Three-Dimensional Perioral Assessment Following Subnasal Lip Lift.

BACKGROUND: The subnasal lip lift is a surgical technique that elevates the "lip line" (interface between vertical maxillary incisor height and upper lip) to achieve a more youthful aesthetic. OBJECTIVES: The authors sought to offer the first ever definition, to their knowledge, of 3-dimensional (3D) changes to the upper lip due to subnasal lip lift. METHODS: A lip lift procedure was performed (on cadaveric samples) in a sequential manner from 2.5- to 5.0-mm intervals (n = 13). 3D photographs were taken with the VECTRA H1 system (Canfield Scientific, Fairfield, NJ), and 3D analysis was performed including vermillion height and width, philtral height, sagittal lip projection, vermillion surface area, and incisor show. A subset of samples (n = 9) underwent a modification of the technique by undermining the upper lip subcutaneous tissue off the underlying muscular fascia. RESULTS: Vermillion surface area (baseline range, 1.45-5.52 cm2) increased by an average of 20.5% and 43.1% with 2.5-mm and 5.0-mm lip lift, respectively. Anterior projection of the vermillion increased in all cases by an average of 2.13 and 4.07 mm at 2.5 and 5.0 mm, respectively. Philtral height decreased in all cases by an average of 3.37 and 7.23 mm at 2.5 and 5.0 mm, whereas incisal show increased on average of 1.9 and 4.09 mm, respectively. CONCLUSIONS: This study is the first to our knowledge to define the 3D morphometric changes to the upper lip following subnasal lip lift. Quantifying these changes aids the surgeon in preoperative planning and guiding patient expectations.

3D Printed Surgical Guides Applied in Rhinoplasty to Help Obtain Ideal Nasal Profile.

INTRODUCTION: As computer simulation for rhinoplasty continues to rise, the technology's utility extends beyond increasing patient conversion. Virtual simulation of the surgical result can assist with surgical planning and intraoperative decision-making. 3D printed anatomic models or surgical guides based on 3D images may help align surgeons with their original surgical plan. This study aims to evaluate the utility of 3D printed surgical guides as an intraoperative tool to help establish dorsal height and tip position. METHODS: Patients undergoing rhinoplasty had preoperative virtual 3D surgical simulations performed. Simulations were used to create a 3D printed nasal kits containing ceramic models of the preoperative nose and simulated nose, sagittal contour guide, and customized postoperative nasal splint. Nasal guides were sterilized for continual intraoperative assessment of profile contour (i.e., dorsal height and tip position). Postoperative 3D images (1-3 months post-op) were then compared to preoperative simulations. The difference between z coordinates and y coordinates determined the difference in projection and rotation, respectively. RESULTS: Fifteen patients met inclusion criteria for this study. With the use of 3D printed surgical guides, the final tip position was on average of 0.8±0.7mm from simulated projection and 0.3±0.2mm from simulated rotation. Similarly, projection for the cartilaginous and bony dorsum was within 1.0±0.8 and 0.8±0.7mm of the simulation, respectively. CONCLUSION: Virtual simulation is useful in defining aesthetic goals preoperatively, but the potential clinical value extends beyond this. 3D printed rhinoplasty guides extend the simulation's utility to decision-making intraoperatively. This technology offers a novel medium for anatomic reference, which may improve adherence to desired aesthetic goals. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266 .

Optimizing Reconstruction in Craniosynostosis: Review of Nonsyndromic Patients Treated With a Novel Technique.

