Nanotechnology and Artificial Intelligence: An Emerging Paradigm for Postoperative Patient Care.

BACKGROUND: An increasing number of aesthetic surgery procedures are being performed in an ambulatory fashion in office-based settings. Postoperative monitoring of these patients has historically required paid private-duty nurses measuring vital signs, encouraging ambulation, and monitoring overall comfort level. Recently, advancements in nanotechnology have permitted high-acuity data acquisition of multiple clinical parameters that can be transmitted to the surgeon's mobile device in a continuous fashion. OBJECTIVE: The aim of this study was to describe the authors' early experience with this emerging artificial intelligence technology in the postoperative setting. METHODS: Twenty-three consecutive patients underwent radiofrequency-assisted liposuction and Brazilian butt lift surgery, and were placed in a monitoring garment, SimpleSense (Nanowear Technologies, Brooklyn, NY) postoperatively. The primary outcome was device usability, reflected by compliance with wearing the device and completeness of data collection. RESULTS: During the first 48 hours, 91% of patients wore the device for more than 12 hours per day. Only 39% were compliant with postoperative positioning. No postoperative events were detected. CONCLUSIONS: The quality of data collected enables detection of clinical derangements and can alert the surgeon in real time, prompting interventions such as drug administration, position changes, or presentation to the emergency room.

Noninvasive Vulvar and Intravaginal Treatments.

Radiofrequency is an effective and safe method for both pelvic floor restoration and nonsurgical labiaplasty. Bipolar radiofrequency with temperature control is more effective than monopolar radiofrequency for volumetric heating of vulvovaginal tissue. Combination of electrical muscle stimulation and radiofrequency can provide combined nonsurgical restoration of the vulvovaginal tissues.

Combination non-invasive radiofrequency and electrical muscle stimulation: A synergistic combination for body contouring.

INTRODUCTION: Patients desiring noninvasive body contouring increasing require a more comprehensive approach to soft tissue laxity, muscle, and adipose hypertrophy. Previous devices have typically focused on only adipose reduction, without impact on muscle or skin laxity. This study describes the first use of noninvasive bipolar radiofrequency in combination with electromagnetic muscle stimulation. METHODS: This study was an IRB-approved study conducted at four sites (TN, TX, PA, NC). In all, 38 patients completed the three-treatment regimen of combined non-invasive bipolar RF and EMS. Efficacy of the Transform (InMode, Lake Forest, CA) treatment was assessed by numerous outcomes including sequential caliper measurements, circumference measurements, comfort during treatment, subject satisfaction, ultrasound measurements, blinded pictures evaluation, and histology. RESULTS: The combination of non-invasive bipolar RF with EMS was found to be safe and efficacious. The three-treatment regimen was statistically efficacious as it related to (1) subject satisfaction, (2) 1 mm ultrasound, (3) 2 mm ultrasound, (4) average of 1 and 2 mm ultrasound, (5) caliper 1 measurements, (6) caliper 2 measurements, (7) average of caliper 1 and 2 measurements, (8) subject comfort, (9) widest circumference measure, (10) 2-inches above circumference measure, (11) 2-inches below circumference measure, (12) average circumference measure, and finally, (13) blinded evaluator photograph agreement. CONCLUSION: The combination of noninvasive bipolar radiofrequency and electrical muscle stimulation is a safe and effective method for treatment of skin laxity, adipose hypertrophy, and muscle.

A Prospective Trial: Handsfree Thermoregulated Bipolar Radiofrequency for Face and Neck Contouring.

