Bioabsorbable Polydioxanone Mesh for Soft Tissue Reinforcement in Revisional Breast Surgery.

Background: The need for revision procedures after breast implant surgery often arises from the failure of soft tissues to provide a stable implant pocket. Meshes or dermal matrices have been used to reinforce the implant's soft tissue support. Durasorb (Surgical Innovation Associates, Chicago, IL) is a resorbable polydioxanone (PDO) mesh indicated for soft tissue reinforcement. Its monofilament, macroporous design allows for ease of handling and rapid tissue incorporation. The extended timeline of PDO bioabsorption provides support during the critical portions of soft tissue healing while avoiding long-term complications of permanent products. Objectives: Evaluate the efficacy of Durasorb PDO mesh for soft tissue reinforcement in revision breast surgery. Methods: This is a prospective case series of 17 patients (27 breasts) undergoing revision breast implant surgery with Durasorb PDO mesh. Results: Five patients (5 breasts) presented for revision after implant placement for breast reconstruction, with the remaining 22 presenting for revision after implant placement for cosmetic indications. Average patient age was 47.9 years, and average BMI 24.3. Indications for surgery were implant malposition (37%), capsular contracture (30%), poor cosmesis/asymmetry (26%), and recurrent soft tissue ptosis (7%). Follow up averaged 355 days (range 174 to 799 days, SD=155). One patient experienced a seroma 2 weeks post-operatively, which resolved after a single aspiration. No infections, wound healing problems, or recurrences of implant malposition/capsular contracture were encountered. Conclusions: Durasorb PDO mesh appears to be efficacious as a breast implant pocket reinforcement in the reoperative setting with a low complication rate and durable results.

Wealth Management and Retirement.

SUMMARY: The purpose of this publication is to introduce basic financial planning concepts and highlight their use in creating a retirement savings plan. These tools may help young surgeons set their financial targets and create a plan to meet them, whereas surgeons later in their careers may reflect on their choices and implement adjustments, or be inspired to pass on the lessons they learned to the next generation. This publication is limited by design and should be thought of as a primer, not a comprehensive treatise. The topic of personal financial management is as vague as it is broad, and there are many concepts and situations that are outside the scope of this publication. Unique goals, income and expense streams, and risk tolerances necessitate individualized solutions, but there are fundamental concepts listed below that are more universally applicable. The discussion is tailored to the high income stream that plastic surgeons can expect, albeit one that starts relatively late in their careers compared to nonphysician colleagues. There are three foundational principles the reader should take away: having a plan is crucial in achieving any financial goal; starting any savings/investment endeavors as early as possible is as or more important than the amount of capital committed to them; and lastly, individual investors (professional and amateur) have consistently demonstrated an inability to consistently do better than the market over the long run.

Photographic Misrepresentation on Instagram After Facial Cosmetic Surgery: Is Increased Photography Bias Associated With Greater User Engagement?

BACKGROUND: Before-and-after images are commonly used on Instagram (Menlo Park, CA) to advertise aesthetic surgical treatments and are a powerful means of engaging prospective patients. Consistency between before-and-after images accurately demonstrating the postoperative result on Instagram, however, has not been systematically assessed. OBJECTIVES: The aim of this study was to systematically assess facial cosmetic surgery before-and-after photography bias on Instagram. METHODS: The authors queried 19 Instagram facial aesthetic surgery-related hashtags on 3 dates in May 2020. The "top" 9 posts associated with each hashtag (291 posts) were analyzed by 3 plastic surgeons by means of a 5-item rubric quantifying photographic discrepancies between preoperative and postoperative images. Duplicate posts and those that did not include before-and-after images of facial aesthetic surgery procedures were excluded. RESULTS: A total of 3,477,178 posts were queried. Photography conditions were observed to favor visual enhancement of the postoperative result in 282/291 analyzed top posts, with an average bias score of 1.71 [1.01] out of 5. Plastic surgeons accounted for only 27.5% of top posts. Physicians practicing outside their scope of practice accounted for 2.8% of top posts. Accounts with a greater number of followers (P = 0.017) and posts originating from Asia (P = 0.013) were significantly associated with a higher postoperative photography bias score. CONCLUSIONS: Photographic misrepresentation, with photography conditions biased towards enhancing the appearance of the postoperative result, is pervasive on Instagram. This pattern was observed across all physician specialties and raises significant concerns. Accounts with a greater number of followers demonstrated significantly greater postoperative photography bias, suggesting photographic misrepresentation is rewarded by greater user engagement.

Incidence of Obstetric Lacerations and Episiotomy Following Labiaplasty.

BACKGROUND: A significant proportion of patients seeking labiaplasty are nulliparous and may experience later changes to their labia following vaginal delivery. OBJECTIVES: In the present study, the authors reported the long-term outcomes of a single surgeon's patient cohort who had vaginal delivery after labiaplasty. METHODS: A retrospective chart review of the senior author's database was conducted. All patients who underwent in-office labiaplasty from 2007 to 2018 were surveyed. The resulting cohort was stratified into patients who had delivered children prior to labiaplasty and those who delivered after labiaplasty. RESULTS: A total of 204 patients responded to a phone survey. Seventy patients had children prior to undergoing labiaplasty, and 33 had children after labiaplasty. The rate of vaginal delivery was lower in the women who had children before labiaplasty (82.6% vs 91.8%, P = 0.015). The tear/episiotomy rate for vaginal deliveries was lower in women who had children prior to labiaplasty compared with after labiaplasty (3.1% vs 17.8%, P < 0.001). Among the women who had children only after labiaplasty, the reported tear/episiotomy rate was 7/39 vaginal deliveries (17.9%). CONCLUSION: Patients in our cohort had over 90% success with vaginal deliveries after labiaplasty. For nulliparous patients contemplating the procedure, the data we present suggest the risk of episiotomy or vaginal tear risk with vaginal birth after labiaplasty is comparable with or lower than the general population, further supporting the safety of this procedure. For patients with previous delivery, the data are more limited but suggest no increased risk in this small cohort.

Personalized Computational Models of Tissue-Rearrangement in the Scalp Predict the Mechanical Stress Signature of Rotation Flaps.

OBJECTIVE: To elucidate the mechanics of scalp rotation flaps through 3D imaging and computational modeling. Excessive tension near a wound or sutured region can delay wound healing or trigger complications. Measuring tension in the operating room is challenging, instead, noninvasive methods to improve surgical planning are needed. DESIGN: Multi-view stereo allows creation of 3D patient-specific geometries based on a set of photographs. The patient-specific 3D geometry is imported into a finite element (FE) platform to perform a virtual procedure. The simulation is compared with the clinical outcome. Additional simulations quantify the effect of individual flap parameters on the resulting tension distribution. PARTICIPANTS: Rotation flaps for reconstruction of scalp defects following melanoma resection in 2 cases are presented. Rotation flaps were designed without preoperative FE preparation. MAIN OUTCOME MEASURE: Tension distribution over the operated region. RESULTS: The tension from FE shows peaks at the base and distal ends of the scalp rotation flap. The predicted geometry from the simulation aligns with postoperative photographs. Simulations exploring the flap design parameters show variation in the tension. Lower tensions were achieved when rotation was oriented with respect to skin tension lines (horizontal tissue fibers) and smaller rotation angles. CONCLUSIONS: Tension distribution following rotation of scalp flaps can be predicted through personalized FE simulations. Flaps can be designed to reduce tension using FE, which may greatly improve the reliability of scalp reconstruction in craniofacial surgery, critical in complex cases when scalp reconstruction is essential for coverage of hardware, implants, and/or bone graft.

Modeling Tissue Expansion with Isogeometric Analysis: Skin Growth and Tissue Level Changes in the Porcine Model.

BACKGROUND: Tissue expansion relies on the ability of skin to grow in response to sustained mechanical strain. This study focuses on correlation of cellular and histologic changes with skin growth and deformation during tissue expansion. METHODS: Tissue expanders were placed underneath the skin of five Yucatan minipigs and inflated with one fill of 60 cc of saline 1 hour, 24 hours, 3 days, and 7 days before the animals were killed, or two fills of either 30 cc or 60 cc at 10 and 3 days or 14 and 7 days before the animals were killed. Skin biopsy specimens and three-dimensional photographs were used to calculate skin growth and stretch according to the authors' novel finite element analysis model. RESULTS: The mitotic index of keratinocytes in the basal layer increased 1 hour after stimulus was applied (4 percent) (p = 0.022), peaked at approximately day 3 (26 percent) (p < 0.0001), and tapered by day 7 (12.5 percent) (p = 0.012) after tissue expansion. The authors demonstrated that it is the volume per fill rather than the total volume in the expander that scales the magnitude of response. Lastly, the authors demonstrated that the ratio of deformation attributable to growth versus stretch (Fgrowth/Fstretch) after 60 cc of tissue expansion fill was 1.03 at 1 hour, 0.82 at 1 day, 0.85 at day 3, and 0.95 at 7 days. CONCLUSIONS: Peak cell proliferation occurred 3 days after tissue expansion fill and is scaled in response to stimulus magnitude. The growth component of deformation equilibrates to the stretch component at day 7, as cell proliferation has started to translate to skin growth.

Anterior and Posterior Commissuroplasty: Taking Labiaplasty to the Next Level.

As the popularity of female cosmetic genital surgery has grown, so has the number of publications detailing surgical techniques, particularly regarding labiaplasty. As a nascent surgical field, much room remains for finesse and exploration of new techniques to optimize outcomes and patient satisfaction. We present the techniques for anterior and posterior commissuroplasty the senior author (O.J.P.) has developed. Anterior commissuroplasty is efficacious in addressing a number of anatomic variations to achieve the appearance of a single midline cleft, which is commonly requested by patients. Posterior commissuroplasty was developed to address skin excess at the posterior fourchette that may develop as a result of labiaplasty. Either technique may be used in combination with labiaplasty or as a stand-alone procedure. These tools may be a useful addition to the repertoire of a surgeon practicing female genital surgery.

Novel Passage of Dermis-Fat Graft for Augmentation of Vermilion Deficiency Following Cleft Lip Repair.

Despite timely repair of cleft lip, secondary deformities such as vermilion notching or "whistle deformity" often require further surgical treatment. The use of dermis-fat graft for soft tissue augmentation of the upper lip is an established technique. We propose an innovation on this technique, by which the dermis-fat graft can be placed reliably and with minimal dissection by use of a soft red rubber sheath to protect the Keith needle while delivering the graft through the submucosal pocket in the dry vermilion, thereby avoiding the needle inadvertently catching soft tissue inside the pocket. We recommend using an 8F red rubber catheter, cutting the catheter to be just shorter than a 2.5-inch Keith needle. This provides a sheath through which the Keith needle can be passed within the submucosal vermilion tunnel. We believe this to be much more reliable for vermilion augmentation than other techniques, including fat injection, and makes graft inset more predictable, faster, and simpler.

Gluteal Vein Anatomy: Location, Caliber, Impact of Patient Positioning, and Implications for Fat Grafting.

BACKGROUND: Deaths in gluteal autografting occur due to gluteal vein injuries, but data are lacking on the precise location and caliber of these veins. OBJECTIVES: The authors sought to present the first in vivo study of gluteal vein anatomy utilizing magnetic resonance imaging. METHODS: Magnetic resonance imaging venography of 16 volunteer hemi-sections was conducted in the supine, prone, prone with a bump (jack-knife), and left and right decubitus positions in 1 session after a single contrast administration. Caliber and course of the superior and inferior gluteal veins (SGV/IGV) were analyzed vs bony landmarks and position changes. RESULTS: The SGV has a very short submuscular course before splitting into 2 smaller branches superolaterally. The IGV runs immediately deep to the gluteus maximus in the center of the buttock as a single large trunk, on average 56 mm deep (mean 27 mm of muscle belly and 30 mm subcutaneous fat). No intramuscular or subcutaneous branches greater than 2 mm were found. In the prone position, the IGV and SGV have an average caliber of 5.96 mm and 5.63 mm. Vessel caliber decreased by 21% and 27%, respectively, in the jack-knife position and by 14% and 15% in lateral decubitus. CONCLUSIONS: The SGV and IGV are immediately deep to gluteus maximus approximately 6 cm deep with a caliber on the order of 6 mm in the prone position. The distribution of these vessels suggests there is no "safe zone" in the intramuscular or submuscular planes. The jackknife or lateral decubitus positions can decrease vein caliber by up to 27%, possibly reducing the risk of injury due to either traction or direct cannula impact.

Simplified Lateral Brow Lift under Local Anesthesia for Correction of Lateral Hooding.

BACKGROUND: A limited incision lateral brow lift has been described as an alternative to the endoscopic or the bicoronal approaches. The senior author has developed a safe and effective lateral brow lift technique that can be performed in an office setting under local anesthesia. METHODS: We retrospectively reviewed 150 consecutive patients who underwent a brow lift by the senior author (TAM). The technique begins with an upper blepharoplasty incision which is used to divide the corrugator under direct vision, followed by a release of the periorbital retaining ligaments. The lateral temporal incision is the access point for dissection above the deep temporal fascia then connecting to the subperiosteal plane, allowing full mobility of the brow. Galea is advanced with sutures and redundant skin is excised. RESULTS: All patients treated with this technique had resolution of lateral brow hooding. Two temporary neuropraxias of the frontal branch of the facial nerve were observed with full resolution and no permanent nerve injuries occurred. The revision rate was 7% and there was a 3% incidence of delayed wound healing at the temporal incision with no infections. One hundred forty-two patients (97%) underwent this procedure with sedation, 52 of which (35%) were in the office with light oral sedation. CONCLUSIONS: The limited incision lateral brow lift as described allows for safe elevation of the lateral brow. When complemented by upper blepharoplasty, this technique provides excellent and natural-appearing rejuvenation of the upper face.

A Quantitative Analysis of Online Plastic Surgeon Reviews for Abdominoplasty.

BACKGROUND: Online reviews increasingly influence patients' decision-making. This is the first systematic, quantitative analysis of online reviews for abdominoplasty. METHODS: Reviews for abdominoplasty were sampled from RealSelf, Yelp, and Google for six major metropolitan areas. A standard social sciences framework known as grounded theory was used to evaluate factors affecting satisfaction. The relative importance of factors was quantified using odds ratios. RESULTS: Seven hundred ninety-four reviews met inclusion criteria. There was significant geographic variation with respect to number of reviews (p < 0.01) and average rating (p = 0.014). The authors identified 10 statistically significant themes affecting satisfaction. Of these, aesthetic outcome was the most mentioned theme [n = 368 (46.3 percent)] and the most dominant driver of satisfaction. Interactions with staff had the second highest odds ratio, driven by the fact that all negative staff interactions led to negative reviews. Postoperative care had the next highest odds ratio, and was demonstrated to counteract the negative effects of poor surgical outcomes on satisfaction. The occurrence of a surgical complication and the cost of surgery were least associated with satisfaction. CONCLUSIONS: This analysis is the first to use quantitative methods to identify dominant and nondominant factors affecting patient satisfaction in cosmetic surgery. The authors found that aesthetic outcome, staff interactions, and postoperative diligence were the most critical factors affecting satisfaction in abdominoplasty, whereas postoperative complications and cost were least important. Understanding the relative importance of factors may help to improve and protect one's online reputation.

Fibrous Dysplasia and Juvenile Psammomatoid Ossifying Fibroma: A Case of Mistaken Identity.

Juvenile psammomatoid ossifying fibroma (JPOF) is a rare benign osseous tumor, usually presenting in the midface. There are many similarities in location, presentation, and radiographic appearance between fibrous dysplasia (FD) and JPOF. Awareness of this entity is important for craniofacial surgeons, as surgical timing and intraoperative management differ between these tumors. Findings that should raise suspicion of JPOF preoperatively include rapid growth, a shell of cortical bone surrounding the lesion, and clearly demarcated borders of the lesion on imaging, as opposed to a gradual transition between normal and abnormal bone. Definitive excision is the treatment of choice, and earlier surgery may provide better results by addressing the lesion at the smallest size possible. In contrast to FD, JPOF is not known to "burn out," so there is minimal benefit to be gained from delay. We present a summary of the evidence for diagnosis and treatment of JPOF as well our experience with JPOF in an 11-year-old female who was initially diagnosed with FD. We aim to draw attention to the similar presentations of these entities so the reader will be able to more accurately manage these patients.

Volumetric Changes of the Mid and Lower Face with Animation and the Standardization of Three-Dimensional Facial Imaging.

BACKGROUND: The objective of this study was to quantify volumetric changes of the mid and lower face caused by facial expression to understand how procedural results measured by three-dimensional imaging can be influenced by lack of standardization. Secondarily, the study identified soft-tissue surface landmarks that can be used to ensure the standardization of three-dimensional images. METHODS: Three-dimensional facial images of subjects performing 22 facial expressions or changes in head position were captured. Variable degrees of animation during smiling and frowning were also evaluated. Volumetric changes of the malar and jowl regions were quantified using a three-dimensional superimposed image subtraction technique. The translation of 14 standard soft-tissue surface landmarks was assessed during various facial animations to determine which three-dimensional landmarks can be used to standardize three-dimensional images. RESULTS: Twenty subjects participated in the study. Sixteen of the 22 facial expression studies had a significant effect on malar and/or jowl volume. Significant volume changes were noted with subtle animation during smiling and frowning. A combination of five landmarks (i.e., glabella, bilateral cheilion, pogonion, and laryngeal prominence) can be used to standardize three-dimensional images for evaluation of mid and lower facial volume changes. CONCLUSIONS: Subtle facial expressions may cause significant volumetric changes in the mid and lower face that can mimic the desired outcomes of surgical and nonsurgical facial rejuvenation procedures. The five-point referencing system allows one to identify subtle changes in head position and facial expression and may aid in the standardization of three-dimensional images.

Major Complications and 30-Day Morbidity for Single Jaw Versus Bimaxillary Orthognathic Surgery as Reported by NSQIP.

OBJECTIVE: Acute complications in orthognathic surgery are reported in single-institution studies with small sample sizes. We aimed to analyze risk factors for acute complications using a national data set to better inform surgical decision-making. METHODS: 2005-2015 National Surgical Quality Improvement Program (NSQIP) data sets were analyzed for patients undergoing Le Fort 1 and/or bilateral sagittal split osteotomies (BSSO) for nontraumatic indications. Demographics, comorbidities, medical, and surgical 30-day complications were tabulated. A logistic regression model was used to determine predictors of complications. RESULTS: Five hundred eight patients met the inclusion criteria: 228 underwent Le Fort I osteotomies, 152 BSSO, and 128 patients underwent both during a single surgical encounter. Overall complication rate was 4.5% (23/508). Superficial infection was the most common complication (11 in BSSO and 2 in Le Fort I cohorts). Increasing age and undergoing BSSO alone were associated with higher overall complication rates (P < .05) and surgical complications specifically (P < .05). Patients undergoing the combined procedure had shorter operative time (208 minutes) than the times for Le Fort I osteotomies alone (177 minutes) and BSSO alone (155 minutes) added together and did not have a longer hospital stay (P = .608) or increased need for transfusion (P = 1.0) compared to the surgeries being done separately. CONCLUSION: This is the first complication risk factor analysis for Le Fort I osteotomy and BSSO using the multi-institutional NSQIP data set. Combining BSSO and Le Fort I osteotomy leads to a shorter overall operative time and does not increase hospital stay duration or 30-day complication rate when compared to the 2 procedures being done separately.