PURPOSE: Open cranial vault remodeling (CVR) with autologous split calvarial bone grafts redistributes and recontours an abnormal calvarium to create an expanded cranial vault in patients with craniosynostosis. We report a 12-year retrospective review of 162 nonsyndromic patients who underwent operative repair using our previously-described technique which portends excellent surgical outcomes and can be applied to patients of any age group and with any variety of suture fusion. METHODS: Data was gathered on patients who underwent CVR from 2005 to 2016. Surgical records for each patient were analyzed and included operative time, estimated blood loss, and intraoperative transfusion volumes. Intraoperative and postoperative complications, the need for revision surgery, postoperative length of stay, and follow-up records were also reviewed. Syndromic patients were excluded, as well as patients with incomplete data sets. Patients who underwent either anterior or posterior vault remodeling were compared. RESULTS: A total of 162 patients were included in this case series. Patients undergoing anterior CVR were significantly older than those undergoing posterior CVR (13.3 versus 11.0 months, P < 0.015) and also had significantly greater intraoperative red blood transfusion volumes (20.3 versus 15.3cc/kg, P < 0.0207) and longer operative time than posterior CVR patients (274.9 versus 216.7 minutes, P < 0.0001). No patients required reoperation for resorption or recurrence or persistent contour irregularities. There were no visual or neurological complications. Calvarial bone was successfully split in 100% of cases. CONCLUSIONS: This surgical approach to CVR results in good surgical outcomes with a low recurrence rate, while also maximizing operative efficiency, and minimizing total blood loss and transfusion volume. This technique can be applied to any affected suture in a patient with craniosynostosis and in patients of any age group.

Analysis of Immediate versus Delayed Sternal Reconstruction with Pectoralis Major Advancement Versus Turnover Muscle Flaps.

BACKGROUND: The pectoralis major muscle flap is a versatile reconstructive option for deep sternal wound infections (DSWI). The timing and surgical technique of bilateral pectoralis major muscle advancement flaps versus unilateral pectoralis major muscle turnover and unilateral pectoralis major muscle advancement flap on patient outcomes remain to be elucidated. The purpose of this investigation was to compare timing, immediate versus delayed reconstruction, and the surgical technique in patients with deep sternal wounds infections on patient outcomes. METHODS: A retrospective review of patients who underwent sternal reconstruction with pectoralis major muscle was conducted. Patients diagnosed with DSWI after undergoing cardiac surgery were included for analysis. Patients were divided by flap timing and flap type for analyses. Bivariate tests were performed to compare patient clinical characteristics. Outcomes of interest were rates of postoperative complications, same admission mortality, reoperation, readmission, operating room time, and length of stay. RESULTS: A total of 88 patients were included for analyses (n = 57 bilateral advancement, n = 31 unilateral advancement with unilateral turnover; n = 62 immediate, and n = 26 delayed). Baseline characteristics did not differ between groups of flap type or timing. When postoperative complication rates were compared, the rate of tissue necrosis was significantly greater in patients with unilateral advancement with unilateral turnover flaps (n = 6 [19.4%]) compared with bilateral advancement flaps (n = 2 [3.5%]; p = 0.021). Mortality during admission did not differ with respect to flap type but differed significantly with respect to flap timing (immediate n = 7 [11.3%], delayed n = 9 [34.6%]; p = 0.015). Length of stay differed significantly by both type and timing (type: bilateral advancement = 26.9 ± 22.6 days, unilateral turnover = 38.0 ± 26.7 days, p = 0.042; timing: immediate = 26.8 ± 22.1 days, delayed = 40.2 ± 27.8, p = 0.019). CONCLUSION: Patients who underwent pectoralis major muscle advancement flaps had lower incidence of tissue necrosis. Furthermore, the timing of immediate sternal reconstruction was associated with a decreased hospital length of stay.

Rank and Research: The Correlation Between Integrated Plastic Surgery Program Reputation and Academic Productivity.