Background: The use of radiofrequency in aesthetic surgery has evolved significantly since it was first introduced in the early 2000s. Nonexcisional correction of the lower one-third of the face and neck has long been a challenging problem. The purpose of this prospective study was to assess the safety and efficacy of the first handsfree thermoregulated bipolar radiofrequency device for face and neck contouring. Methods: This prospective multicenter (New York, Nevada) IRB-approved study evaluated healthy candidates who desired noninvasive correction of their lower face and neck laxity. The primary objective of this study was to evaluate safety and soft tissue remodeling pretreatment and at 1-, 3-, and 6-months post last treatment. Assessment was made using blinded evaluators, 3D photographic analysis (Quantificare, France), and volumetric measurements. Investigator and subject assessments were obtained using a 0-4 point Likert scale. Results: A total of 34 patients completed both the cheek and chin applicator treatment series. Average age of patients was 38 (STD 3.4), BMI 27 (STD 2.2), average Baker Face & Neck classification 2.6 (STD 1.1), and average Fitzpatrick type 2.4 (STD 1.2). Mean treatment time was 41 min (STD 3.5) with a temperature of 42°C-43°C. Patient discomfort data were statistically very low based on t-test analysis. Satisfaction metrics measured at 1- and 3-month follow-up demonstrated a significant change in subject skin appearance, subject overall satisfaction, and investigator improvement perception. More patients were satisfied at the 3-month follow-up compared with the 1-month follow-up for all three measures. Volumetric data demonstrated an average change of -3.2 cm3 (STD ±1.2 cm3) per side for the cheek applicator and -4.1 (STD ±2.3) for the submental applicator. Of note there were cases where volume increases were noted that were believed to be related to soft tissue contraction. Conclusions: This is the first prospective study to evaluate a handsfree thermoregulated bipolar radiofrequency device for face and neck contouring. This device demonstrates a significant advance in the control and delivery of radiofrequency for aesthetic purposes. With a favorable safety and comfort profile, this device is able to concentrate thermal energy consistently at a depth that allows for fibroseptal network tightening to improve lower third of face and submental soft tissue contraction.

Trigger-Site Deactivation Surgery for Nerve Compression Headaches.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Identify patients who are candidates for headache surgery. 2. Counsel the patient preoperatively with regard to success rates, recovery, and complications. 3. Develop a surgical plan for primary and secondary nerve decompression. 4. Understand the surgical anatomy at all trigger sites. 5. Select appropriate International Classification of Diseases, Tenth Revision, and CPT codes. SUMMARY: Headache surgery encompasses release of extracranial peripheral sensory nerves at seven sites. Keys to successful surgery include correct patient selection, detailed patient counseling, and meticulous surgical technique. This article is a practical step-by-step guide, from preoperative assessment to surgery and postoperative recovery. International Classification of Diseases, Tenth Revision, and CPT codes, in addition to complications and salvage procedures, are discussed. Intraoperative photographs, videos, and screening questionnaires are provided.

Plume Effect of Fractional Radiofrequency Verus Laser Resurfacing: Considerations in the COVID-19 Pandemic.

INTRODUCTION: The COVID-19 pandemic requires us all to re-evaluate aesthetic practices to ensure optimal patient safety during elective procedures. Specifically, energy-based devices and lasers require special consideration, as they may emit plume which has been shown to contain tissue debris and aerosolized biological materials. Prior studies have shown transmission of viruses and bacteria via plume (i.e., HIV and papillomavirus). The purpose of this study was to evaluate plume characteristics of the Er:YAG resurfacing laser (Sciton; Palo Alto, CA) and compare it to the Morpheus8 fractional radiofrequency device (InMode; Lake Forest, CA). METHODS: Five patients who underwent aesthetic resurfacing and/or skin tightening of the face and neck were treated with the Er:YAG (Sciton Joule, Palo Alto, CA) and/or fractional radiofrequency (Morpheus8, Lake Forest, CA) between April 1 and May 11, 2020. Data collected included patient demographics, past medical history, treatment parameters, adverse events, particle counter data, as well as high magnification video equiptment. Patients were evaluated during treatment with a calibrated particle meter (PCE; Jupiter, FL). The particle meter was used at a consistent focal distance (6-12 inches) to sample the surrounding environment during treatment at 2.83 L/min to a counting efficiency of 50% at 0.3 µm and 100% at >0.45 µm. Recordings were obtained with and without a smoke evacuator. RESULTS: Of our cohort (n = 5), average age was 58 years old (STD ±7.2). Average Fitzpatrick type was between 2 and 3. Two patients received Er:YAG fractional resurfacing in addition to fractional radiofrequency during the same treatment session. Two patients had fractional radiofrequency only, and one patient had laser treatment with the Er:YAG only. There were no adverse events recorded. The particle counter demonstrated ambient baseline particles/second (pps) at 8 (STD ±6). During fractional radiofrequency treatment at 1-mm depth, the mean recording was 8 pps (STD ±8). At the more superficial depth of 0.5 mm, recordings showed 10 pps (STD ±6). The Er:YAG laser resurfacing laser had mean readings of 44 pps (STD ±11). When the particle sizes were broken down by size, the fractional radiofrequency device had overall smaller particle sizes with a count of 251 for 0.3 µm (STD ±147) compared with Er:YAG laser with a count of 112 for 0.3 µm (STD ±84). The fractional radiofrequency did not appear to emit particles >5 µm throughout the treatment, however, the Er:YAG laser consistently recorded majority of particles in the range of 5-10 µm. The addition of the smoke evacuator demonstrated a 50% reduction in both particles per second recorded as well as all particle sizes. CONCLUSION: Re-evaluation of the plume effect from aesthetic devices has become important during the COVID-19 pandemic. Further studies are required to characterize viability of COVID-19 viability and transmissibility in plume specimens. Based on this pilot study, we recommend that devices that generate little to no plume such as fractional radiofrequency devices be used in Phase I reopening of practice while devices that generate a visible plume such as Er:YAG laser resurfacing devices be avoided and only used with appropriate personal protective equipment in addition to a smoke evacuator in Phase IV reopening.

