Aesthetic Surgery Journal最新文献

Background: Although pure hemi-periareolar incisions for mastectomy can prevent visible scarring, nipple-areolar complex (NAC) necrosis is a potential risk. Superficial-arterial inflow of the NAC can be evaluated by indocyanine green angiography (ICG-A).

Objectives: This study evaluated the impact of ICG-A assisted periareolar incision on NAC necrosis during nipple-sparing mastectomy (NSM) and direct-to-implant (DTI) breast reconstruction.

Methods: Between December 2018 and November 2021, lateral hemi-periareolar incisions for NSM were routine. After that time, ICG-A-assisted hemi-periareolar incisions were performed between December 2021 and Sept. 2023. The location of the main arterial inflow was evaluated during preoperative ICG-A and the periareolar incision was planned to avoid disruption. NAC necrosis in the ICG-A-assisted and blind-incision groups was compared using univariate and multivariate analyses.

Results: A total of 202 breasts were analyzed including 80 breasts from 75 patients in the ICG-A-assisted group and 122 breasts from 115 patients in the blind-incision group. On preoperative ICG-A, superficial-arterial inflow was observed in 67 of 80 (83.75%) breasts. Perfusion of the nipple without superficial-arterial inflow (base-perfusion pattern) was observed in 13 breasts (16.25%). The main arterial inflow was most common in the upper-medial direction at the areolar margins (65.67%). The full-thickness NAC necrosis rate in the ICG-A-assisted incision group was significantly lower than that in the blind-incision group (2.5% vs. 13.1%, p = 0.010). Multivariate analysis demonstrated that ICG-A-assisted incisions significantly reduced the risk of NAC necrosis (odds 0.155, p = 0.030).

Conclusions: ICG-A-assisted pure hemi-periareolar incisions reduced NAC necrosis in DTI breast reconstructions.

Background: While percutaneous external fixation has gained popularity in transconjunctival blepharoplasty due to its simplicity and minimal incision, internal fixation remains the standard approach in transcutaneous blepharoplasty.

Objectives: This study aims to assess the safety and effectiveness of percutaneous external fixation specifically in transcutaneous fat repositioning blepharoplasty.

Methods: From May 2022 to December 2023, a consecutive cohort of 97 patients underwent this surgical technique. Building upon the principles of transconjunctival fat repositioning, the procedure involved a minimal incision targeting the muscle layer, a conservative release of the tear trough ligament, and the repositioning of fat secured with percutaneous external fixation. Surgical outcomes were evaluated using the Barton grading system and FACE-Q scales for patient-reported outcomes.

Results: Following a mean follow-up of 7.2 months (ranging from 6 to 17 months), a resolution of tear trough deformities and eyelid bags was achieved in over 92% of cases. Notably, significant improvements (P < 0.05) were observed in lower eyelid aesthetics as measured by the FACE-Q scale, with a concomitant enhancement in patients' social confidence (P < 0.05). Overall, patients expressed satisfaction with their decision to undergo the procedure (71.0±19.1). Complications necessitating revision surgery included isolated cases of hematoma evacuation, fat injection, excision of excess fat, and skin excision.

Conclusions: External fixation in transcutaneous blepharoplasty is technically less complex and minimally invasive, effectively securing transposed fat pedicles safely, presenting a viable alternative to conventional fixation techniques.

Background: Postmastectomy radiation therapy (PMRT) improves disease-free survival in breast cancer but reduces aesthetic satisfaction. Proton PMRT has gained popularity due to fewer systemic complications. There is a lack of data regarding revision surgeries for pre-pectoral implant-based breast reconstruction (PP-IBBR) following radiation.

Objectives: To compare the revision surgeries in PP-IBBR with photon versus proton PMRT.

Methods: A single-institution retrospective cohort study included breast cancer patients undergoing mastectomy and PP-IBBR with PMRT (January 2020-October 2022) The mean follow-up duration for the cohort was 1056.4 days (2.89 years). Revision surgeries evaluated were fat grafting, conversion to autologous flaps, implant replacement, implant removal, capsulectomy, and scar revision.

Results: 116 PP-IBBR were divided into two cohorts: photon (75, 64.66%) and proton (41, 35.34%) radiation cohorts. Overall corrective surgeries were higher with photon (27.5% overall; 32.4% photon vs 19.5% proton, p=0.132). The odds of any revision surgery were nearly double with photon (OR=1.98), and the conversion to an autologous flap was significantly more likely with photon (OR=4.55, p=0.025). Multivariable analysis showed an increased tendency for photon therapy patients to require any revision surgeries (OR=1.62, p=0.359), autologous flaps (OR=5.97, p=0.049), fat grafting (OR=1.52, p=0.664) and scar revision (OR=4.51, p=0.273).

