Preferred Nasolabial Angle in Rhinoplasty: A Cross-Sectional Analysis.

BACKGROUND: The perception of an ideal nose is influenced by a variety of factors, with demographic characteristics playing a significant role in what is considered an ideal nose. The nasolabial angle (NLA) is considered one of the defining features shaping the nose. OBJECTIVES: In this study we set out to capture the perception of the ideal nasolabial angle among Canadian, Saudi, Kuwaiti, and Lebanese populations. METHODS: An online questionnaire-based cross-sectional study was conducted to investigate the ideal nasolabial angle among Canadian, Saudi, Kuwaiti, and Lebanese populations (n = 197). Participants were patients attending outpatient clinics, plastic surgery residents, and medical students. The questionnaire included demographics and the perception of respondents of the ideal NLA for each gender: male (85°, 90°, 95°, 100°, 110°) and females (95°, 100°, 110°, 115°). RESULTS: The majority of respondents were female (81.2%), ages between 20 and 39 (84.3%). The mean and standard deviation of ideal NLA choices in both male and female models were 97.1 ± 6.39 and 109.5 ± 5.32, respectively. The ideal male NLA choices were found to correlate significantly with age (P = .044) and work status (P = .019). In choosing the ideal female NLA, age was a significant factor (P = .012). CONCLUSIONS: Identifying the ideal NLA is essential to establishing aesthetic goals for patient and surgeon alike. It is important to understand the effects of demographics on the choice of the ideal NLA, which ultimately influences the planning and outcome of the rhinoplasty procedure.

The Effect of Tranexamic Acid Administration During Liposuction on Bleeding Complications and Ecchymosis: A Systematic Review.

Liposuction is the most frequently performed cosmetic procedure. Tranexamic acid (TXA) has emerged as a promising blood loss reducing agent in plastic surgery, but its value in liposuction is still being studied. This systematic review investigates the safety and efficacy of TXA in reducing blood loss during liposuction procedures. A systematic review of PubMed (US National Library of Medicine, Bethesda, MD), MEDLINE (US National Library of Medicine), EMBASE (Elsevier, Amsterdam, the Netherlands), and Cochrane databases (Wiley, Hoboken, NJ) from inception to June 2023 was performed. The primary objective was to compare blood loss, hematoma rate, and ecchymosis from liposuction procedures in patients who received TXA versus those who did not. The secondary objective was to assess the incidence of TXA-related complications. A total of nine studies were included, published between 2018 and 2023 of which eight were prospective and one was retrospective. A total of 345 intervention versus 268 control arms were compared. Follow-up time ranged from 1-14 days. Mean age, and mean BMI ranged from 33 - 50 years, 23 to 30 kg/m2, respectively. Blood loss in aspirate was significantly less with TXA administration assessed by five studies (p < 0.05). Of the five studies that assessed the incidence of ecchymosis, all reported less bruising with TXA use. Among all the studies, only one found post-operative complications with five patients requiring transfusion in the control group (without TXA). The evidence provided in the literature suggests that TXA use in liposuction is safe and effective for reducing blood loss and ecchymosis with IV and local administration.

Aesthetic Surgery Before-and-After Photography Bias on Instagram.

PURPOSE: This study aims to systematically assess body and facial aesthetic surgery before-and-after photography bias on Instagram. METHODS: An Instagram search using the term "plastic surgeon" was conducted on October 2020. The top 11 plastic surgeons' accounts were selected, and the first 15 images were selected from these profiles pertaining to different anatomical locations. Each photo was analyzed by a blinded board-certified plastic surgeon utilizing a 5-domain clinical photography bias score. The domains covered: (1) photo quality; (2) photo background; (3) position; (4) exposure/coverage; (5) bias. RESULTS: The search strategy identified a total of 161 sets of before and after. The most common anatomical site posted was the nose (n=47), followed by breasts (n=37). The most common angles posted were anterior-posterior view (n=61). The majority of images showed bias toward the post-operative image (70.8%). The main culprit with photo characteristics occurred due to there being a different post-operative background which was more flattering for the post-operative result (n=46, p=0.006) and a different view or angle, which again, flattered the post-operative image (n=36, p=0.02). Other factors that influenced the post-operative bias included photos of the patient covered with clothing (n=15, p=0.014) or standing (n=20, p=0.001), compared to a supine pre-operative image. CONCLUSION: Before-and-after photography conditions in aesthetic surgery is biased toward the post-operative result on Instagram. This observation was noticed across all surgical anatomical areas. Accounts photographer tends to misrepresent the photo background, view of angle, patients pose or position, or covering certain body parts. LEVEL OF EVIDENCE IV: 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Methodological Quality of Open Access Compared to Traditional Journal Publications in the Plastic Surgery Literature.

BACKGROUND: The methodological quality of open access studies has long been questioned due to increasing popularity and accessibility. The objective of this study is to compare the methodological quality of open access versus traditional journal publications in the plastic surgery literature. METHODS: Four traditional plastic surgery journals with their sister open access journals were chosen. For each of the eight journals, 10 articles were randomly selected for inclusion. Methodological quality was examined using validated instruments. Publication descriptors were compared to methodological quality values using ANOVA. Logistic regression was used to compare quality scores between open access and traditional journals. RESULTS: There was a wide distribution of levels of evidence, with a quarter being level one. Regression of non-randomized studies indicated a significantly higher proportion of traditional journal articles were of high methodological quality (89.6%) when compared to open access journals (55.6%; p < 0.05). This difference persisted in three quarter of the sister journal groups. No publication descriptions were associated with methodological quality. CONCLUSIONS: Methodological quality scores were higher among traditional access journals. Higher degrees of peer review may be necessary to ensure appropriate methodological quality in open access plastic surgery publications. 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Outcomes of Free Muscle Flaps versus Free Fasciocutaneous Flaps for Lower Limb Reconstruction following Trauma: A Systematic Review and Meta-Analysis.

BACKGROUND: Free flap reconstruction of the lower limb following trauma often suffers higher complication rates than other areas of the body. The choice of muscle or fasciocutaneous free flap is an area of active debate. METHODS: A systematic review of EMBASE, MEDLINE, PubMed, and Cochrane Register from inception to April 1, 2022 was performed. Articles were assessed using the methodological index for non-randomized studies instrument. The primary outcome was to assess and compare the major surgical outcomes of partial or total flap failure, reoperation, and amputation rates. RESULTS: Seventeen studies were included. All studies were retrospective in nature, of level three evidence, and published between 1986 and 2021. The most common muscle and fasciocutaneous free flaps used were latissimus dorsi flap (38.1%) and anterolateral thigh (ALT) flap (64.8%), respectively. Meta-analysis found no significance difference in rates of total flap failure, takeback operations, or limb salvage, whereas partial flap failure rate was significantly lower for fasciocutaneous flaps. The majority of studies found no significant difference in complication rates, osteomyelitis, time to fracture union, or time to functional recovery. Most, 82.4% (14/17), of the included studies were of high methodological quality. CONCLUSION: The rate of total flap failure, reoperation, or limb salvage is not significantly different between muscle and fasciocutaneous free flaps after lower limb reconstruction following trauma. Partial flap failure rates appear to be lower with fasciocutaneous free flaps. Outcomes traditionally thought to be managed better with muscle free flaps, such as osteomyelitis and rates of fracture union, were comparable.

Simplified Technique for Creating an Umbilicus with Scarless Caudal Aspect and Superior Hooding.

A non-aesthetic post-abdominoplasty umbilicus is known to be a significant concern for many patients who consider this procedure, due to its central and visible location. The goal of this method is to minimize the visible scar and create a natural-looking and aesthetically pleasing umbilicus. In this multimedia article, we illustrate our technique that is both reproducible and easy to perform. It produces a scarless caudal aspect, pleasant depth, and natural superior hooding appearance to the post-op umbilicus. Limitations of this technique are discussed.Level of Evidence IV 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Breast Equalization Augmentation: The Use of Ultrasonic Assisted Liposuction for Correction of Primary Breast Asymmetry with Bilateral Augmentation.

BACKGROUND: The purpose of this study was to determine the effectiveness of using ultrasonic assisted liposuction (UAL) to achieve sufficient breast symmetry allowing for the use of same sized implants in patients presenting for elective breast augmentation surgery. METHODS: A retrospective review was performed of patients presenting for augmentation mammoplasty with breast asymmetry who underwent ultrasonic assisted liposuction in combination with implant augmentation. Pre-operative differences in breast volumes were determined using water displacement, and these measurements were compared to final lipoaspirates required to achieve symmetry. To estimate the volume of lipoaspirate required, we suggested to aim for twice the volume difference obtained by water displacement. The success of the procedure was measured by the ability to use the same size implants bilaterally. RESULTS: A total of 35 patients were included in this review. In 85% of patients, UAL was sufficient to permit the use of equally sized implants bilaterally. However, when different sized implants were required, the size difference between implants was not greater than 25 cc. The UAL was also effective in correcting minor ptosis and nipple position. The main observed disadvantage was prolonged bruising and swelling. CONCLUSION: The use of UAL for correction of primary breast asymmetry with bilateral breast augmentation allows balancing of breast tissue volumes and the use of same size implants and eliminates the need for balancing mastopexy procedures. LEVEL OF EVIDENCE IV: 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Autologous Versus Alloplastic Reconstruction for Patients with Obesity: A Systematic Review and Meta-analysis.

BACKGROUND: Autologous flaps may have superior outcomes when compared to implant breast reconstruction in patients with obesity. To date, no published review has illustrated the superiority of autologous to implant-based reconstruction in this study group in terms of aesthetics outcomes and surgical complications. METHODS: A systematic search was conducted on PubMed, Cochrane, Google Scholar, and Embase from inception to December 31, 2020. Studies comparing the outcomes (patient satisfaction and complications) of autologous versus implant-based reconstruction in patients with BMI > 30 were selected. RESULTS: The search yielded 1633 articles, of which 76 were assessed in full text. A total of 12 articles fit inclusion for qualitative review; of them, 7 were meta-analyzed. Autologous reconstruction had a lower incidence of infection (OR 0.74 [95% CI 0.59, 0.92]), hematoma/seroma formation (OR 0.34 [95% CI 0.23, 0.49]), and reconstructive failure (OR 0.47 [95% CI 0.36, 0.62]), but not skin necrosis (OR 0.95 [95% CI 0.73, 1.25]) or wound dehiscence (OR 1.03 [95% CI 0.72, 1.49]) when compared to implant-based reconstruction. Deep vein thrombosis (DVT) and pulmonary embolism occurred more frequently with autologous versus alloplastic reconstruction (OR 2.21 [95% CI 1.09, 4.49] for DVT and OR 2.49 [95% CI 1.13, 5.48] for PE). BREASTQ scores were higher for the autologous breast reconstruction when compared to implant-based group, but failed to reach significance (p value >0.05). CONCLUSION: The current evidence in the literature suggests that autologous breast reconstruction has lower surgical complication rate when compared to implant-based reconstruction at the expense of higher risk of thrombotic complications for patients with BMI > 30. LEVEL OF EVIDENCE III: 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Is Orbicularis Oculi Muscle Resection Necessary in Upper Blepharoplasty? A Systematic Review.

BACKGROUND: Our objective is to evaluate the evidence on the aesthetic effect and complications of skin-OOM strip resection compared to skin only upper blepharoplasty. METHODS: A systematic search of EMBASE, PubMed, Cochrane and Google Scholar databases was performed using our search strategy through to 31 December 2019. Only comparative studies of the two upper blepharoplasty techniques were included. Three reviewers performed study selection process, data extraction, and quality assessment. RESULTS: A total of six articles were eligible for final inclusion. The included studies consist of two controlled retrospective cohorts and four small randomized controlled studies (RCT). Three of which, were double blinded. Those RCTs were assigned level 2 evidence due to small size and methodological limitations. The sample size of included was studies 407 in the two retrospective studies and 57 in the four RCTs. The outcomes showed that resection of OOM along with skin in upper blepharoplasty showed no difference in long-term aesthetic outcome when skin only procedure is performed. Muscle strip resection was associated with initially higher ophthalmological morbidity (edema, bruising, pain, dry eye, sluggish eye closure and lagopthalmos). Those resolved a few weeks later with conservative treatment. CONCLUSION: The resection of OOM along with skin in upper blepharoplasty showed no difference in long-term aesthetic outcome and was associated with initially higher ophthalmological morbidity compared to skin only procedure. While we are not suggesting that OOM resection is never required, the evidence strongly support its preservation during standard upper blepharoplasty. LEVEL OF EVIDENCE III: 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 the online Instructions to Authors www.springer.com/00266 .

Body Contouring Surgery Improves Weight Loss after Bariatric Surgery: A Systematic Review and Meta-Analysis.

INTRODUCTION: Our main objective is to evaluate the effect of body contouring surgery (BCS) on the magnitude and durability of weight loss after bariatric surgery. METHODS: Medline, EMBASE, Cochrane, and Scopus search were conducted from the time of their inception to June 2020. We included comparative studies that assessed weight progression, in terms of Body Mass Index change (∆BMI), Total Body Weight Loss (TBWL%), and Excess Weight Loss (%EWL) for the post-bariatric patient population and the effect of BCS on weight progression. RESULTS: Eleven articles were included. The pooled sample size was 2307, of which 691 were cases who underwent BCS post-bariatric surgery, and 1616 were comparative controls. The mean follow-up time for cases and controls were 61.6 ± 23.8 months and 52.2 ± 23.8 months, respectively. Nine studies reported results of BMI changes, six provided %EWL, and five used %TBWL. Significant improvement in weight loss was observed in the BCS group when measured by either ∆BMI (3 kg/m2 points decrease, p 0.023), %TBWL (6% increase, P < 0.0001), or %EWL (14% increase, P < 0.0001). Sub-group analysis showed that increased follow-up time was associated with higher TBWL% (p 0.02). CONCLUSION: The evidence provided in this review strongly supports the added long-term benefits of body contouring surgery for selected patients after massive weight loss following bariatric surgery. Having a multidisciplinary team that involves a bariatric and a plastic surgeon as well as nutritionists and psychologists for the management of patients with obesity going through the bariatric pathway is recommended. LEVEL OF EVIDENCE III: 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266.