Hematoma After Non-Oncologic Breast Procedures: A Comprehensive Review of the Evidence.

BACKGROUND: Hematoma after non-oncologic breast surgery is a common concern requiring expeditious treatment. The purpose of this study is to perform an evidence-based review of perioperative factors that may contribute to hematoma in non-oncologic breast procedures. METHODS: A comprehensive literature review was performed of non-oncologic breast procedures: breast augmentation, single-stage augmentation-mastopexy, mastopexy, and reduction. In total, 28 studies highlighting incidence and potential risk factors for hematoma were included; overall level of evidence was established regarding each perioperative factor examined and hematoma rate. RESULTS: The hematoma rate in breast augmentation ranges from 0.2 to 5.7%. There is inconclusive evidence to support an association between pocket choice or incision location and hematoma rate (Level III) and no evidence of an association between implant type and hematoma (Level V). Single-stage augmentation-mastopexy may have a lower hematoma rate than augmentation alone (Level II). Hematoma may increase the risk of capsular contracture (Level III). In breast reduction, the hematoma rate ranges from 1.0 to 9.3%. Evidence of an association between incision choice and hematoma rate is inconclusive (Level III). Use of epinephrine-containing solution, pedicle choice, and resection weight do not appear to affect hematoma rate (Level V, II, and II, respectively). The use of postoperative drains and ketorolac do not affect the incidence of hematoma (Level I and III, respectively). Intraoperative hypotension may increase the risk of hematoma after breast reduction (Level III). CONCLUSIONS: Breast hematomas are not uncommon complications. Current literature lacks ample evidence for risk factors for hematoma after non-oncologic breast procedures, warranting further, high-powered investigations. 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 .

Le Fort III Distraction With Internal vs External Distractors: A Cephalometric Analysis.

OBJECTIVE: This study compares the change in midface position following Le Fort III advancement using either rigid external distraction (group 1) or internal distraction (group 2). We hypothesized that, with reference to right-facing cephalometry, internal distraction would result in increased clockwise rotation and inferior displacement of the midface. DESIGN: Le Fort III osteotomies and standardized distraction protocols were performed on 10 cadaveric specimens per group. Right-facing lateral cephalograms were traced and compared across time points to determine change in position at points orbitale, anterior nasal spine (ANS), A-point, and angle ANB. SETTING: Institutional. PATIENTS, PARTICIPANTS: Twenty cadaveric head specimens. INTERVENTIONS: Standard subcranial Le Fort III osteotomies were performed from a coronal approach and adequately mobilized. The specified distraction mechanism was applied and advanced by 15 mm. MAIN OUTCOME MEASURE(S): Changes of position were calculated at various skeletal landmarks: orbitale, ANS, A-point, and ANB. RESULTS: Group 1 demonstrated relatively uniform x-axis advancement with minimal inferior repositioning at the A-point, ANS, and orbitale. Group 2 demonstrated marked variation in x-axis advancement among the 3 points, along with a significant inferior repositioning and clockwise rotation of the midface ( P < .0001). CONCLUSION: External distraction resulted in more uniform advancement of the midface, whereas internal distraction resulted in greater clockwise rotation and inferior displacement. External distraction appears to provide increased vector control of the midface, which is important in creating a customized distraction plan based on the patient's individual occlusal and skeletal needs.

Customized "In-Office" Three-Dimensional Printing for Virtual Surgical Planning in Craniofacial Surgery.

BACKGROUND: Virtual surgical planning using three-dimensional (3D) printing technology has improved surgical efficiency and precision. A limitation to this technology is that production of 3D surgical models requires a third-party source, leading to increased costs (up to $4000) and prolonged assembly times (averaging 2-3 weeks). The purpose of this study is to evaluate the feasibility, cost, and production time of customized skull models created by an "in-office" 3D printer for craniofacial reconstruction. METHODS: Two patients underwent craniofacial reconstruction with the assistance of "in-office" 3D printing technology. Three-dimensional skull models were created from a bioplastic filament with a 3D printer using computed tomography (CT) image data. The cost and production time for each model were measured. RESULTS: For both patients, a customized 3D surgical model was used preoperatively to plan split calvarial bone grafting and intraoperatively to more efficiently and precisely perform the craniofacial reconstruction. The average cost for surgical model production with the "in-office" 3D printer was $25 (cost of bioplastic materials used to create surgical model) and the average production time was 14  hours. CONCLUSIONS: Virtual surgical planning using "in office" 3D printing is feasible and allows for a more cost-effective and less time consuming method for creating surgical models and guides. By bringing 3D printing to the office setting, we hope to improve intraoperative efficiency, surgical precision, and overall cost for various types of craniofacial and reconstructive surgery.