Conclusions: Compared to proton therapy, traditional photon therapy has a higher conversion rate to autologous flaps with PP-IBBR. Photon therapy had higher rates of overall revision surgeries, however not statistically significant. Proton therapy is safer, with fewer revision surgeries, warranting larger studies and broader utilization.

Background: Enophthalmia (abnormally sunken eyeball in the socket) and ptotic upper lid as well as with lower lid symptoms are commonly observed in patients seeking periorbital rejuvenation. It is not only functionally disruptive, causing restricted eye opening, but also aesthetically displeasing, thus creating a demand for more sophisticated solutions.

Objectives: Conventional transconjunctival lower blepharoplasty (TCLB) has been performed mainly for lower lid symptoms with the removal and transposition of excess lower orbital fat compartment (LOFC). In this study, TCLB is modified by adding de-flaming and decompression maneuvers to the LOFC and its support structures to obtain better results in both the lower and upper lids. The results after the modified TCLB clearly demonstrate increased eye-opening ability and marked resolution of observable symptoms. The anatomical dynamics of the orbit involved in this procedure are detailed through scientific data.

Methods: Modified TCLB was performed in patients with lower eyelid symptoms. Palpebral fissure height (PFH) (the distance between the upper and lower eyelids in vertical alignment with the center of the pupil) was measured before surgery and 12 months postoperatively using 3 dimensional photographs. This data was compared to validate the postoperative eye-opening effect. The weight of the excised fat from each LOFC was also measured and compared.

Results: Forty patients (36 females and 4 males) who underwent modified TCLB in 2022 were followed up 12 months postoperatively. Preoperative PFHs were 8.41±1.15 (6.1-10.7) mm for the right and 8.41±1.12 (5.5-10.4) mm for the left. Postoperative PFHs were 9.26±0.95 (6.4-11.1) mm for the right eyelid and 9.21±0.94 (6.2-11.1) mm for the left eyelid. The improvement in postoperative eye opening was statistically significant. The total excised LOFC was 0.43±0.24 (01.2) g for the right and 0.42±0.25 (0-1.5) g for the left. The largest amount of fat was excised bilaterally from the lateral LOFC, and the difference was statistically significant.

Conclusions: The modified TCLB with de-framing and decompression of the LOFC was not only effective in improving symptoms present in the lower lid but also increased the eye-opening ability with marked aesthetic improvements in most patients.

Background: The CDC/Kaiser Adverse Childhood Experiences (ACE) study documented that ACEs predict adult health and self-harming behaviors. ACEs have been documented in physicians and are higher in physicians treated for problematic behavior. Plastic surgeons have never been assayed.

Objectives: Might ACE prevalences in plastic surgeons predict their adult health and/or behavior?

Methods: 252 ABPS-certified plastic surgeons (72% men, 28% women, ) completed the 10-question CDC/Kaiser ACE survey by de-identified email. Data was collected on adult health and behaviors previously associated with ACEs in the literature.

Results: 42% of plastic surgeons had 1 or more ACEs; 9.9% had 4 or more. Emotional abuse was 2 times higher than the control CDC/Kaiser population, though other ACEs were lower. Gender differences existed: women suffered more sexual abuse (17% vs. 8%), physical neglect (7% vs. 1%), violence against their mothers (7% vs. 2%), and self-defined burnout (32% vs. 17%). ACEs occurred in clusters. Total ACEs predicted autoimmune disorders, chronic pain/fatigue, self-defined depression, irritable bowel, antidepressant/anxiolytic use, alcohol abuse, >3 marriages, >10 sexual partners, sex and work addiction, eating disorders, and self-defined burnout (all p< 0.020). Emotional abuse predicted alcohol abuse. Sexual abuse predicted sex addiction. Emotional neglect predicted autoimmune disease, antidepressant/anxiolytic use, eating disorder, and work addiction. Physical neglect predicted chronic fatigue/chronic pain, depression, and burnout (all p< 0.001 or less).

Conclusions: Adverse childhood experiences occurred in 42% of our 252-member plastic surgeon cohort and predicted 13 adult illnesses and self-harming behaviors that can impair surgeons' lives and performances. Recognition may facilitate their recognition and treatment.

Background: Liposuction has gained significant popularity, leading to increased demand for secondary procedures due to complications such as scars and fibrosis that affect aesthetic outcomes. High-Definition Liposuction (HDL) has emerged as a preferred technique, but the presence of fibrosis from prior surgeries may limit its effectiveness.

Objectives: This study explores the application of ultrasound-assisted VASER (Vibration Amplification of Sound Energy at Resonance; VASER-Solta Medical, Bothell, WA) liposuction in secondary abdominal liposculpture to address these challenges.

Methods: A prospective cohort study was conducted from May 2022 to May 2023, including patients undergoing secondary abdominal liposculpture with ultrasound-assisted VASER liposuction, at least 12 months post their initial procedure. Pre-operative ultrasound examinations were performed to identify and mark findings related to previous liposuction. Data on demographics, photographic results, and complications were collected and analyzed.