Achieving Predictability in Augmentation Mastopexy: An Update.

BACKGROUND: One-stage augmentation mastopexy is a challenging procedure, with the highest cited revision rates in plastic surgery. This is because when mastopexy and augmentation are performed together, they lead to opposing forces, which must be balanced carefully to avoid complications. The goal of this study was to revisit a previously described predictable and safe approach to one-stage augmentation mastopexy, and provide long-term updated results. METHODS: One hundred seventy-one patients who underwent augmentation mastopexy, performed by a single surgeon (R.J.R.), were included in this retrospective review between January 2005 and January 2019. Wise pattern mastopexy with wide pedicle was performed before placement of a small subpectoral implant. Demographic information, preoperative breast measurements, intraoperative technique, implant choice, and postoperative complications were analyzed. Specifically, postoperative measurement of vertical limbs was performed to assess long-term elongation of the lower breast pole. RESULTS: Cumulative complication rate was 11.7%. This rate decreased to 6% in the last 88 patients in this series as the technique matured. The most common complication was revision for implant size exchange. Long-term follow-up demonstrated elongation of nipple-to-inframammary fold distance by 1.0-2.2 cm. There was no recurrence of ptosis requiring reoperation. CONCLUSIONS: This one-stage augmentation mastopexy technique provides a safe and reliable surgical approach with predictable and minimal elongation of the lower breast pole. The reoperation rate of this technique is less than half of >20% revision rate currently cited in the literature.

A Systematic Review of Nonsurgical Vulvovaginal Restoration Devices: An Evidence-Based Examination of Safety and Efficacy.

BACKGROUND: The efficacy and safety of vulvovaginal restoration devices were called into question in a U.S. Food and Drug Administration statement on July 30, 2018, claiming that women are being harmed by laser and other energy-based devices. The goal of this systematic literature review was to assess existing data, determine gaps in evidence, and propose opportunities for continued investigation pertaining to laser and energy-based vaginal restoration techniques. METHODS: A review of literature using PubMed, Cochrane Library databases, Embase, MEDLINE, and the Cumulative Index to Nursing and Allied Health Literature was conducted on January 9, 2019, and articles up to this point were considered. For inclusion, studies had to be available or translated in English and relate to clinical medicine, direct patient care, and nonsurgical energy-based vulvovaginal procedures. RESULTS: The authors found five level I studies, 19 level II studies, four level III studies, and 46 level IV studies that used 15 different devices. Various degrees of improvement of symptoms were reported in all studies. Adverse events/side effects were noted in two of the 13 radiofrequency device studies, 15 of the 23 erbium:yttrium-aluminum-garnet device studies, and 17 of the 37 carbon dioxide device studies. The majority of adverse events were considered mild. CONCLUSIONS: The majority of studies resulted in mild to no adverse side effects. However, there is a large gap in level I evidence. As a result, the authors emphasize the necessity of supplemental data surrounding this subject and suggest that additional randomized sham-controlled studies be conducted to further investigate vulvovaginal restoration devices in an effort to address women's health issues.

Aesthetic Applications of Radiofrequency: Lymphatic and Perfusion Assessment.