Are our publications failing the inspection?: a review of the publications in rectal cancer surgery between 2002 and 2012.

BACKGROUND: Quality of publications is considered a subjective measurement, and more weight is placed on prospective studies, especially randomized clinical trials and meta-analyses. OBJECTIVE: This study describes the type of publications and evaluates the quality of randomized clinical trials and review articles using an objective measurement. DATA SOURCES: Medline (PubMed) is the data source for this work. STUDY SELECTION: We used the terms "rectal neoplasms/surgery" and the filters "10 years," "humans," and "English." MAIN OUTCOME MEASURES: We measured compliance with checklist items. Randomized clinical trials were reviewed using the Consolidates Standards of Reporting Trials statement; systematic reviews/meta-analyses were reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. RESULTS: A total of 3603 articles were identified: 20.8% were case report/series, 20.5% were retrospective cohorts, 14.0% were reviews or meta-analyses, 16.4% were prospective cohorts, 14.0% were other types of articles (comments, letters, or editorials), 5.5% were clinical trials (phase I/II), 4.2% were randomized clinical trials, and 4.4% were cross-sectional studies. We reviewed 108 randomized clinical trials; the maximum score possible was 74.0, the average score was 44.6 (range, 20.0-64.0), 4 (3.7%) were graded as "excellent," 21 (19.4%) were "good," 44 (40.7%) were "deficient," and 39 (36.1%) were graded as "fail." The predictors of higher scores for randomized clinical trials were year of publication after 2007 (p = 0.00), higher impact factor (p = 0.03), and declared funding (p = 0.01). Twenty-nine meta-analyses were reviewed; the average score was 19.64 (range, 12.0-25.0); 5 articles (17.2%) were graded as "excellent," 12 (41.4%) were "good," 10 (34.5%) were "deficient," and 2 (6.9%) were "fail." LIMITATIONS: Only 1 electronic database was used, so we lacked a validated score. In addition, the search terms did not include "colorectal." CONCLUSIONS: A total of 20.8% of the articles published were case reports and 25.0% of the articles were prospective or clinical trials. Although randomized clinical trials and systematic reviews provide the highest level of evidence, publications with missing data limit replication of the study and affect the generalizability of results to other populations. To improve the quality of our publications, authors, reviewers, and journal editors should consider the endorsement of standardize checklists.

Revision Rhinoplasty Finesse with Digital Osteotomies.

SUMMARY: Revision rhinoplasty is a finesse procedure requiring careful consideration of all of its requisite steps. Lateral osteotomies are required in many cases and, in the setting of prior lateral osteotomies, can often be recreated with digital pressure alone, without the use of an osteotome. The advantages of doing so include decreased dead-space creation and preservation of attachments between the skeleton and overlying soft tissue.

Neuromodulator Finesse for Masseter Hypertrophy and Bruxism.

SUMMARY: A particularly prominent mandibular angle or a hypertrophied masseter muscle can result in an excessively wide facial appearance, which some individuals may find less aesthetically pleasing. Although normally a benign condition and strictly an aesthetic concern, a hypertrophied masseter can also cause pain, bruxism, and headaches. Neuromodulator for masseter reduction and treatment of bruxism has become first-line treatment. In this article, the authors present the senior author's (R.J.R.) anatomic approach to neuromodulator injection of the masseter, with a corresponding video of the injection technique.

Neuromodulator Injection for Gummy Smile.

SUMMARY: Neuromodulators have become a treatment of choice for the management of excess gingival show, or "gummy smile." There have been many proposed algorithms for the optimal placement and dosage of neuromodulator to inject in these locations. The authors aim to clarify these points and provide surgeons with a reliable way to manage the gummy smile that results from hyperactive muscles of the midface.

Incidental Abdominal Wall Endometriosis in Plastic Surgery: Two Cases and Review of the Literature.

Endometriosis is a common cause of pain and infertility. Abdominal wall endometriosis (AWE) is a form of extrapelvic endometriosis that can be encountered during abdominal surgery such as abdominoplasty or free flap harvest. We report two cases of AWE; one found intraoperatively in a 32-year-old woman desiring body contouring after undergoing cesarean section, and a second in a 36-year-old woman requiring resection and reconstruction of a left chondroid tenosynovial giant cell tumor of her temporomandibular joint. During free flap planning, she was found to have endometriosis of her right hemi-abdomen. Both patients underwent resection of their AWE and were referred to their obstetrics and gynecology physicians for consideration of menstrual suppression to decrease their risk of recurrence.

