillary techniques. OBJECTIVES: The authors sought to utilize convolutional neural network algorithms alongside patient-reported FACE-Q outcomes to evaluate perceived age reduction and patient satisfaction following various facelift techniques. METHODS: Standardized preoperative and postoperative (1-year) images of patients who underwent facelift procedures were analyzed by 4 neural networks to estimate age reduction after surgery (n = 105). FACE-Q surveys were employed to measure patient-reported facial aesthetic outcome. We compared (1) facelift procedure type: skin-only vs superficial musculoaponeurotic system (SMAS)-plication, vs SMAS-ectomy; and (2) ancillary techniques: fat grafting (malar) vs no fat grafting. Outcomes were based on complications, estimated age-reduction, and patient satisfaction. RESULTS: The neural network preoperative age accuracy score demonstrated that all neural networks were accurate in identifying our patients' ages (mean score = 100.4). SMAS-ectomy and SMAS-plication had significantly greater age-reduction (5.85 and 5.35 years, respectively) compared with skin-only (2.95 years, P < 0.05). Fat grafting compared to no fat grafting demonstrated 2.1 more years of age reduction. Facelift procedure type did not affect FACE-Q scores; however, patients who underwent fat grafting had a higher satisfaction with outcome (78.1 ± 8 vs 69 ± 6, P < 0.05) and decision to have the procedure (83.0 ± 6 vs 72 ± 9, P < 0.05). CONCLUSIONS: Artificial intelligence algorithms can reliably estimate the reduction in apparent age after facelift surgery. Facelift technique, like SMAS-ectomy or SMAS-plication, and specific technique, like fat grafting, were found to enhance facelifting outcomes and patient satisfaction.

Plastic Surgery Chairs and Program Directors: Are the Qualifications Different for Men and Women?

BACKGROUND: The gender disparity between the number of female and male chairs and program directors has been previously established. The aim of this study was to determine whether any differences in objective credentials existed between male and female plastic surgery department chairs/division chiefs and program directors. METHODS: Information about each plastic surgery program director and chair/chief was extracted from the websites of all institutions affiliated with a plastic surgery residency program. For each individual, information about the length of their career, number of fellowships completed, and number of publications was recorded. The two-tailed t test was used to compare differences between male and female chairs and program directors. RESULTS: A total of 99 chairs were recorded, of which nine (9.1 percent) were female. Of the 99 program directors, 13 (13.1 percent) were female. There was no difference in the number of years in practice or number of fellowships between men and women for either position. On average, male chairs had significantly fewer publications than female chairs (71.9 versus 128; p < 0.05). There was no significant difference in the number of publications between male and female program directors. Compared to program directors, chairs had significantly more years in practice and numbers of publications, which held true for both men and women. CONCLUSIONS: Women are not only underrepresented in the department chair and program director positions, but also possess higher qualifications that may reflect differences in standards for promotion and appointment. Additional research is needed to elucidate the reasons behind the observed differences in qualifications.

Is There Gender Inequality in Plastic Surgery? Evaluation of Society Leadership and Composition of Editorial Boards.

BACKGROUND: Women now constitute 40.5 percent of integrated plastic surgery residents; however, in 2007, women represented only 11.3 percent of the leadership positions in plastic surgery societies and journal editorial boards. The authors analyzed female representation in these societies and editorial boards over the past 10 years. METHODS: Names of board members from the major plastic surgery societies (American Society of Plastic Surgeons, The Plastic Surgery Foundation, and American Society for Aesthetic Plastic Surgery, among others) for the past 10 years and the major plastic journals (Plastic and Reconstructive Surgery, Annals of Plastic Surgery, and so on) from the past 5 years were extracted from their websites. The yearly percentage of female plastic surgery residents was obtained from Accreditation Council for Graduate Medical Education published data. The proportions of women in society leadership, editorial boards, and residency were compared with data analyses of time series trend and linear and Auto Regressive Integrated Moving Average time series modeling. RESULTS: Over the past 10 years, the percentage of female residents has grown steadily, from 21.84 percent to 37.31 percent. Similarly, female representation in society leadership has grown from 6.78 percent to 20.29 percent. Both growth coefficients were statistically significant and showed no statistical difference between the two. In contrast, editorial board leadership over the past 5 years showed statistically insignificant growth and showed a statistically significant difference when compared to the growth of the percentage of female residents and female representation in society leadership. CONCLUSION: Female representation in plastic surgery society leadership shows promising growth, whereas their representation on editorial boards showed significantly less growth, which may reflect the slower turnover on these boards.

Cervical Branch of Facial Nerve: An Explanation for Recurrent Platysma Bands Following Necklift and Platysmaplasty.

