Is Irradiated Homologous Costal Cartilage Reliable? A Meta-Analysis of Complication Rates in Rhinoplasty.

Background: Irradiated homologous costal cartilage (IHCC) may be a convenient, cost-effective and efficient alternative source of graft material in rhinoplasty; however, a systematic review and meta-analysis on this topic have not been previously performed. Objectives: We sought to summarize and pool data on complications associated with the use of IHCC grafting in rhinoplasty. Methods: A systematic review and meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. We conducted PubMed, Cochrane, Embase, Web of Science database searches, and screened articles using specific inclusion and exclusion criteria. Pooled complication rates were analyzed using a random-effects model. Results: Of the 13 studies that met criteria for systematic review, 11 studies involving 1017 patients, with 1956 IHCC grafts used, were included in the meta-analysis. Mean follow-up across all studies was 47 months. Overall, the pooled complication rates were 1.14% (95% CI: 0.3%-2.0%) for resorption, 0.5% (95% CI: 0.1%-0.9%) for warping, 1.2% (95% CI: 0.3%-2.1%) for infection, 1.0% (95% CI: 0.1%-2.0%) for mobility, and 0.8% (95% CI: 0.1%-1.6%) for graft removal or replacement. No allergic reactions or systemic disease associated with IHCC use were reported in any of the studies. Conclusions: The overall complications associated with IHCC use in rhinoplasty were very low. Costal cartilage allografts are an area of renewed interest that may represent an alternative to autologous costal cartilage grafting in rhinoplasty due to their low complication rates, convenience, cost-effectiveness, and elimination of donor-site complications.

Renseignements généraux: Le cartilage costal homologue irradié peut être une source de matériel de greffe de rechange pratique, rentable et efficace dans les cas de rhinoplastie; or, une revue systématique et une méta-analyse sur le sujet n'avaient jamais été réalisées. Objectifs: Nous avons cherché à résumer et à regrouper les données sur les complications associées à la greffe recourant à un cartilage costal homologue irradié dans les cas de rhinoplastie. Méthodologie: Une revue systématique et une méta-analyse ont été réalisées à l'aide des critères PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses, Éléments de rapport préférés pour effectuer des examens systématiques et des méta-analyses). Nous avons effectué des recherches dans les bases de données PubMed, Cochrane, Embase et Web of Science, puis évalué des articles en utilisant des critères d'inclusion et d'exclusion spécifiques. Les taux de complications regroupés ont été analysés au moyen d'un modèle à effets aléatoires. Résultats: Parmi les 13 études qui répondaient aux critères de revue systématique, 11 études avaient été menées auprès de 1 017 patients et 1 956 greffes effectuées à l'aide d'un cartilage costal homologue irradié ont été incluses dans la méta-analyse. Dans l'ensemble des études, le suivi moyen était de 47 mois. Globalement, les taux de complications regroupés ont été de 1,14% (IC à 95%: 0,3%-2,0%) pour la résorption, de 0,5% (IC à 95%: 0,1%-0,9%) pour la déviation, de 1,2% (IC à 95%: 0,3%-2,1%) pour les infections, de 1,0% (IC à 95%: 0,1%-2,0%) pour la mobilité et de 0,8% (IC à 95%: 0,1%-1,6%) pour le retrait ou le remplacement du greffon. Aucune réaction allergique ou maladie systémique associée à l'utilisation du cartilage costal homologue irradié n'a été signalée dans quelque étude que ce soit. Conclusions: Dans l'ensemble, les complications associées à l'utilisation du cartilage costal homologue irradié dans les cas de rhinoplastie étaient très faibles. Les allogreffes de cartilage costal représentent un domaine d'intérêt renouvelé, qui pourrait constituer une solution de rechange à la greffe de cartilage costal autologue dans les cas de rhinoplastie, et ce, en raison de leurs faibles taux de complications, de leur caractère pratique, de leur rentabilité et de l'élimination des complications liées aux régions de prélèvement des greffons chez les donneurs.

Fat Grafting to Improve Results of Facelift: Systematic Review of Safety and Effectiveness of Current Treatment Paradigms.

BACKGROUND: Autologous fat grafting is a helpful supplement to facelift surgery that helps to combat age-related volume loss of facial structures. Despite the widespread prevalence of combined facelift and fat-grafting, significant procedural variation exists between providers. OBJECTIVES: The primary purpose of this systematic review was to study the efficacy and complication rates of facelift with lipofilling compared with facelift alone. METHODS: A systematic review of the Cochrane Library and MEDLINE databases as completed was undertaken to identify all clinical reports of fat grafting combined with facelift surgery based on the following key terms: ("fat grafting" OR "lipotransfer" OR "lipofilling" OR "fat transfer") AND ("facelift" OR "rhytidectomy" OR "SMASectomy" OR "facial rejuvenation"). Data on techniques, outcomes, complications, and patient satisfaction were collected. RESULTS: The systematic review was performed in April 2017. In total, 248 articles were identified for review. After application of exclusion criteria, 15 primary studies were included in this review. Various facelift techniques were reported, including deep-plane or sub-superficial musculoaponeurotic system (SMAS) facelift, SMAS facelift, modified minimal access cranial suspension lift, component facelift, midface lift, SMAS plication, SMAS-stacking/SMASectomy, and SMASectomy. The most common locations of fat graft injection included the nasolabial folds, tear troughs, temporal regions, midface/cheek/malar eminence, marionette groove, lips, and ear lobes. The addition of fat grafting to facelift surgery resulted in significant improvements in facial volume and aesthetic assessments. CONCLUSIONS: Combined facelift and fat grafting is a safe and efficacious means to simultaneously address age-related ptosis and volume loss. Further research is required to validate and improve existing treatment modalities.

Endoscopic Brow Lift Fixation With Mitek Suture Anchors: A 9-Year Experience of a New "Ideal" Technique.

PURPOSE: In recent years, the endoscopic technique has emerged as a minimally invasive approach to forehead rejuvenation, although the specific need for and mode of brow fixation for endoscopic brow lifts remain under considerable debate. An ideal fixation device should provide non-palpable long-lasting fixation and allow retention of the device post-operatively without the need for removal. It should also allow precise intraoperative adjustment for symmetry and correction of brow ptosis. METHODS: The authors describe an endoscopic brow lift technique using an absorbable bone anchor, Mitek Microfix. A retrospective chart review was conducted in patients who underwent endoscopic brow lift procedures utilizing this fixation method at an academic practice. Outcomes evaluated included operative times, reoperation rates, palpability, fixation device permanence, incremental costs comparisons to conventional methods, efficacy, and technical learning curve. Complication rates were evaluated and the economic, incremental cost analysis of current fixation methods was reviewed. RESULTS: Eighty-two patients underwent single-procedure endoscopic brow fixation using the Mitek anchor over a 9-year period (2005-2014). The mean operative time was 100 minutes. There were no cases of implant palpability, alopecia, or other postoperative complications. Two patients underwent revision secondary lifts after an average of 5.5 months for temporal ptosis. CONCLUSION: The Mitek Microfix QuickAnchor provides durable, long-lasting fixation without device palpability. Its technical ease of use is demonstrated by the reasonable mean operative time achieved with the active involvement of resident surgeons. This device is operator-friendly, easy to use, fully indwelling, and provides lasting fixation without the development of palpability or alopecia.

OBJECTIFS: Ces dernières années, la technique endoscopique est devenue une approche peu invasive du rajeunissement du front, mais la nécessité et le moyen de fixer les sourcils font l'objet de vifs débats. Le dispositif de fixation idéal doit être non palpable, durable et demeurer en place sans devoir être retiré. Il doit également assurer le rajustement intraopératoire précis de la symétrie et de la correction de la ptose des sourcils. MÉTHODOLOGIE: Les auteurs décrivent une technique de redrapage endoscopique des sourcils à l'aide de l'ancre osseuse absorbable Mitek Microfix. Ils ont procédé à une analyse rétrospective des dossiers des patients qui avaient subi un redrapage endoscopique des sourcils à l'aide de cette méthode de fixation dans un cabinet universitaire. Ils ont évalué la durée de l'opération, le taux de réopérations, la palpabilité, la permanence du dispositif de fixation, les comparaisons des coûts différentiels par rapport aux méthodes traditionnelles, l'efficacité et la courbe d'apprentissage technique. Ils ont également évalué le taux de complications et examiné l'analyse des coûts différentiels des méthodes de fixation. RÉSULTATS: Sur une période de neuf ans (de 2005 à 2014), 82 patients ont subi une seule intervention de fixation endoscopique des sourcils à l'aide de l'ancre Mitek. L'opération durait 100 minutes en moyenne. Il n'y a eu aucun cas de palpabilité de l'implant, d'alopécie ou d'autres complications postopératoires. Deux patients ont subi un redrapage secondaire après une ptose temporale au bout d'une période moyenne de 5,5 mois. CONCLUSION: L'ancre Mitek Microfix QuickAnchor procure une fixation durable sans palpabilité du dispositif. La simplicité de la technique est démontrée par le temps moyen raisonnable de l'opération obtenu avec la participation active de résidents en chirurgie. Ce dispositif à demeure est facile à utiliser pour l'opérateur et procure une fixation durable sans apparition de palpabilité ou d'alopécie.

Review of Endoscopic Repair of Mandible Fractures.

INTRODUCTION: Fractures of the mandibular condyle represent more than 30% of all mandible fractures. If required, reduction has been performed using either a closed or an open technique with similar outcomes. Endoscopic fracture repair is a minimally invasive approach for open reduction, but there is limited data regarding indications and outcomes. This study aims to systematically review the demographics, features, and outcomes following endoscopic repair of mandibular fractures in adult patients. METHODS: The following databases were searched from their inception to December 31, 2016: PubMed, Cochrane, Web of Science, and the WHO Global Health Library, using terms related to endoscopy and mandibular fractures. Articles were screened and data were extracted by 2 independent reviewers. Disagreements arbitrated by discussion or a 3rd reviewer. RESULTS: Twenty-two manuscripts were included, representing 509 adult patients who had endoscopic repair of a mandibular fracture over 18 years. All endoscopic repairs were of the mandibular condyle, including both subcondylar and condylar neck fractures. The sample-sized weighted mean age was 33.5 years with 74.5% males in the study population. Permanent facial nerve injury was reported once (0.24%) and occlusive complications reported in 31 patients (6.5%). CONCLUSION: This systematic review identifies a large cohort of patients who underwent endoscopic repair of their mandibular fractures. Complications were rare and usually temporary, with permanent complications occurring at a respectable rate. The demographics and outcomes identified in this study can be used as an epidemiologic baseline for future research on endoscopic repair of mandibular fractures.

Triple-C SMAS Plication Facelift for Natural Facial Rejuvenation.

Various methods are used to reposition the superficial musculoaponeurotic system (SMAS) during facelift procedures. This study presents a novel, radially oriented, layered SMAS plication: the triple-C SMAS plication. This technique utilizes customizable vectors in the pattern of a "C" to plicate the SMAS in 3 layers to lift and tighten the deep structures of the face. METHODS: A retrospective review was performed of patients undergoing the triple-C SMAS plication over a 1-year period. Patients with a length of follow-up less than 100 days were excluded from the study. Demographic data, operative data, complication rates, and satisfaction rates were assessed. RESULTS: One hundred ninety-one consecutive patients underwent a triple-C SMAS plication over a 12-month period. One hundred ten patients met inclusion criteria. Average follow-up was 404.5 days. Complications assessed included temporary facial nerve neuropraxia (0.91%), major hematoma (1.82%), minor hematoma (2.73%), seroma (4.54%), great auricular nerve injury (0%), postauricular skin slough >2 cm (1.82%), and infection (0.91%). Two revision procedures were performed (1.82%). Patient satisfaction rate was 96.4%. CONCLUSIONS: Traditional SMAS plication techniques involve single-layer, straight-line plications to lift the lower face and neck, limiting their versatility. The triple-C SMAS plication represents a novel technique to safely and effectively elevate the deep structures of the face in a radial pattern to restore a more youthful contour to the malar area, jawline, and neck. This represents a unique strategy for face lifting by which excellent results can be consistently obtained.

Plastic Surgery Resident-Run Cosmetic Clinics: A Survey of Current Practices.

BACKGROUND: The recently increased minimum aesthetic surgery requirements set by the Plastic Surgery Residency Review Committee of the Accreditation Council for Graduate Medical Education highlight the importance of aesthetic surgery training for plastic surgery residents. Participation in resident aesthetic surgery clinics has become an important tool to achieve this goal. Yet, there is little literature on the current structure of these clinics. OBJECTIVES: The authors sought to evaluate current practices of aesthetic resident-run clinics in the United States. METHODS: A survey examining specific aspects of chief resident clinics was distributed to 70 plastic surgery resident program directors in the United States. Thirty-five questions sought to delineate clinic structure, procedures and services offered, financial cost to the patient, and satisfaction and educational benefit derived from the experience. RESULTS: Fifty-two questionnaires were returned, representing 74.2% of programs surveyed. Thirty-two (63%) reported having a dedicated resident aesthetic surgery clinic at their institution. The most common procedures performed were abdominoplasty (n = 20), breast augmentation (n = 19), and liposuction (n = 16). Most clinics offered neuromodulators (n = 29) and injectable fillers (n = 29). The most common billing method used was a 50% discount on surgeon fee, with the patient being responsible for the entirety of hospital and anesthesia fees. Twenty-six respondents reported feeling satisfied or very satisfied with their resident aesthetic clinic. CONCLUSIONS: The authors found aesthetic chief resident clinics to differ greatly in their structure. Yet the variety of procedures and services offered makes participation in these clinics an effective training method for the development of both aesthetic surgical technique and resident autonomy.

Liposomal Bupivacaine in Implant-Based Breast Reconstruction.

PURPOSE: This study evaluates the role of liposomal bupivacaine in implant-based breast reconstruction. METHODS: A prospective, randomized, single-blind trial of liposomal bupivacaine in implant-based breast reconstruction was performed. Patients in the control arm were treated with 20 mL 0.25% bupivacaine with epinephrine 1:200,000 to each breast pocket. Patients in the experimental arm were treated with 10 mL 1.3% liposomal bupivacaine delivered to each breast pocket. Pain scores were recorded over the course of patients' hospital stay. Consumption of pain medications, benzodiazepines, and anti-emetics was monitored. Length of stay and other direct cost data were collected. RESULTS: Twenty-four patients were enrolled, with 12 women randomized to each arm. Average postoperative pain scores were 3.66 for patients in the control arm and 3.68 for patients in the experimental arm. Opioid consumption was 1.43 morphine equivalent dosing/h for patients in the control arm and 0.76 morphine equivalent dosing/h for patients in the experimental arm (P = 0.017). Diazepam consumption was 0.348 mg/h for patients in the control arm and 0.176 mg/h for patients in the experimental arm (P = 0.011). Average length of hospital stay was 46.7 hours for patients in the control arm and 29.8 hours for patients in the experimental arm (P = 0.035). Average hospital charges were $18,632 for patients in the control arm and $10,828 for patients in the experimental arm (P = 0.039). CONCLUSIONS: Liposomal bupivacaine reduces opioid and benzodiazepine consumption, length of stay, and hospital charges. These data support a role for liposomal bupivacaine in implant-based breast reconstruction.

Redefining the Ideal Buttocks: A Population Analysis.

BACKGROUND: The buttocks are a key element of female beauty, with aesthetic gluteoplasty becoming one of the fastest growing plastic surgery procedures. However, there remains no clear standard for the ideal buttocks. The authors performed a population analysis of the characteristics of the ideal buttocks to guide surgical planning. METHODS: Images of buttocks were digitally altered to create buttocks of varying proportions on posterior and lateral views. Waist-to-hip ratios and varying vertical proportions were studied. Data were stratified and analyzed according to age range, gender, ethnicity, and nationality of the respondents. RESULTS: A total of 1146 responses were collected. Of 989 respondents who submitted their gluteal preferences, 482 respondents (48.7 percent) were women and 507 (51.3 percent) were men. Overall, the most attractive buttocks waist-to-hip ratio is 0.65 from the posterior view (44.2 percent of respondents). The next most attractive ratio was 0.60 (25 percent of respondents). Positioning of the lateral prominence at the inferior gluteal fold was rated by 26.3 percent of respondents as the most attractive. From the lateral view, the most attractive buttocks have a waist-to-hip ratio of 0.70 (29.8 percent of respondents), with the most prominent portion positioned at the midpoint of the buttocks (45.1 percent of respondents), which is a 50:50 vertical ratio. There were no significant differences in preferences between respondent ages, genders, or ethnicities. CONCLUSIONS: New ideal waist-to-hip ratios of 0.6 and 0.65 update the previous standards and indicate a more dramatic and "curvier" new ideal, signaling an important preference paradigm shift. The information derived from this study has the potential to guide gluteoplasty practices and techniques.

Facial Feminization: Systematic Review of the Literature.

BACKGROUND: Facial feminization surgery encompasses a broad range of craniomaxillofacial surgical procedures designed to change masculine facial features into feminine features. The surgical principles of facial feminization surgery can be applied to male-to-female transsexuals and anyone desiring feminization of the face. Although the prevalence of these procedures is difficult to quantify, because of the rising prevalence of transgenderism (approximately one in 14,000 men) along with improved insurance coverage for gender-confirming surgery, surgeons versed in techniques, outcomes, and challenges of facial feminization surgery are needed. This review is designed to critically appraise the current facial feminization surgery literature. METHODS: A comprehensive literature search of the Medline, PubMed, and EMBASE databases was conducted for studies published through October of 2014 with multiple search terms related to facial feminization. Data on techniques, outcomes, complications, and patient satisfaction were collected. RESULTS: Fifteen articles were selected and reviewed from the 24 identified, all of which were either retrospective or case series/reports. Articles covered a variety of facial feminization procedures. A total of 1121 patients underwent facial feminization surgery, with seven complications reported, although many articles did not explicitly comment on complications. Satisfaction was high, although most studies did not use validated or quantified approaches to address satisfaction. CONCLUSIONS: Facial feminization surgery appears to be safe and satisfactory for patients. Further studies are required to better compare different techniques to more robustly establish best practices. Prospective studies and patient-reported outcomes are needed to establish quality-of-life outcomes for patients. However, based on these studies, it appears that facial feminization surgery is highly efficacious and beneficial to patients.

Polyostotic Juvenile Ossifying Fibroma: An Exceptionally Rare Case.

Accurate and early diagnosis of benign fibroosseous lesions is important because the treatment and resulting outcomes of each differ. Juvenile ossifying fibromas typically occur in young patients and grow rapidly with a high recurrence rate. Their monostotic nature has previously differentiated these tumors from other fibroosseous lesions. We describe an interesting and extremely rare case of polyostotic juvenile ossifying fibromas in a 14-year-old boy with involvement of the maxilla and mandible. The available literature on juvenile ossifying fibromas is also briefly reviewed. When diagnosing a polyostotic fibroosseous lesion, it is important to not exclude the possibility of juvenile ossifying fibromas because this may warrant a different treatment.

Cryolipolysis for fat reduction and body contouring: safety and efficacy of current treatment paradigms.

BACKGROUND: Cryolipolysis is a nonsurgical technique for localized fat reduction. With the increased risk of complications from more invasive methods such as liposuction, cryolipolysis presents a promising method for nonsurgical body contouring. This study presents a systematic review of the available clinical data, with an emphasis on the efficacy, methods, safety, and complications of cryolipolysis. METHODS: To identify clinical studies that assessed outcomes of cryolipolysis, a systematic review of the MEDLINE and Cochrane databases was performed with the search algorithm cryolipolysis OR cool sculpting OR fat freezing OR lipocryolysis. RESULTS: The primary literature search returned 319 articles. After inclusion criteria were applied and additional articles were idenfied via manual review of article references, 19 studies were selected for review. Average reduction in caliper measurement ranged from 14.67 percent to 28.5 percent. Average reduction by ultrasound ranged from 10.3 percent to 25.5 percent. No significant impact on lipid levels or liver function tests after cryolipolysis treatments was noted in any study. Only mild, short-term side effects, such as erythema, swelling, and pain, were noted. Paradoxical adipose hyperplasia was described in one patient. CONCLUSIONS: Cryolipolysis is a promising procedure for nonsurgical fat reduction and body contouring and presents a compelling alternative to liposuction and other, more invasive methods. This procedure appears to be safe in the short term, with a limited side effect profile, and results in significant fat reduction when used for localized adiposities. It remains unclear whether posttreatment manual massage and multiple treatments in the same anatomic area enhance the efficacy of cryolipolysis.

Perioperative management for microsurgical free tissue transfer: survey of current practices with a comparison to the literature.

BACKGROUND: Free tissue transfer is an important technique in reconstructive surgery. Due to a lack of evidence-based guidelines, a variety of practices are currently implemented by microsurgeons. This motivated the authors to define current practices and identify key areas where these practices can be optimized. METHODS: An anonymous online survey consisting of 40 questions regarding perioperative management for free tissue transfer was generated via an online survey platform. Questions covered topics including patient selection, anesthesia, patient temperature, fluid management, vasoactive agents, and analgesia. Approval was received from the American Society for Reconstructive Microsurgery and the survey was distributed to its members via two emails, in May and June 2013. RESULTS: Survey responses were received from 82/706 microsurgeons (12% response rate): 36% of respondents believed that complications of these cases are "sometimes" or "often" related to anesthesia; 55% of respondents stated they do not use specific goals and protocols to guide fluid management for these cases; 38% of respondents stated that they have no target range for hemoglobin and hematocrit for these procedures; and 70% of respondents stated that they do not permit the use of a vasopressor in nonemergent situations. CONCLUSION: Current practices remain exceedingly diverse and at times differ from best practices, which may be identified from the available literature. Key areas where patient care can be standardized and optimized include anesthesia, patient temperature, fluid management, the use of vasoactive agents, and analgesic medications. Standardized, evidence-based guidelines have the potential to further improve patient care and free flap outcomes.

Vaginal labiaplasty: current practices and a simplified classification system for labial protrusion.

BACKGROUND: Vaginal labiaplasty has been described for the management of functional and aesthetic problems associated with protrusion of the labia minora. Despite increasing numbers of procedures performed, there is a paucity of data to guide treatment paradigms. This systematic review aims to establish a simple, unifying classification scheme for labial protrusion and summarize current labiaplasty techniques and practices. METHODS: A systematic literature review was performed using the PubMed database. Additional articles were selected after reviewing references of identified articles. RESULTS: The search returned 247 articles. After applying inclusion criteria to identify prospective and retrospective studies evaluating different techniques, outcomes, complications, and patient satisfaction, 19 articles were selected. Labiaplasty of the labia minora was described in 1949 patients. Seven different surgical techniques were used for labiaplasty, including deepithelialization, direct excision, W-shaped resection, wedge resection, composite reduction, Z-plasty, and laser excision. Patient satisfaction rates for each technique ranged from 94 to 100 percent. The most common postoperative complication for all techniques was wound dehiscence (4.7 percent). Key areas for perioperative patient management were defined. CONCLUSIONS: Labiaplasty is safe and carries a high satisfaction rate. However, current practices remain exceedingly diverse. The authors propose a simplified classification system based on the distance of the lateral edge of the labia minora from that of the labia majora, rather than from the introitus. