Beyond Alar Base Resection: Contouring of the Alar Rim and Base.

SUMMARY: Alar base surgery is approached with hesitancy and is often avoided by many surgeons because of inexperience and a lack of understanding. However, with a thorough knowledge of the anatomy and dynamic nature of the lower third of the nose, alar base resection can achieve favorable and reproducible results. Beyond correcting alar flare, an appropriately diagnosed and performed alar base procedure serves to contour both the alar rim and the alar base. The following article presents a case series of 436 consecutive rhinoplasties from a single surgeon, 214 of which underwent alar base surgery. The outcomes demonstrate that the procedure is safe and yields desirable results without a single revision being required. As the third in a series of three articles on alar base surgery by the senior author (R.J.R.), this article unifies the management of the alar base. An intuitive approach to the classification and management of alar flare and the implications of alar base surgery on contouring of the alar base and alar rim is presented. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Gender Considerations in Rhinoplasty.

SUMMARY: Precise nasofacial analysis ahead of rhinoplasty is imperative. Features common to the White masculine nose are reviewed in a stepwise fashion and contrasted with those of the White feminine nose. A solid understanding of the cisgender male, masculine nose enables the plastic surgeon to determine the changes required for a successful facial feminizing rhinoplasty as a part of facial gender confirmation surgery.

An Evidence-Based and Case-Based Comparison of Modern Face Lift Techniques.

BACKGROUND: Facial aging is a multifactorial process that affects each component of facial anatomy. The two general groups of face lift techniques are superficial musculoaponeurotic system (SMAS) elevation and SMAS manipulation. The purpose of this article is to describe and compare the advantages, disadvantages, and limitations of face lift techniques. METHODS: A systematic review was performed to describe current outcomes evidence for face lift techniques. A subcohort of articles was selected for case-based analysis based on designated facial assessment criteria. Analysis was performed to determine the advantages, disadvantages, and limitations of each respective technique. RESULTS: A total of 65 articles were selected for systematic review, of which 15 met criteria for case-based review. Patient satisfaction was found to be equivocal for various face lift techniques. Specific advantages and disadvantages for each face lift technique were dependent on the techniques' approach to skin shift vector along with its degree of mobilizing superficial facial fat. Facial fat grafting was universally applicable for restoration of deep malar volume. Facial fat grafting was also used differently depending on the SMAS technique to address its specific limitations. CONCLUSIONS: The authors' review confirms that there are many methods to obtain excellent outcomes in facial rejuvenation. Experienced surgeons are able to obtain consistent results through a variety of techniques based on understanding the aesthetic needs of the individual patient, the quality of the soft tissues being manipulated, and how to vary a specific technique to reach desired aesthetic end points.

Subcutaneous Lateral Temporal Lift.

Over the past decades, the understanding of the nuances of forehead anatomy and facial aging has grown immensely. Safe and reliable options for forehead rejuvenation followed. Although noninvasive techniques are an important adjunct in forehead rejuvenation, the mainstay of treatment of the eyebrow is operative intervention. The senior author's technique has developed over many years, first focusing on the open coronal and anterior hairline approach to the forehead lift, then the endoscopic brow lift, and most recently, the lateral subcutaneous temporal lift. This technique allows for reliable and safe elevation of the lateral brow with minimal complications.

The Alar Equalization Suture for Nasal Tip Refinement.

SUMMARY: Anatomic subtleties of the nasal tip have a dramatic impact on the overall appearance of the nose. Creation of the ideal nasal tip in rhinoplasty requires straight lower lateral cartilages, everted lateral crura, a higher caudal edge of the lower lateral cartilages relative to the cephalic margin, and a diamond-shaped tip. In this article, the authors describe the alar equalization suture, a suture technique that further refines nasal tip shaping after traditional maneuvers have been performed.

TGF-ß1 mediates pathologic changes of secondary lymphedema by promoting fibrosis and inflammation.