Background: Recurrent platysma bands remain a common problem in neck rejuvenation. Objectives: The goals of this cadaver study were to document the course of the cervical branches of the facial nerve and investigate the pattern of platysma muscle innervation before and after various platysmaplasty maneuvers. Methods: A total of 8 fresh cadaver specimens were dissected for a total of 16 hemifaces/necks. After subcutaneous undermining and identification of the main trunk of the facial nerve, the cervical branch was dissected as distally/anteriorly as possible under loupe magnification. The following 4 platysmaplasty maneuvers were each performed on 4 hemifaces/necks: platysma window, extended SMAS with platysma flap, full width platysma transection, and lateral skin-platysma displacement (LSD). Upon completion of the techniques, the integrity of the cervical branches was evaluated. Results: Contrary to some reports, all specimens in this study had only 1 main cervical branch. There were no branches detectable under 3.2× magnification until branches were given off to the platysma muscle at approximately the location of the facial vessels. The main cervical branch continued distally/anteriorly to the medial edge of the muscle below the thyroid cartilage. After performing the various platysma techniques, all cervical branches were in continuity in all specimens. Specifically, the main cervical branch was in continuity to the medial border of the muscle caudal to all platysmaplasty maneuvers. Conclusions: Undermining the platysma muscle results in no injury to platysmal innervation unless continued beyond the facial vessels. Recurrent bands are likely related to persistent innervation of the medial platysma, which remains intact cranial and caudal to any described platysmal transection maneuvers.

The Public Face of Rhinoplasty: Impact on Perceived Attractiveness and Personality.

BACKGROUND: The authors assess the impact of rhinoplasty on public perception of a patient's appearance and personality. METHODS: A survey was created using standardized before-and-after photographs of 10 Caucasian women who had undergone primary rhinoplasty. Photographs of two additional women who had not undergone facial surgery were randomly included as controls, for a total of 12 survey items. Preoperative and postoperative photographs were placed side by side. The survey was administered by means of crowd-sourcing. Respondents were asked to evaluate which photograph better represented 11 traits of appearance or personality, according to a seven-point Likert scale. A score of 1 meant the preoperative photograph was much better, 7 meant the postoperative photograph was much better, and 4 meant no difference. T tests and analyses of variance were used to evaluate rating changes for each trait and differences between demographic groups. RESULTS: There were 264 responses received. Averaged scores across the 10 survey patients produced a value for each appearance or personality trait. In 10 of 11 categories (i.e., symmetry, youthfulness, facial harmony, likeability, trustworthiness, confidence, femininity, attractiveness, approachability, and intelligence), the postoperative photograph was significantly favorable compared with the preoperative photograph (p < 0.00001). The preoperative photograph was rated higher only in aggressiveness (p < 0.001). The same scores were calculated for the controls; no significant difference in any category was seen except confidence, where the right image was viewed as more confident (mean, 4.19; p < 0.005). CONCLUSION: Aesthetic rhinoplasty improves the public perception of a person's appearance and personality in multiple aspects.

Routine Pathologic Evaluation of Plastic Surgery Specimens: Are We Wasting Time and Money?

BACKGROUND: Recent health care changes have encouraged efforts to decrease costs. In plastic surgery, an area of potential cost savings includes appropriate use of pathologic examination. Specimens are frequently sent because of hospital policy, insurance request, or habit, even when clinically unnecessary. This is an area where evidence-based guidelines are lacking and significant cost-savings can be achieved. METHODS: All specimen submitted for pathologic examination at two hospitals between January and December of 2015 were queried for tissue expanders, breast implants, fat, skin, abdominal pannus, implant capsule, hardware, rib, bone, cartilage, scar, and keloid. Specimens not related to plastic surgery procedures were excluded. Pathologic diagnosis and cost data were obtained. RESULTS: A total of 759 specimens were identified. Of these, 161 were sent with a specific request for gross examination only. There were no clinically significant findings in any of the specimens. There was one incidental finding of a seborrheic keratosis on breast skin. The total amount billed in 2015 was $430,095. CONCLUSIONS: The infrequency of clinically significant pathologic examination results does not support routine pathologic examination of all plastic surgery specimens. Instead, the authors justify select submission only when there is clinical suspicion or medical history that warrants evaluation. By eliminating unnecessary histologic or macroscopic examination, significant cost savings may be achieved.

Face-Lift Satisfaction Using the FACE-Q.