Pitanguy Ligament Preservation in Structural Precision Rhinoplasty.

The Pitanguy ligament is a crucial structure in nasal tip support and in maintaining the integrity of the soft tissue envelope of the nose. In this cadaveric study, we dissected out the Pitanguy ligament on a series of fresh human cadaver specimens to better elucidate the structure of the ligament and its fate in open rhinoplasty. The Pitanguy ligament can act as a tethering force to the nasal tip when reshaping the nasal tip. Release of the Pitanguy ligament alleviated downward tension on the nasal tip, and tip shaping to a more appropriate position demonstrated that this ligament was displaced from its ideal position. In patients seeking rhinoplasty, this structure may require release and reconstruction to successfully alter tip position and avoid supratip deformity.

Systematic Review of Capsular Contracture Management following Breast Augmentation: An Update.

BACKGROUND: Capsular contracture is one of the most frequent indications for revision following breast augmentation. Management goals focus on restoring breast aesthetics and minimizing subsequent recurrence of capsular contracture. As new data emerge, close review of the data are merited to build evidence-based clinical guidelines to inform surgical practice and management of capsular contracture. METHODS: A systematic review of the MEDLINE, Embase, and Cochrane Database of Systematic Reviews databases was conducted to characterize the surgical management of capsular contracture in revision breast augmentations. The primary endpoint was capsular contracture recurrence rate. RESULTS: The review was conducted in November of 2021. Primary search revealed 14,163 results. Initial screening by title left 1223 articles. Abstract review left 90 articles for full-text review, of which 34 were ultimately included and were all observational in nature. CONCLUSIONS: Capsular contracture management remains an important topic, with limited high-level evidence for establishing clear evidence-based treatment guidelines. Although more evidence is required to assess the effects of capsulectomy, implant exchange, and plane change, these appear to be useful mechanisms for reducing recurrent capsular contracture. There is more evidence regarding the use of acellular dermal matrix, although this still requires long-term follow-up studies. New developments regarding textured implants limit the revision breast augmentation surgeon to smooth devices.

Refinements in Component Dorsal Reshaping in Primary Rhinoplasty.

SUMMARY: Dorsal reduction and reshaping is an essential part of many rhinoplasty procedures. The steps of component dorsal reduction have been well established. The authors describe refinement of the dorsal reshaping process to improve the quality and consistency of results.

Management of the Post Hemangioma Nose - 5 Key Rhinoplasty Components.

Hemangiomas of the nasal tip are a relatively uncommon presentation of a common tumor. While optimal medical and surgical management of nasal tip infantile hemangiomas has been described and debated extensively in the literature, to our knowledge, there is no report of secondary aesthetic and functional rhinoplasty in these patients at skeletal maturity until now. This special topic provides an excellent example of the five key technical elements to revision rhinoplasty in the skeletally mature patient with history of nasal tip infantile hemangioma.

Finesse Buccal Fat Pad Excision.

SUMMARY: The buccal fat pad has long been noted for its complex anatomy and its significance to facial aesthetics. Its bulk is mostly deep facial fat immediately superficial to the buccinator muscle. The buccal fat pad has a main body and four extensions: buccal, pterygoid, superficial temporal, and deep temporal. It can be removed in patients with round, heavy faces and anterior buccal fullness to slim the lower face and contour the jawline. This article describes the authors' technique for buccal fat pad removal, with a goal of conservative fat pad reduction.

Differential Fat Grafting to Address Facial Asymmetry in Facelifting.

The modern facelift is a complex operation involving the repositioning of tissues and the refilling of volume atrophy. Preoperative analysis is key to the successful diagnosis of aging changes. Facial asymmetry is universal, and must be recognized and incorporated into surgical planning. In this paper, we address the role of fat grafting to manage facial aging in the setting of facial asymmetry.

Lip Lifting: The Missing Link in Central Facial Rejuvenation.

The lip lift is a powerful yet finesse operation in the realm of facial rejuvenation. In an era of booming non-surgical lip augmentation, the astute plastic surgeon must identify which patients will end up with a dreaded unnatural appearance should they receive volume enhancement alone in pursuit of central facial and perioral rejuvenation. In this paper, we review the ideal youthful lips, the characteristics of the aged lip and indications for lifting. We present our preferred surgical technique, the underlying principles that it respects, and adjunct procedures to optimize results in central facial rejuvenation.

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.

Longevity of ptosis correction in mastopexy and reduction mammaplasty: A systematic review of techniques.