BACKGROUND: Secondary lymphedema is a common complication of cancer treatment, and previous studies have shown that the expression of transforming growth factor-beta 1 (TGF-ß1), a pro-fibrotic and anti-lymphangiogenic growth factor, is increased in this disease. Inhibition of TGF-ß1 decreases the severity of the disease in mouse models; however, the mechanisms that regulate this improvement remain unknown. METHODS: Expression of TGF-ß1 and extracellular matrix molecules (ECM) was assessed in biopsy specimens from patients with unilateral breast cancer-related lymphedema (BCRL). The effects of TGF-ß1 inhibition using neutralizing antibodies or a topical formulation of pirfenidone (PFD) were analyzed in mouse models of lymphedema. We also assessed the direct effects of TGF-ß1 on lymphatic endothelial cells (LECs) using transgenic mice that expressed a dominant-negative TGF-ß receptor selectively on LECs (LECDN-RII ). RESULTS: The expression of TGF-ß1 and ECM molecules is significantly increased in BCRL skin biopsies. Inhibition of TGF-ß1 in mouse models of lymphedema using neutralizing antibodies or with topical PFD decreased ECM deposition, increased the formation of collateral lymphatics, and inhibited infiltration of T cells. In vitro studies showed that TGF-ß1 in lymphedematous tissues increases fibroblast, lymphatic endothelial cell (LEC), and lymphatic smooth muscle cell stiffness. Knockdown of TGF-ß1 responsiveness in LECDN-RII resulted in increased lymphangiogenesis and collateral lymphatic formation; however, ECM deposition and fibrosis persisted, and the severity of lymphedema was indistinguishable from controls. CONCLUSIONS: Our results show that TGF-ß1 is an essential regulator of ECM deposition in secondary lymphedema and that inhibition of this response is a promising means of treating lymphedema.

The Five-Step Rhinoplasty Dead Space Closure Technique.

SUMMARY: The creation of dead space in rhinoplasty creates a welcoming environment for erratic soft -tissue contraction. If rhinoplasty surgeons can control and reliably predict skin contraction and wound healing, rhinoplasty results will undoubtedly improve. Obliteration of dead space is a key component in rhinoplasty as it minimizes soft-tissue contraction, resulting in a more predictable outcome. In this article, the authors present a systematic five-step dead space closure surgical plan.

A Novel Algorithm for Defining the Mandibular Border.

SUMMARY: Techniques for defining the mandibular angle are a particular focus for patients around the world. Developing the desirable sharp contours is a combination of reducing bulkiness around the mandible while augmenting the border. Invasive techniques (e.g., face lifts and chin augmentation) can help define the mandible; however, younger patients are demanding more affordable and less invasive procedures. The "Nefertiti lift," masseter neurotoxin, buccal fat excision, mandibular border augmentation with filler, and liposuction of the neck can all be done in the office and will produce excellent results. If the loss of definition is due to superior soft tissue, the next step is to determine if this is based on anterior or posterior soft-tissue excess. Posteriorly, it is caused by masseter hypertrophy, and anteriorly, it may be because of an enlarged or full buccal fat pad in the lower cheek area. If the loss of definition is inferior, the next step is to again define if it is anterior or posterior. Anterior excess tissue can be corrected with liposuction of the neck along with energy-based skin tightening technology. Posteriorly, the inferior pull of the platysma can be blunted with neurotoxin. Finally, once the soft tissues are adequate, the mandibular border can be augmented with filler. In this article, the authors propose an algorithm for when to utilize each of these procedures while reviewing proper technique.

An Update on the Surgical Management of the Bulbous and Boxy Tip.

SUMMARY: The bulbous and box tips are two common morphologies encountered in rhinoplasty. Nasal tip reshaping is a challenging aspect of rhinoplasty. Understanding the classifications of nasal tip morphologies aids when performing a nasal-facial analysis. The management algorithm for both tip morphologies shares various techniques. These techniques include but are not limited to cephalic trim, transdomal sutures, and interdomal sutures. A graduated approach to managing the variations in bulbous and boxy tips will help in achieving consistent results. New concepts applied to the management include supporting alar rims with alar contour grafts, closing dead space through a series of techniques, and managing the soft-tissue envelope, which is often in excess.

