Mentorship in Plastic Surgery: A Critical Appraisal of Where We Stand and What We Can Do Better.

SUMMARY: Mentorship is a critical tool for professional development and career success. In academic surgery, supportive mentorship affords higher job satisfaction, academic productivity, and diversity and inclusion. It protects against burnout and increasing academic surgery attrition rates. Women, underrepresented minorities, and junior plastic surgeons report lower job satisfaction and fewer mentorship opportunities. Given the unique challenges these groups face in a constantly changing health care system, the importance of mentorship cannot be overstated. Through a survey of American Society of Plastic Surgeons members, this study evaluated different aspects of mentorship to describe the current state in plastic surgery. Despite 94.05 percent of plastic surgeons believing that mentorship is valuable, only 15.16 percent reported a structured mentorship system, often without evaluation. Male and female participants agree that mentorship is needed for both professional (clinical judgment) and personal (work-life balance) development. Interestingly, women plastic surgeons felt it was important for mentees to have gender and race/ethnicity concordance to their mentors (p < 0.001). There was no agreement regarding the most effective method to implement mentorship programs, highlighting the challenges of this problem. Through thoughtful planning and commitment, mentorship programs can be instituted to benefit not just the mentee, but the mentor as well.

How Comprehensive Are Aesthetic Surgery Fellowship Websites?

BACKGROUND: Fellowship programs heavily utilize websites in the recruitment of senior residents. Studies in subspecialty areas have demonstrated deficiencies in website content; however, no study has evaluated the websites of esthetic surgery fellowships. The recent establishment of the aesthetic fellowship match in 2018 highlights the need for accessible program information. OBJECTIVE: To assess the success in accessibility of educational and recruitment content of aesthetic surgery fellowship websites for prospective applicants. METHODS: Websites of aesthetic surgery fellowships were eligible for study inclusion. Aesthetic fellowship websites (AFWs) were evaluated for content regarding fellow education and fellow recruitment. Website content was analyzed using Fisher exact test and analysis of variance. RESULTS: Twenty-eight programs were compiled from the American Society of Aesthetic Plastic Surgery website. Regarding fellowship education, 35.7% of AFWs described operative experience and research requirements, and 28.6% of AFWs included information on didactics, but less than 11% outlined rotation schedules, annual meetings, or academic conferences. None listed fellow evaluation criteria. Regarding recruitment information, 85.7% of AFWs had program descriptions, but less than 33% listed affiliated hospitals, faculty, or current fellows. Of the 67.9% of AFWs that listed eligibility criteria, none listed selection criteria. When programs were stratified by the type of aesthetic training offered, fellowships that offered whole-body aesthetic training had significantly more recruitment content (P = 0.0394) on their websites than those specializing in facial aesthetics only. CONCLUSIONS: There is a paucity of information regarding recruitment and education on AFWs. Programs should strive to create a comprehensive website to better attract and assist residents applying for fellowship.

Breast Lift with and without Implant: A Synopsis and Primer for the Plastic Surgeon.

Breast ptosis is a common occurrence following weight loss, pregnancy, and breastfeeding, or as a consequence of normal aging. This results in loss of a youthful shape and contour of the breast, with a change in the position of the nipple-areolar complex. Mastopexy can restore this youthful appearance and transpose the nipple-areolar complex to a more aesthetic position on the breast. Various techniques exist that address the skin and parenchyma of the breast and are chosen based on the degree of ptosis and skin laxity, as well as the patient's goals. These techniques all differ in scar burden and risk profile. Additionally, this can be done simultaneously or in a staged manner. In this literature review, we aim to provide an overview of mastopexy procedures, with and without augmentation. Further, we aim to detail recent advancements in technical approaches, and delineate common complications in certain patient demographics. To this end, we performed a literature search with a medical librarian, using PubMed/Medline to identify pertinent literature. In the context of the review, we discuss important considerations in patient selection and counseling to set expectations and ultimately, optimize surgical outcome and patient satisfaction.

The Medial Femoral Condyle Corticoperiosteal Free Flap for Frontal Sinus Reconstruction.

Although the medial femoral condyle has been used for reconstruction in various areas of the body, to the authors' knowledge it has not been used for frontal sinus reconstruction. The authors describe a novel approach to a complex patient using the medial femoral condyle cortiocoperiosteal free flap to reconstruct an anterior frontal sinus defect in conjunction with a recalcitrant mucocele.

The Modern Male Rhytidectomy: Lessons Learned.