BACKGROUND: The use of radiofrequency in aesthetics has increased in popularity since the early 2000s. To date, there have been limited studies investigating the effect of thermal energy secondary to radiofrequency treatment. The purpose of this study was to evaluate perfusion and lymphatic assessment tools pre and post bipolar and fractional radiofrequency treatment. METHODS: A retrospective IRB-approved study was conducted between January 2019 and April 2019. Patients who were independently deemed appropriate candidates for radiofrequency soft tissue remodeling were evaluated. Diagnostic perfusion and lymphatic imaging obtained were reviewed using indocyanine green (SPY, Stryker) and optical coherence tomography (Vivosight OCT). RESULTS: A total of 63 patients were treated during the study period, of which 37 had diagnostic perfusion and lymphatic imaging. Average patient age was 47 (STD 12), 95% (35/37) of patients were women, and no patients were active smokers. In total, 27% (10/37) of patients were post-surgical patients with recurrent laxity, 32% (12/37) did not have enough skin laxity to justify traditional excisions procedures, and 41% (15/37) may have been candidates for excisional procedures but were willing to accept more moderate results to avoid excisions surgery. Indocyanine green perfusion and lymphatic assessment for bipolar and fractional radiofrequency, as well as optical coherence tomography pre and post radiofrequency, did not show compromise from thermal injury. CONCLUSIONS: This study supports safety of radiofrequency in terms of preservation of tissue perfusion and lymphatic drainage. This correlated to our low clinical incidence of burns, prolonged swelling, or tissue ischemia.

Facial Fat Augmentation Finesse.

Volume restoration with autologous fat augmentation has become a key technique in facial rejuvenation. It is highly versatile and useful as an independent operation or as an adjunct to rhytidectomy and blepharoplasty. The goal of this article and the accompanying videos is to provide a detailed step-by-step guide to achieving predictable and optimized surgical results.

The Use of Radiofrequency in Aesthetic Surgery.

The use of radiofrequency for soft tissue tightening has increased over the past 10 years. Both minimally invasive and noninvasive devices are frequently in use. This article describes the different types of radiofrequency technology and the current evidence behind their safety and efficacy.

Multimodal Radiofrequency Application for Lower Face and Neck Laxity.

Nonexcisional facial skin tightening has long been an elusive goal in aesthetic surgery. The "treatment gap" includes cases who are not "severe" enough for excisions surgery but not "mild" enough for most traditional noninvasive aesthetic modalities. In this retrospective review, we present the largest evaluation to date of radiofrequency (RF) skin tightening technology combination including bipolar RF (FaceTite; InMode) and fractional bipolar RF (Fractora modified to Morpheus8; InMode). METHODS: A multicenter retrospective study was conducted between January 2013 and December 2018 using a combination of bipolar RF and fractional bipolar RF for the treatment of facial aging. Data collection included demographic information, Baker Face/Neck Classification, amount of energy used, adverse events, and patient satisfaction. Four cadaver dissections were also conducted to correlate the underlying neuromuscular anatomy with RF treatment of the lower face and neck. RESULTS: Two hundred forty-seven patients (234 women and 13 men) were included in the study. Average age was 55.1 years (SD, ±8), body mass index was 24.3 (±2.4), and 9% (23/247) of patients were active smokers at the time of treatment. Patients had an average Baker Face/Neck Classification score of 3.1 (SD, ±1.4). The procedure was performed under local anesthesia in 240/247 cases (97.2%). Patients objectively improved their Baker Face/Neck Classification score by 1.4 points (SD, ±1.1). Ninety-three percent of patients indicated that they were pleased with their results and would undergo the procedure again. Complications recorded for our cohort included prolonged swelling >6 weeks (4.8%, 12/247), hardened area >12 weeks (3.2%, 8/247), and marginal mandibular neuropraxia (1.2%, 3/247), which all resolved without further intervention. When considering possible control variables, age seems to be a significant factor. That is, older patients were more likely to benefit from a larger magnitude of the treatment effect (as demonstrated by a decrease in the Baker rating from pre- to posttreatment) when compared with younger patients. However, both groups did demonstrate significant improvements across time. CONCLUSION: While this combination RF treatment (FaceTite bipolar RF and fractional bipolar RF) does not aim to replace a facelift/necklift in appropriate candidates, it does broaden the plastic surgeons' armamentarium to potentially fill a treatment gap.

Warping Characteristics of Rib Allograft Cartilage.