Background: Mastopexy and reduction mammaplasty are commonly performed procedures in plastic surgery with many variations in incision pattern, pedicle design, and additional support maneuvers. Aesthetically pleasing on table results are widely accomplished; however, the longevity of the outcome and sustained correction of ptosis or pseudoptosis is not universal. A systematic review of mastopexy and reduction mammaplasty procedures was performed to investigate which techniques provided the greatest long-term correction of ptosis. Methods: A broad search of the literature was performed using the PubMed database from inception to December of 2021. Study characteristics, number of patients, number of breasts, technique, outcome, and average follow-up time were extracted for analysis. Study quality was assessed using the Newcastle-Ottawa Scale when applicable. Results: The primary search yielded 1123 articles. After two levels of screening, 24 articles were identified for analysis. This included 16 case series, seven cohort studies, and one randomized controlled study. From these studies, 1235 patients and 2235 breasts were analyzed. The majority of articles reported on a change in the nipple to inframammary fold and sternal notch to nipple distances. Conclusions: In the analytical studies, superior and superomedial pedicles tended to provide greater long-term stability than inferior pedicles. Mesh, dermal suspension flaps, and muscular slings showed promise in providing additional support over standard techniques. No single procedure is ideal for all patients; however, this systematic review provides a valuable description of techniques and long-term outcomes to guide surgical planning.

Platelet rich plasma for photodamaged skin: A pilot study.

INTRODUCTION: Despite increasing popularity of platelet-rich plasma (PRP) in treating aging facial skin, the quality of evidence supporting its use is poor due to the lack of consistent methods of its preparation and application. OBJECTIVE: This study was conducted to assess treatment efficacy and patient satisfaction with a single PRP treatment prepared with a simplified preparation and application technique. METHODS: Four millilitre of PRP were injected into 6 standardized points on each side of the face. Outcomes were assessed by independent physician evaluation of pretreatment and posttreatment photographs using the Wrinkle Severity Rating Scale (WSRS) and Global Aesthetic Improvement Scale (GAIS). In addition, patient-reported outcomes were evaluated using the FACE-Q. RESULTS: Thirty-one participants ranging from 27 to 71 years of age (median, 38; IQR 32-58) were recruited for this study. Posttreatment WSRS scores improved in only 1 patient; the GAIS scores of 14 patients indicated aesthetic improvement. Analysis of FACE-Q scores revealed statistically significant increases in participant satisfaction with overall facial appearance and cheeks. The most frequently reported adverse effects were tenderness (23.4%; 7 of 31), facial tightness (20.0%; 6 of 31), and swelling (20.0%; 6 of 31). CONCLUSIONS: A simple method of PRP preparation offers modest benefit in treating the effects of skin aging and photodamage. Future research studies should alter our methods using a stepwise approach to optimize the treatment of aging facial skin with PRP.

Evolution in Monitoring of Free Flap Autologous Breast Reconstruction after Nipple-Sparing Mastectomy: Is There a Best Way?

BACKGROUND: Free flap monitoring in autologous reconstruction after nipple-sparing mastectomy remains controversial. The authors therefore examined outcomes in nipple-sparing mastectomy with buried free flap reconstruction versus free flap reconstruction incorporating a monitoring skin paddle. METHODS: Autologous free flap reconstructions with nipple-sparing mastectomy performed from 2006 to 2015 were identified. Demographics and operative results were analyzed and compared between buried flaps and those with a skin paddle for monitoring. RESULTS: Two hundred twenty-one free flaps for nipple-sparing mastectomy reconstruction were identified: 50 buried flaps and 171 flaps incorporating a skin paddle. The most common flaps used were deep inferior epigastric perforator (64 percent), profunda artery perforator (12.1 percent), and muscle-sparing transverse rectus abdominis myocutaneous flaps (10.4 percent). Patients undergoing autologous reconstructions with a skin paddle had a significantly greater body mass index (p = 0.006). Mastectomy weight (p = 0.017) and flap weight (p < 0.0001) were significantly greater in flaps incorporating a skin paddle. Comparing outcomes, there were no significant differences in flap failure (2.0 percent versus 2.3 percent; p = 1.000) or percentage of flaps requiring return to the operating room (6.0 percent versus 4.7 percent; p = 0.715) between groups. Buried flaps had an absolute greater mean number of revision procedures per nipple-sparing mastectomy (0.82) compared with the skin paddle group (0.44); however, rates of revision procedures per nipple-sparing mastectomy were statistically equivalent between the groups (p = 0.296). CONCLUSION: Although buried free flap reconstruction in nipple-sparing mastectomy has been shown to be safe and effective, the authors' technique has evolved to favor incorporating a skin paddle, which allows for clinical monitoring and can be removed at the time of secondary revision. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.