Nasal Tip Shaping Finesse in Rhinoplasty.

SUMMARY: Anatomic subtleties of the nasal tip have a dramatic impact on the overall appearance of the nose. Mastery of normal nasal aesthetics and anatomy is a critical prerequisite to adeptly performing nasal tip refinement during open rhinoplasty. This article and series of videos aim to provide a focused review of nasal tip analysis, anatomy, and surgical technique, with particular emphasis on pertinent tip sutures and cartilage grafts.

Why Primary Rhinoplasty Fails.

SUMMARY: Rhinoplasty remains one of the most challenging operations performed by plastic surgeons. The complexity lies in the ability to have a consistent and predictable aesthetic result. The unpredictability is mainly attributable to the interplay of manipulated internal structures and wound healing dynamics. In addition, setting realistic expectations with the patient is essential for achieving high postoperative patient satisfaction. An open rhinoplasty approach enables an accurate and in-depth evaluation and intervention. The authors provide a detailed analysis and discussion on why primary rhinoplasty fails, along with the surgical approach for preventing these failures.

Evidence-Based Medicine in Plastic Surgery: From Then to Now.

SUMMARY: Evidence-based medicine, as described by Dr. Sackett, is defined as the "conscientious, explicit, and judicious use of current best evidence, combined with individual clinical expertise and patient preferences and values, in making decisions about the care of individual patients." In the late 2000s, seminal articles in Clinics in Plastic Surgery and Plastic and Reconstructive Surgery introduced evidence-based medicine's role in plastic surgery and redefined varying levels of evidence. The American Society of Plastic Surgeons sponsored the Colorado Springs Evidence-Based Medicine Summit that set forth a consensus statement and action plan regarding the increased incorporation of evidence-based medicine into the field; this key meeting ushered a new era among plastic surgeons worldwide. Over the past decade, Plastic and Reconstructive Surgery has incorporated evidence-based medicine into the Journal through an increase in articles with level I and II evidence, new sections of the Journal, and the introduction of validated tools to help authors perform prospective and randomized studies that ultimately led to best practices used today. Plastic surgery is a specialty built on problem-solving and innovation, values starkly in-line with evidence-based medicine. Evidence-based medicine is becoming more ingrained in our everyday practice and plastic surgery culture; however, we must work actively to ensure that we continue this trend. In the next decade, we will possibly see that level I and II evidence articles start to inhabit many of our journal issues.

The Role of the Buccal Fat Pad in Facial Aesthetic Surgery.

SUMMARY: Social media have triggered a buccal fat pad excision frenzy. Not surprisingly, there is tremendous appeal of having a slimmer lower face and more defined jawline after undergoing a small intraoral procedure under local anesthesia. Although this procedure is great for social media and seemingly beneficial for jawline aesthetics, the evidence remains limited as to whether or not this is an effective long-term solution. How much the buccal fat pad persists or diminishes as we age is an area of debate. However, the possibility of causing premature aging and midface distortion in the long run is disconcerting.

Social Media Guidelines for Young Plastic Surgeons and Plastic Surgery Training Programs.

SUMMARY: Social media are a powerful tool that creates a unique opportunity for the young plastic surgeon and trainee to share content, brand oneself, educate the public, and develop one's own professional voice early. The majority of all plastic surgery programs and particularly those that are highly ranked have social media opportunities for their residents, yet clear rules to guide implementation of social media programming in residency have remained unspecified. These guidelines and pitfalls can be used to inform a productive and professional entry into plastic surgery social media use for the resident and young plastic surgeon. Details regarding specific platform use to maximize exposure are provided. The core principles of patient safety and privacy, authentic photography, plastic surgery education and advocacy, and professionalism inform these guidelines. Pitfalls include establishment of an online physician-patient relationship, engaging in debate by means of online reviews, providing medical entertainment, and engaging in non-plastic surgery politics. Use of these guidelines will allow the young plastic surgeon and trainee to succeed by means of social media platforms in an ethical and professional manner.

Secondary Rhinoplasty for Unilateral Cleft Nasal Deformity.

BACKGROUND: Secondary cleft rhinoplasty presents some of the most challenging cases of both cosmetic and functional nasal deformities. Understanding the anatomy and growth abnormality seen with the cleft nasal deformity helps to tailor surgical management. This article seeks to expand on the application of current concepts in secondary rhinoplasty for unilateral cleft lip nasal deformity. METHODS: The authors review nasal analysis in the cleft rhinoplasty patient and provide the surgical management for each aspect in the secondary cleft rhinoplasty. RESULTS: The secondary rhinoplasty was divided into seven areas: piriform hypoplasia, septal reconstruction, dorsal reshaping, tip reshaping, tip projection, alar reshaping, and alar repositioning. Surgical management for each is provided. CONCLUSION: Secondary cleft rhinoplasty requires an understanding of the structural dysmorphology, and the use of cosmetic, functional, and secondary rhinoplasty techniques for its successful management.

Revisiting Primary Otoplasty: Surgical Approach to the Prominent Ear.

SUMMARY: Prominent ears and other ear deformities are some of the most common congenital deformities of the head, affecting over 10 percent of the general population. In 2018, more than 10,000 otoplasties were performed in the United States, with over one-third performed on men. The goal of primary otoplasty is creation of a normal-appearing ear without evidence of surgical intervention. This article and video detail the authors' preferred technique for the treatment of prominent ears. This novel method allows for reduction of a hypertrophic concha and obtuse conchoscaphal angle, as well as creation of an adequate antihelical fold.

Perioperative Approach to Reducing Hematoma during Rhytidectomy: What Does the Evidence Show?

BACKGROUND: Postoperative hematoma remains the most common complication in rhytidectomy, prompting surgeons to use a multitude of adjunctive measures to prevent its occurrence. The goal of this systematic review was to determine which of these measures are supported by strong evidence, and to highlight those that remain unsubstantiated and require further investigation. METHODS: A systematic search was performed of the PubMed and Embase databases for English literature from 1975 to March of 2020 containing designated keywords, and focusing specifically on adjunctive measures aimed at preventing hematoma in rhytidectomy. The resultant articles were then systematically screened according to predefined inclusion and exclusion criteria to determine eligibility for inclusion in the study. RESULTS: The keyword search yielded a total of 2391 articles. Title and abstract screening resulted in 103 articles that were eligible for full-text review. Ultimately, 48 articles met final inclusion criteria. The articles were categorized into their particular mode of intervention: fibrin tissue sealants, perioperative medications (anesthetics, antihypertensives, miscellaneous medications), and intraoperative maneuvers (hemostatic agents, preinfiltration, intraoperative maneuvers, and drains). Nine studies were indexed as evidence Level II and 24 as evidence Level III. The remainder of studies constituted Level IV evidence. CONCLUSIONS: Adjunctive interventions have been borne out of necessity in efforts to reduce postoperative hematoma after rhytidectomy. Although many of these interventions have promising results, the current literature supports the senior author's (R.J.R.) experience that an evidence-based, multimodal approach is ideal to minimize the rates of hematoma after rhytidectomy.

Management of Patients with Textured Surface Breast Implants.

SUMMARY: The purpose of this special topic article is to present an evidence-based approach and provide recommendations for the management of both asymptomatic and symptomatic patients with textured surface breast implants. There are currently no scientific data to support complete removal of a benign capsule. When unnecessary capsulectomies are performed, the patient is at higher risk for developing postoperative complications. Ultimately, the decision to keep, exchange, or remove breast implants is the patient's decision and the procedure should be performed only by a qualified surgeon.