When septal cartilage is lacking, commercially available costal cartilage allograft can be used. Such allografts have "off-the-shelf" accessibility, are available in multiple sizes, are aseptically processed to meet sterility, and are screened to minimize infectious risks. The purpose of this study was to evaluate the effect of donor age, storage temperature, and orientation of a bilayered construct on the degree of warping of a commercialized fresh frozen costal cartilage allograft in vitro over time. A total of 140 fresh frozen costal cartilage cadaveric specimens were separated into three donor age groups. These were allocated into three harvesting subgroups: group a, single pieces (cephalocaudal segments); group b, two laminated pieces of the same rib sutured together in anatomical position (laminated group); and group c, two pieces from the same rib reversed onto each other and sutured together (oppositional group). Photographs were examined and analyzed to determine the degree of cartilaginous warping. Decreased rates of warping were seen in commercially available, aseptically processed costal cartilage allografts procured from older cadavers. Warping was also decreased when oppositional suturing techniques were used as a way to address those intrinsic cartilage forces.

Radiofrequency Treatment of Labia Minora and Majora: A Minimally Invasive Approach to Vulva Restoration.

Labiaplasty has rapidly increased in popularity over the past 5 years.Traditional labiaplasty is associated with potential complications, such as dehiscence, hematoma, flap necrosis, narrowed introitus, pain, and asymmetry. Minimally invasive techniques such as radiofrequency (RF) have emerged as viable alternatives to traditional labiaplasty through a temperature-controlled bipolar mechanism to heat tissues to target temperatures of 40°C-45°C. This controlled energy delivery leads to an inflammatory cascade initiating neocollagenesis, angiogenesis, and elastogenesis over the coming 3-4 months. A single surgeon series of labia minora and majora treatment by RF (InMode, Lake Forrest, Calif.) was reviewed between April 2018-October 2018. Demographic data were collected as well grade of hypertrophy (pre/posttreatment), number of vaginal deliveries, and reason for treatment. Procedural parameters were recorded, including internal/external temperatures, total energy used, and time of treatment. All adverse events were recorded. Objective and subjective data points were obtained in the form of patient surveys and photographic evaluation by lay persons as well as plastic surgeons objective to the treatment. Ten consecutive patients were treated with bipolar RF (InMode, Lake Forrest, Calif.) between April 2018-October 2018. Mean age was 44 (29-54). Average number of pregnancies was 2 (STD 1.1). Three patients were treated for aesthetic concerns, 3 for functional complaints, and 4 desired improvement in both. Overall graded improvement in labia size/contour was +50% (STD ±15.3). Patient satisfaction scale data demonstrated 9.5/10 (±1.7). All patients (10/10) stated that they would undergo treatment again. In all cases, the surgeon observed tightening of the clitoral hood, introitus, forchett, as well as improved distribution of dark pigmentation of the labia minora. There were no significant complications and no need for additional procedures. Average recovery time was 14 days (STD 2.2). Treatment of labia hyperplasia and laxity with bipolar RF may potentially fill a treatment gap of women seeking aesthetic and functional improvements without surgical labiaplasty. A powered prospective randomized double-blinded study is needed to further elucidate the role of this technology.

Developing Consistency in Rhinoplasty.

This invited Special Topic article outlines the authors' evolution and technique to optimize consistent results in rhinoplasty.

Dietary Supplements and Current Available Evidence.

Dietary supplements are frequently used in surgical patients. Surgeons should be up to date with regard to the efficacies and potential complications related to these supplements. This article provides the most updated practices and evidence of commonly used supplements.

Changing Role of Septal Extension versus Columellar Grafts in Modern Rhinoplasty.

Effective control of nasal tip projection and rotation is a key component in modern rhinoplasty. Tip projection is a product of several anatomical factors: length and strength of lower lateral cartilages, the suspensory ligament, fibrous connections to the upper lateral cartilages, and the anterior septal angle. Several cartilage grafts have been described for effectively altering nasal tip projection and rotation. Columellar struts and septal extension grafts are both commonly used in modern rhinoplasty to affect projection and rotation of the nasal tip. Although columellar strut grafts have shown moderate efficacy in maintaining tip projection and unifying the tip complex, their effect on increasing tip projection has been shown to be very limited. In comparison, septal extension grafts have been shown to effectively control tip projection, rotation, and shape by securing the nasal tip to the septum. Varieties of septal extension grafts have been described to support the medial crura and control tip shape, all of which depend on the presence of a stable caudal septum. The type of graft used is dependent on the specific characteristics of the underlying tip structures. The authors' aim is to provide an updated classification of cartilage grafts for altering nasal tip projection and rotation, and an algorithmic approach for their implementation. Although both columellar struts and septal extension grafts offer the modern rhinoplasty surgeon a way to alter tip projection and rotation, they do vary in efficacy. Understanding which graft to use and in what setting is key in successfully controlling projection, rotation, and shape of the nasal tip.