BACKGROUND: Determinants of residency program reputation are multifactorial and include operative training, academic productivity, and geographic location. However, little is known about these relationships. This study aims to investigate the correlation between academic reputation of integrated plastic surgery programs and the research productivity of their respective full time faculty members. METHODS: Program rankings were identified from the 2016 Doximity standings and divided into 4 quartiles (Q1-Q4). Full-time faculty and program directors were identified through program websites. Publications by faculty members from 2000 to 2015 were identified through PubMed. Variables collected included affiliated institution, date of publication, authorship position, and journal. RESULTS: A total of 67 programs with 607 full-time faculty members were identified. Although not significantly different, program directors had a higher mean number of publications compared with faculty members for Q1, Q2, and Q4. Program departmental chairs had a significantly higher mean number of publications for Q1 and Q2. The Q1 faculty had a significantly higher mean number of publications as compared with Q2, Q3, and Q4. Although all quartiles had similar mean first author publications, Q1 and Q2 had more middle and last author publications. In addition, the higher-ranked programs were more likely to have faculty as middle authors of articles with more contributors. They were also more likely to publish in Plastic Reconstructive Surgery compared with other journals. CONCLUSIONS: Academic reputation of integrated plastic surgery residency programs is correlated with the scholarly activity of full-time faculty.

Putting our heads together: The future of craniopagus twin separation.

Computer-assisted design and computer-assisted modeling (CAD/CAM), virtual surgical planning (VSP) and augmented/virtual reality (AR/VR) aid our ability to plan and perform complex craniofacial procedures. This study seeks to define the role of the aforementioned techniques in the separation of craniopagus conjoined twins. Six teams were identified who had successfully performed craniopagus twin separation with the use of CAD/CAM, VSP and/or AR/VR. Surgeons involved in separating craniopagus twins have increasingly utilized tools such as CAD/CAM models, VSP and AR/VR to plan and execute successful separation, and these tools are associated with higher success rates than historical controls.

The Impact of Alar Flare Reduction Goes Beyond Just the Ala.

BACKGROUND: Alar flare reduction (AFR) is a widely used technique in rhinoplasty. Although the impact of AFR on the alar base has been well studied, its effect on the surrounding tissues is largely unknown. This study aims to elucidate the potential effect of AFR on the overall nasal and perinasal anatomy. METHODS: AFR was performed on cadavers ( n = 7) with sequential crescent-shaped alar excisions of 2, 4, and 6 mm. Two- and three-dimensional photographs were obtained at baseline and subsequent intervals. Analysis was performed with Adobe Photoshop and Vectra. Standardized landmarks were placed at the nasal tip point (NTP) and alar base point to quantify NTP vector distances, NTP surface distances, and alar crease angle. RESULTS: The surface and vector distances between the NTP and alar base point decreased for increasing AFR intervals. AFR created a surface decrease of 1.90 ± 1.60, 3.54 ± 1.85, and 4.91 ± 1.89 mm, respectively. AFR created a vector decrease of 1.50 ± 1.14, 2.83 ± 1.37, and 3.97 ± 1.38 mm, respectively. NTP projection decreased by 0.54 ± 0.31 mm for 6-mm excision. AFR led to cheek elevation of 0.87 ± 0.70, 1.25 ± 0.60, and 1.96 ± 0.48 mm, respectively. This alar crease elevation blunted the transition between the cheek and upper lip skin at the level of the alar rim with the angle of this transition increasing 26.62 ± 12.78 degrees from baseline to 6 mm. CONCLUSIONS: Three-dimensional analysis demonstrates the influence of AFR on the alar base and surrounding perinasal contour. AFR results in nasal tip deprojection, alar crease elevation, and alar flare width narrowing. Further investigation into the impact of modifying the alar base on surrounding structures is warranted.

Comparing Postoperative Taping vs Customized 3D Splints for Managing Nasal Edema after Rhinoplasty.

Background: Significant swelling after rhinoplasty can temporarily obscure results and lead to distress for patients and surgeons. We recently developed three dimensional (3D)-printed nasal splints that aim to protect the nose and limit edema by applying gentle compression. This prospective, randomized study compares postoperative nasal edema in patients being treated with traditional taping versus 3D-printed splints. Methods: Patients undergoing primary rhinoplasty (2019-2020) were randomized into two groups: taping versus 3D-printed splinting. For 12 weeks, patients either applied steri-strips to the dorsum and tip, or used 3D-printed splints, which were based on nasal simulations. The percentage change in volume (cm3) was calculated for the total nose, dorsum, and nasal tip at various time points. Results: Nasal taping (n = 34) demonstrated a volume reduction of 4.8%, 9.9%, 10.0%, 10.3%, and 10.6% (compared with baseline) at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year, respectively. In contrast, the resolution of swelling with 3D splints (n = 36) was 5.0%, 8.6%, 11.0%, 14.9%, and 15.1% at the same time points. Inter-group comparison showed that 3D splints led to significantly less edema of the total nose at 6 months and 1 year (P ≤ 0.05), as well as consistent reductions in the tip and dorsum, specifically (1 year, P ≤ 0.1, 0.01, respectively). Conclusions: 3D-printed splints after rhinoplasty leads to a significant reduction of edema, most noticeable at 6 months and 1 year. This study suggests that customized 3D-printed splints offer an effective clinical alternative to traditional taping to reduce postoperative edema after rhinoplasty.

Topical Tranexamic Acid Does Not Reduce The Incidence Of Hematoma In Reduction Mammoplasty: A Double-Blinded, Randomized Placebo-Controlled Trial.

BACKGROUND: Breast reduction mammoplasty (BRM) is among the most common procedures in plastic surgery, with a 1-7% postoperative hematoma incidence reported. Tranexamic acid (TXA) has been shown to reduce perioperative bleeding and need for transfusion when administered intravenously or topically, but remains underutilized in plastic surgery. This study aims to investigate whether topical administration of topical TXA reduces postoperative hematoma following BRM. METHODS: A double-blinded, randomized controlled trial of 98 patients (196 breasts) undergoing bilateral primary reduction mammoplasty at a single academic institution was performed. Patients were used as internal matched controls, with one breast randomized to receive 1000mg of topical TXA before closure, and the other receiving saline. All members of the surgical team and patient were blinded as to which breast received the study drug. Postoperative complications, including hematoma, within 30 days of surgery, drain outputs, and duration of drain use, were compared between treatment and placebo breasts. RESULTS: The overall hematoma rate was 1.5%. There was no significant association between application of TXA and development of a hematoma (p=0.56) or other complications. The hematoma rate of patients enrolled in the trial was similar to the overall rate of hematoma during the study time period (1.5% versus 2.4%, p=0.511). In a multivariate model, TXA was not significantly associated with differences in drain output after controlling for resection weight, age, and duration of drain use (p=0.799). No adverse effects or thromboembolic events from TXA were observed. CONCLUSION: Topical application of TXA does not decrease the incidence of hematoma following reduction mammoplasty.

Current Trends in Ideal Nasal Aesthetics Show Younger Patients Have a Preference Toward Longer Augmented Noses.

Background: Aesthetic norms fluctuate over time and often result in generational differences in preferred ideal nasal aesthetics. While some traditional concepts of the ideal nasal aesthetic have been suggested in our literature, there has been no study to date that has identified contemporary preferences across different age groups. Objectives: To understand the general population's current perception of ideal nasal profiles. Methods: Two-dimensional images of female noses (n = 10) of varying ethnicities were simulated to alter either the radix height or nasolabial angle (NLA) independently. Radix height was manipulated by increasing or decreasing the height by 5 mm relative to baseline. For NLA, 3 images were created with the following measurements: (1) 90°, (2) 100°, and (3) 110°. Groups were categorized by generation and age at the time of completing the study: Generation Z (Gen Z; age 18-23), Millennial 20s (age 24-30), Millennial 30s (age 31-39), and Generation X (Gen X; age 40-55). Each figure consisted of either 3 variations in radix height (n = 10) or 3 variations in NLA (n = 10). Within each figure, volunteers were asked to choose their preferred nose. Results: The younger generations, Gen Z and Millennial 20s and 30s, preferred a more augmented radix compared to Gen X which preferred a baseline radix height. Gen Z, Millennial 20s, and Gen X preferred a 90° NLA, while Millennial 30s preferred an NLA of 100°. Conclusions: The authors found that younger populations (Gen Z, Millennial 20s, and Millennial 30s) preferred a more augmented appearance to the nasal radix and, on average, a more acute NLA than published data suggest.

The "YouTube" method of correcting pixie ear and poor alar base inset.

It is well established that raw edges of the skin have a natural tendency to tube on themselves. Although this often presents a challenge for plastic surgeons, the following article demonstrates how the plastic surgeon can capitalize on this phenomenon to successfully recreate the natural appearance of curved anatomic elements. Two areas that are particularly susceptible to appearing "unnatural" after surgery are the earlobe and alar base. Herein, we present the concept of "autotubing" to recreate the natural curvature of these anatomic regions.

Virtual Surgical Planning and Three-Dimensional Printing in Rhinoplasty.

Recent developments in three-dimensional (3D) imaging technology offer a more comprehensive means of assessing facial features. 3D printing allows for the transition of planning from simply a preoperative tool to an intraoperative device with the use of tools such as 3D-printed cutting guides, marking guides, or positioning guides. With the advent of 3D printing technology, 3D surface images can now be used to generate new medical models, devices, or tools to assist with rhinoplasty during preoperative, intraoperative, and postoperative phases. In the field of rhinoplasty, 3D printing can be applied in three main areas: (1) reference models, (2) surgical guides, and (3) nasal splints. The value of 3D imaging extends far beyond the benefits of "conversion" during a preoperative consultation and has the potential to greatly enhance the overall treatment of rhinoplasty patients with enhanced communication and personalized devices that can be used during surgery and in the postoperative phase.

Intraoperative Navigation in Plastic Surgery with Augmented Reality: A Preclinical Validation Study.

BACKGROUND: Augmented reality allows users to visualize and interact with digital images including three-dimensional holograms in the real world. This technology may have value intraoperatively by improving surgical decision-making and precision but relies on the ability to accurately align a hologram to a patient. This study aims to quantify the accuracy with which a hologram of soft tissue can be aligned to a patient and used to guide intervention. METHODS: A mannequin's face was marked in a standardized fashion with 14 incision patterns in red and nine reference points in blue. A three-dimensional photograph was then taken, converted into a hologram, and uploaded to HoloLens (Verto Studio LLC, San Diego, Calif.), a wearable augmented reality device. The red markings were then erased, leaving only the blue points. The hologram was then viewed through the HoloLens in augmented reality and aligned onto the mannequin. The user then traced the overlaid red markings present on the hologram. Three-dimensional photographs of the newly marked mannequin were then taken and compared with the baseline three-dimensional photographs of the mannequin for accuracy of the red markings. This process was repeated for 15 trials (n = 15). RESULTS: The accuracy of the augmented reality-guided intervention, when considering all trials, was 1.35 ± 0.24 mm. Markings that were positioned laterally on the face were significantly more difficult to reproduce than those centered around the facial midline. CONCLUSIONS: Holographic markings can be accurately translated onto a mannequin with an average error of less than 1.4 mm. These data support the notion that augmented reality navigation may be practical and reliable for clinical integration in plastic surgery.

Progenitor cell trafficking is regulated by hypoxic gradients through HIF-1 induction of SDF-1.

The trafficking of circulating stem and progenitor cells to areas of tissue damage is poorly understood. The chemokine stromal cell-derived factor-1 (SDF-1 or CXCL12) mediates homing of stem cells to bone marrow by binding to CXCR4 on circulating cells. SDF-1 and CXCR4 are expressed in complementary patterns during embryonic organogenesis and guide primordial stem cells to sites of rapid vascular expansion. However, the regulation of SDF-1 and its physiological role in peripheral tissue repair remain incompletely understood. Here we show that SDF-1 gene expression is regulated by the transcription factor hypoxia-inducible factor-1 (HIF-1) in endothelial cells, resulting in selective in vivo expression of SDF-1 in ischemic tissue in direct proportion to reduced oxygen tension. HIF-1-induced SDF-1 expression increases the adhesion, migration and homing of circulating CXCR4-positive progenitor cells to ischemic tissue. Blockade of SDF-1 in ischemic tissue or CXCR4 on circulating cells prevents progenitor cell recruitment to sites of injury. Discrete regions of hypoxia in the bone marrow compartment also show increased SDF-1 expression and progenitor cell tropism. These data show that the recruitment of CXCR4-positive progenitor cells to regenerating tissues is mediated by hypoxic gradients via HIF-1-induced expression of SDF-1.

Use of virtual 3-dimensional surgery in post-traumatic craniomaxillofacial reconstruction.

Traumatic craniofacial injuries often present as difficult reconstructive challenges for maxillofacial surgeons. Reconstruction is often complicated by significant soft tissue loss, comminuted bony fragments, a tenuous blood supply, and wound contamination. For panfacial injuries, restoration of normal facial width, facial height, and sagittal projection may be difficult to achieve. Marked swelling may limit the surgeons' ability to palpate and recognize subtle bony defects and malunion. Furthermore, a true 3-dimensional assessment of bony alignment may not be possible with traditional surgical exposures to the craniofacial skeleton. This article builds on previous work that introduced the use of 3-dimensionally guided surgery for microvascular free-flap reconstruction of the craniofacial skeleton. Use of this technology improves the planning, timing, and overall precision of microvascular reconstructive surgery. Based on this experience, a similar approach to reconstructing patients with significant craniofacial trauma has been adopted.

Labioplasty: anatomy, etiology, and a new surgical approach.

Increasing numbers of women are seeking correction of labial hypertrophy for aesthetic and/or functional reasons. It is therefore important for plastic surgeons to become familiar with labioplasty surgical techniques. The authors review the history and current status of labioplasty surgery for practicing plastic surgeons, with particular emphasis on anatomy, diagnosis, indications, and various techniques.

Three-Dimensional Facial Scanning at the Fingertips of Patients and Surgeons: Accuracy and Precision Testing of iPhone X Three-Dimensional Scanner.

BACKGROUND: The iPhone X (Apple, Inc., Cupertino, Calif.) is the first smartphone to be released with a high-fidelity three-dimensional scanner. At present, half of all U.S. smartphone users use an iPhone. Recent data suggest that the majority of these 230 million individuals will upgrade to the iPhone X within 2 years. This represents a profound expansion in access to three-dimensional scanning technology, not only for plastic surgeons but for their patients as well. The purpose of this study was to compare the iPhone X scanner against a popular, portable three-dimensional camera used in plastic surgery (Canfield Vectra H1; Canfield Scientific, Inc., Parsippany, N.J.). METHODS: Sixteen human subjects underwent three-dimensional facial capture with the iPhone X and Canfield Vectra H1. Results were compared using color map analysis and surface distances between key anatomical landmarks. To assess repeatability and precision of the iPhone X three-dimensional scanner, six facial scans of a single participant were obtained and compared using color map analysis. In addition, three-dimensionally-printed facial masks (n = 3) were captured with each device and compared. RESULTS: For the experiments, average root mean square was 0.44 mm following color map analysis and 0.46 mm for surface distance between anatomical landmarks. For repeatability and precision testing, average root mean square difference following color map analysis was 0.35 mm. For the three-dimensionally-printed facial mask comparison, average root mean square difference was 0.28 mm. CONCLUSIONS: The iPhone X offers three-dimensional scanning that is accurate and precise to within 0.5 mm when compared to a commonly used, validated, and expensive three-dimensional camera. This represents a significant reduction in the barrier to access to three-dimensional scanning technology for both patients and surgeons.