BACKGROUND: Cosmetic surgery among male patients has become increasingly popular. The face-lift technique is different in male patients, specifically regarding preservation of hair follicles, restoration of a youthful and well appearance, and reduction of the risk of hematoma. METHODS: A retrospective review of a single surgeon's past 20 years of consecutive male rhytidectomies revealed a cohort of 83 patients. A control group was created by random selection of 83 age-matched female rhytidectomy patients during the same period. Data were collected and analyzed critically for factors contributing to complications, including hematoma, seroma, skin sloughing, alopecia, infection, and nerve injury. The evolution in the senior author's technique in male rhytidectomy is described. RESULTS: Differences in facial analysis and rhytidectomy technique in male patients and female patients are highlighted. Five male patients (6.0 percent) and no female patients in the control group developed postoperative hematoma (p = 0.0587). No other complications occurred. CONCLUSION: Respecting the patterns of hair growth in incision design, avoiding damage to follicles during dissection, and exercising standard of care (especially avoidance of hypotensive anesthesia) in prevention of postoperative hematoma have delivered safe and consistently reproducible aesthetic outcomes and acceptable complication rates. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Neurectomy for the Treatment of Chronic Postoperative Pain after Surgery of the Trunk.

BACKGROUND: Incidence of chronic postoperative neurogenic pain after open and laparoscopic trunk operations is reported between 1 and 20 percent, rendering a large population in the United States and worldwide. One possible treatment is selective surgical neurectomy. METHODS: All patients who underwent neurectomy for chronic trunk or groin postoperative neurogenic pain were identified. Based on individual history and examination, patients underwent neurectomies of the ilioinguinal, iliohypogastric, genitofemoral, lateral-femoral cutaneous, or intercostal nerves. Recorded preoperative pain levels (Likert score ranging from 0 to 10) were compared to postoperative pain levels and quality-of-life indices were assessed. RESULTS: Fifty-six patients (32 men and 24 women) were included. Mean age was 49 years. All patients underwent preoperative nerve blocks by either surgeon, radiologist, or referring physician, and had either complete or significant response defined as over 50 percent relief. Forty-five patients completed the survey. Median follow-up was 2.8 years (range, 1.0 to 5.7 years). Average pain level was 9.0 preoperatively and 3.5 postoperatively. Quality-of-life impairment improved from 8.3 preoperatively to 3.5 postoperatively. A subset of patients (n = 12) had minimal improvement, reporting a decrease in pain from 8.5 to 7.2 and quality-of-life improvement from 8.5 to 7.1. CONCLUSIONS: Complete avoidance of nerve injury during all trunk and groin operations is likely unattainable. When chronic postoperative neurogenic pain develops, neurectomy can be an effective means of treatment, significantly improving pain and quality of life in most patients. Better insight is necessary into a patient subset responding to nerve blocks yet experiencing minimal postoperative improvement. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Digital Imaging in Secondary Rhinoplasty.

BACKGROUND: Rhinoplasty remains one of the most commonly performed operations in plastic surgery. Little is known regarding the use of imaging in secondary rhinoplasty. Secondary rhinoplasty is a far more complex operation than primary rhinoplasty. The objective of this study was to assess the role of software imaging in patients undergoing secondary rhinoplasty. METHODS: A retrospective review was performed to identify patients undergoing secondary rhinoplasty performed by the senior author (R.J.R.) from January of 2000 to August of 2013. Forty consecutive patients met inclusion criteria. The degree of improvement was graded in comparison with both the preoperative photographs and software imaging using a graded scale. RESULTS: A total of 40 patients met inclusion criteria. There were 35 women (87.5 percent) and five men (12.5 percent). The nasal dorsum was found to have an average rating of 2.36 between the two observers, the midvault had an average rating of 2.65, the nasal tip had an average rating of 2.27, the nasal alae had an average rating of 2.63, and the nasal base had an average score of 2.99 CONCLUSIONS:: Based on the results of this study, the authors have determined that preoperative digital imaging can provide a reasonable expectation for patients undergoing secondary rhinoplasty. However, digital imaging must be used with caution, as secondary rhinoplasty patients have heightened expectations and unknown anatomy from their previous operation. The nasal tip and dorsum are especially difficult to adequately predict, and this should be discussed with the patient before surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Secondary Neck Lift and the Importance of Midline Platysmaplasty: Review of 101 Cases.

BACKGROUND: The authors believe that open access to the submental region, platysmaplasty, and wide skin undermining provide the most long-lasting results in neck rejuvenation, and sought to evaluate this hypothesis by reviewing their neck-lift patients. METHODS: The authors performed a retrospective chart review of their experience with neck-lift procedures and patients who underwent a secondary procedure. Patient age, sex, initial technique, visible neck deformities, and reasons for revision were assessed. Photographs were used to assess the features of persistent or recurrent neck-lift deformity and techniques to correct them. RESULTS: Of 1089 neck lifts reviewed, 101 patients underwent secondary or revision procedures (approximately 10 percent of total). The average patient age was 57.4 years, 95 percent were women, and secondary procedures were performed 10.3 years after the first procedure. Seventy percent of the revisions were of the authors' own primary neck lifts, and all of these after 10 years. The most common aesthetic deformities--recurrent platysmal bands (87 percent), persistent/recurrent jowling (48 percent), fat malposition/irregularities (10 percent), and vertical band deformity (8 percent)--were most often corrected with open platysmaplasty and medial or lateral plication and skin redraping. All patients had their submental region opened in the secondary procedure. All secondary operations were performed at least 10 years after primary surgery. CONCLUSIONS: The authors believe their technique of open submental neck access and platysmal approximation in patients with medial bands provides long-lasting results. The authors use precise preoperative evaluation, recontouring of neck fat irregularities, opening of the submental region with platysmaplasty, drains, and strict hemostasis. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Newer Understanding of Specific Anatomic Targets in the Aging Face as Applied to Injectables: Superficial and Deep Facial Fat Compartments--An Evolving Target for Site-Specific Facial Augmentation.

The identification of specific fat compartments of the face has greatly improved the plastic surgeon's approach to facial rejuvenation. These superficial and deep compartments are discretely partitioned into multiple independent units by fascial barriers and undergo age-dependant volumetric changes. This knowledge has created a topographical map allowing for the direct and precise augmentation of those compartments that are deflated preferentially. These include the deep medial cheek, nasolabial, superficial middle, and lateral cheek compartments. Once this volume loss has been addressed, the overlying superficial musculoaponeurotic system and skin envelope can be treated to address laxity and bridge the compartments, creating a smooth cheek contour. Facial augmentation can be performed alone in the correct patient; however, it most often complements face-lifting. It is, therefore, important to have a thorough understanding of this anatomy and the changes that occur during aging.

The Role of the Superwet Technique in Face Lift: An Analysis of 1089 Patients over 23 Years.

BACKGROUND: The use of superwet technique of infiltration and autologous tissue sealants during rhytidectomy has benefits of decreasing bleeding and edema, improving visualization, and easing dissection. The purpose of this study was to analyze whether these intraoperative strategies resulted in more consistent and reproducible outcomes and significantly decreased hematoma rates. METHODS: A retrospective review was performed on 1089 consecutive face lifts performed by a single surgeon. Fisher's exact test was used to determine significant differences in hematomas between those patients who received platelet-rich plasma and superwet technique and those who did not. Multivariate logistic regression was used to evaluate demographic variables and intraoperative interventions for risk of complication. RESULTS: Five hundred eighty-seven of 1089 face lifts received platelet-rich plasma and 926 of 1089 underwent a superwet technique. Ten hematomas were recorded, six in the group that did not receive platelet-rich plasma compared to four who did (p = 0.527). One hematoma was observed before implementation of the superwet technique and nine were in the group after (p = 1.00). Multivariate analysis showed male sex to be a significant factor for hematoma (p < 0.001). CONCLUSIONS: This analysis showed excellent outcomes with a hematoma rate of 0.9 percent. Although no significant differences were noted, the authors attribute their consistent and reproducible results to the use of the superwet technique and platelet-rich plasma. The superwet technique allows for improved safety and visualization with improved hemostasis. Platelet-rich plasma potentially decreases ecchymosis and edema. Prospective studies are needed to determine significant differences between these intraoperative interventions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Laser Resurfacing at the Time of Rhytidectomy.

BACKGROUND: Laser resurfacing with simultaneous rhytidectomy has been used to augment aesthetic results and decrease overall patient recuperative time, yet presents a potential dual insult to the microvasculature supply of facial skin flaps. This study describes the authors' experience with rhytidectomy and simultaneous laser resurfacing. METHODS: Between May of 1999 and January of 2013, 85 face lifts with concomitant erbium laser resurfacing were reviewed retrospectively. Seven procedures were excluded for incomplete charting. Patient demographics, treatment zone, concomitant procedures, and secondary/tertiary face lifts were analyzed for associations with postoperative complications attributable to laser resurfacing. RESULTS: No complications were reported in the perioral resurfacing group. There was one instance of delayed wound healing and prolonged erythema in the full face group, and one instance of moderate hyperpigmentation in the central face group. No instances of hypopigmentation or flap necrosis attributable to laser resurfacing were noted. The overall complication rate was 3.8 percent. There was a statistically significant difference when comparing the number of complications between the facial laser resurfacing zones (p = 0.037). When analyzing zone of laser resurfacing as an independent risk factor for complications, no significant association was derived, but full face zone resurfacing approached statistical significance (p = 0.063). CONCLUSIONS: Although a significant difference in the number of complications between treatment groups existed, the authors were not able to definitively attribute this solely to the extent of laser resurfacing. Simultaneous laser resurfacing and rhytidectomy can be performed safely in select patients using ablative mode only over the undermined flap. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Evolution of hypertension management in face lifting in 1089 patients: optimizing safety and outcomes.

BACKGROUND: Hematoma continues to be the most common complication after rhytidectomy. Perioperative hypertension is a known risk factor, and meticulous control of this has been shown to significantly reduce the incidence of postoperative hematoma development, thus improving outcomes and decreasing patient morbidity. Despite this, there are few well-described hypertension management regimens in the literature today. METHODS: A retrospective chart review of 1089 patients undergoing rhytidectomy performed by a single surgeon was conducted. A predetermined antihypertensive protocol was used in all patients that included the routine use of transdermal clonidine. A target systolic blood pressure of 140 mmHg or less was the goal of therapy, and close hemodynamic monitoring was used throughout the entire perioperative phase. The incidence of postoperative hematoma was then assessed. RESULTS: The overall incidence of postoperative hematoma was 0.9 percent (10 patients). Of these patients, five were female (0.05 percent) and five were male (5.2 percent). Preoperatively, 170 patients were noted to be hypertensive, with a systolic blood pressure greater than 140 mmHg. Postoperatively, 355 patients were found to be hypertensive (p < 0.001). Of the patients who developed a postoperative hematoma, eight patients (80 percent) had documented hypertension (systolic blood pressure >140 mmHg) in the postanesthesia care unit (p = 0.045). Male sex was found to be a significant risk factor for the development of hematoma (p < 0.001). CONCLUSIONS: Meticulous perioperative blood pressure control significantly reduces the rate of postoperative hematoma formation. The use of a specific protocol developed by our senior author and primary anesthesia provider contributed to our very low hematoma rates.

Face lifting in the massive weight loss patient: modifications of our technique for this population.

BACKGROUND: The authors evaluated their experience with facial rejuvenation in the massive weight loss patient. METHODS: A retrospective chart review of the senior author's (R.J.R) face-lift patients was conducted. Data on patient age and body mass index, surgical techniques used (when available), and intraoperative and postoperative complications were collected. RESULTS: Of the senior author's 25-year database of 1089 patients, 22 were identified (15 women and seven men). Nineteen patients had primary face lifts performed; three patients were secondary cases. Average age at face lift was 52.7 years (range, 41.0 to 67.0 years). Body mass index at the time of surgery was 26.0. There were no intraoperative complications. Postoperative complications included one hematoma that responded to drainage. Nineteen patients (86 percent) had volume loss in the midface and nasolabial groove regions. Thirteen patients (59 percent) had perioral volume loss, all had skin excess and redundancy in the jowl and submental region, and 18 (82 percent) had documented platysmal bands. The superficial musculoaponeurotic system (SMAS) was addressed in 20 patients (91 percent) with a SMASectomy. Fat augmentation was performed in all patients. On average, almost twice as much fat was used (22 ml versus 12 ml in non-massive weight loss patients). CONCLUSIONS: In the massive weight loss population, there are common techniques that can enhance results. (1) Individualized components analysis can be used; (2) to treat laxity of skin and deflation of fat compartments, twice as much fat augmentation is needed; (3) SMASectomy is used for redundant skin; and (4) SMAS neck suspension sutures are used in thicker-skinned patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Refining the anesthesia management of the face-lift patient: lessons learned from 1089 consecutive face lifts.

BACKGROUND: The importance of anesthetic technique is often underappreciated in face-lift procedures and is sparsely written about in the literature. Appropriate control of blood pressure, anxiety, pain, and nausea is essential for reducing the complications of face lift, primarily, hematoma risk. This study discusses the standard anesthetic protocol provided at the authors' institution and describes the preoperative, intraoperative, and postoperative management of face-lift patients resulting in low hematoma and complication rates. METHODS: One thousand eighty-nine patients who underwent face-lift procedures performed by a single surgeon (R.J.R) were included in a retrospective chart review following institutional review board approval. Patient demographics, operative data including additional ancillary procedures, and the anesthesia regimen were recorded. In addition, postoperative complications and reoperation rates were documented. RESULTS: Between 1990 and 2013, 1089 face-lift procedures were performed. Of these, 10 patients developed postoperative hematomas. Benzodiazepines were commonly administered preoperatively to reduce anxiety level. Intraoperatively, a specific regimen and combination of inhalation agents, neuromuscular blockers, antiemetics, antihypertensives, and narcotics was given to control the ease of induction and emergence from anesthesia. Postoperatively, nausea, vomiting, anxiety, pain, and hypertension were treated as needed. CONCLUSIONS: The described protocol is safe and has been instituted at the authors' facility for approximately 20 years. The benefit of this regimen is related to the synergy of combination therapy. It is successful in reducing patient anxiety and pain, controlling blood pressure and postoperative emesis, and subsequently results in a reduced risk of hematoma. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.