Results: Intraoperative ultrasound (I-US) significantly improved the detection of fibrotic lesions, leading to more precise, rapid, and atraumatic outcomes. The use of I-US optimized surgical procedures, reducing both costs and operation time. Clear communication with patients regarding potential limitations due to chronic damage was essential for setting realistic expectations.

Conclusions: I-US has proven to be an invaluable tool in secondary liposculpture, enhancing surgical precision and outcomes. This methodology allows for better recognition of complications, promoting effective treatment strategies and ultimately improving patient satisfaction in the context of secondary abdominal liposculpture.

Background: The existing literature is conflicted on whether nasal deviation is primarily attributable to trauma or the result of asymmetric facial development.

Objectives: The aim of this study was to establish the prevalence of nasal trauma and facial asymmetry in patients undergoing rhinoplasty, and to determine if a correlation exists between the laterality of facial asymmetry and nasal deviation.

Methods: A retrospective review was undertaken of patients who had undergone primary rhinoplasty with the senior author over a 12-month period. Patient charts were reviewed and clinical photographs were analyzed.

Results: In total, 144 patients underwent rhinoplasty over the study period; 68 patients underwent revision rhinoplasty and were excluded. Of the 76 patients who underwent primary rhinoplasty, 9% reported prior nasal trauma, 68% had deviated nasal bones, 46% had deviated nasal tips, 70% had asymmetric midfaces, and 36% had deviated chins. In patients without prior trauma history, nasal bones were most commonly deviated towards the side of midface hypoplasia (53%, P = .008). The nasal tip was most commonly deviated contralateral to the side of septal deviation (59%, P = .001). There was no association between nasal bone and chin deviation. Nasal tip deviation was not associated with midface hypoplasia or chin deviation.

Conclusions: Nasal deviation is primarily driven by asymmetric facial growth rather than being the result of nasal trauma.

Level of evidence: 3:

Following the advent of glucagon-like peptide-1 receptor agonists (GLP-1RAs), subsequent unintended effects such as accelerated facial aging and altered skin health have been noted. This review delves deeper into the causative underlying mechanisms and provides insights into the intricate relationship between GLP-1RAs, adipose tissue, and premature facial aging, thereby highlighting the need for a nuanced understanding of their effects on facial alterations and skin health. Studies exploring the potential effects of GLP-1RAs on facial alterations and offering insights into the possible underlying mechanisms, causes, and clinical implications were included. The accelerated facial aging and altered skin health observed in GLP-1RA patients appears to be multifactorial, involving loss of dermal and subcutaneous white adipose tissue, and altered proliferation and differentiation of adipose-derived stem cells (ADSCs), and impacts on the production and secretion of hormonal and metabolic factors. These changes compromise the structural integrity and barrier function of the skin and may lead to diminished facial muscle mass, further exacerbating the appearance of aging. The insights presented call for a paradigm shift in the clinical management of facial changes induced by GLP-1RAs, with a focus on treatment strategies aimed at targeting ADSC stimulation. These include autologous fat transfers to reintroduce cells rich in ADSCs for rejuvenation, composite fat grafting combining autologous fat with/without stromal vascular fraction, and the strategic use of soft tissue fillers for volume restoration and biostimulation. This review highlights the potential role of GLP-1RAs in modulating adipose tissue dynamics, thereby contributing to accelerated aging through metabolic, structural, and hormonal pathways.

Level of evidence: 5:

A clinical practice guideline (CPG) from the American Society of Plastic Surgeons recommended not to use drains in breast reduction. This CPG was based on 3 randomized controlled trials (RCTs). The objective of this review was to double-check the methodological quality of the 3 RCTs. These RCTs were critically appraised using: (1) the "User's Guide to the Surgical Literature" checklist to critically appraise the methodological quality, (2) the CONSORT guidelines for reporting quality, and (3) the Cochrane risk-of-bias tool 2 (RoB 2) for risk of bias. Weaknesses were identified in all assessments for the 3 RCTs. Items with the poorest adherence in the "User's Guide" included: "Were patients stratified?," "Was follow-up complete?," and "Were all clinically important outcomes considered?" The overall adherence to the CONSORT reporting checklist across all 3 studies was moderate with 40.0%, 62.1%, and 48.3% adherence. All 3 RCTs had a similar low to moderate risk of bias, with no areas with a high risk of bias. None of the studies took into consideration a single critical outcome (such as major hematoma) and the outcome's minimally important difference as the basis for the sample size and power calculation of the study. All 3 RCTs additionally lacked clear reporting of treatment effect sizes or precision of estimates. Our re-examination of the evidence questions the recommendation of the CPG. We believe that the recommendation should have been: "We remain uncertain whether drains in breast reduction have a salutary effect." As such, we recommend that a methodologically robust RCT be conducted to resolve the question of whether drains should be used in breast reduction.