BACKGROUND: Face lifting is one of the most common operative procedures for facial aging and perhaps the procedure most synonymous with plastic surgery in the minds of the lay public, but no verifiable documentation of patient satisfaction exists in the literature. This study is the first to examine face-lift outcomes and patient satisfaction using a validated questionnaire. METHODS: One hundred five patients undergoing a face lift performed by the senior author (C.H.T.) using a high, extended-superficial musculoaponeurotic system with submental platysma approximation technique were asked to complete anonymously the FACE-Q by e-mail. FACE-Q scores were assessed for each domain (range, 0 to 100), with higher scores indicating greater satisfaction with appearance or superior quality of life. RESULTS: Fifty-three patients completed the FACE-Q (50.5 percent response rate). Patients demonstrated high satisfaction with facial appearance (mean ± SD, 80.7 ± 22.3), and quality of life, including social confidence (90.4 ± 16.6), psychological well-being (92.8 ± 14.3), and early life impact (92.2 ± 16.4). Patients also reported extremely high satisfaction with their decision to undergo face lifting (90.5 ± 15.9). On average, patients felt they appeared 6.9 years younger than their actual age. Patients were most satisfied with the appearance of their nasolabial folds (86.2 ± 18.5), cheeks (86.1 ± 25.4), and lower face/jawline (86.0 ± 20.6), compared with their necks (78.1 ± 25.6) and area under the chin (67.9 ± 32.3). CONCLUSION: Patients who responded in this study were extremely satisfied with their decision to undergo face lifting and the outcomes and quality of life following the procedure.

Precision in otoplasty: combining reduction otoplasty with traditional otoplasty.

BACKGROUND: Otoplasty for prominent ears is a routine procedure that is generally met with satisfaction by patients and family members. A significant percentage of patients requesting otoplasty, however, have some degree of macrotia in addition to protruding ears. Combining ear reduction with traditional otoplasty allows correction of these deformities. There are few studies in the literature that describe ear reduction, and those that do, describe small subsets of patients. METHODS: A retrospective review was performed of the senior author's (C.H.T.) otoplasty procedures from 2010 to 2013. Charts were reviewed for patient demographics, preoperative assessment, surgical technique used, complications, and need for revision. All otoplasty procedures, primary or secondary, were included in the series. RESULTS: Over a 3-year period, 84 total otoplasty procedures were performed. Of these, 30 patients had some degree of scaphal reduction as a component of the procedure. Five patients (6 percent) also had shortening of the earlobes in addition to the scaphal reduction. Nineteen of the patients (23 percent) had an otoplasty previously (none performed by the senior author) but were not completely satisfied. Complications of reduction otoplasty were limited to a single patient with a suture protrusion behind the ear. None of the patients in this series have required reoperation. CONCLUSIONS: Scaphal reduction to modify the contour of the upper auricle and/or decrease the overall size of the ear can be a valuable adjunct to otoplasty and may be indicated in a larger than expected percentage of patients presenting for otoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Ear lobule reconstruction using nasal septal cartilage.

Surgical reconstruction of an earlobe requires adequate support without sacrificing the delicacy necessary for an attractive result. A two-stage ear lobule reconstruction using a mastoid skin pocket and cartilage from the nasal septum was performed in six patients. The earlobe aesthetics were acceptable and allowed ear piercing. There were no major complications, including no loss of flap, graft extrusion, septal perforation, or infection. Range of follow-up was 1 to 6 years, with an average of 3 years. No revisions have been performed. A two-stage technique for ear lobule reconstruction is described using septal cartilage to preserve shape and definition that has the additional advantage of minimal morbidity.

Cutis aplasia: perioperative management and case report.

Aplasia cutis congenita, a rare congenital disorder involving defects of some or all of the layers of the cranium, is associated with potential life-threatening complications. Although treatment involves both nonsurgical and surgical techniques, the importance of perioperative management cannot be overstressed. A multidisciplinary team, including personnel from nursing, neonatology, pediatrics, radiology, neurosurgery, and plastic surgery services, diagnosed aplasia cutis congenita and planned local wound care, surgical correction, and prevention of potentially life-threatening complications in a 1-day-old boy with a 6×5-cm full-thickness scalp defect.

Ear deformities, otoplasty, and ear reconstruction.

LEARNING OBJECTIVES: After reviewing this article, the participant should be able to: 1. Evaluate patient's ears for needed adjustments to size, shape, prominence, and symmetry. 2. Identify common ear deformities and describe methods to repair them. 3. Avoid or manage common complications associated with otoplasty and ear reconstruction. SUMMARY: The essentials of otoplasty will be described/illustrated for the following conditions: Prominent ears, underdeveloped helical rims (shell ear), macrotia, Stahl's ear, constricted ear, cryptotia, and question mark ear.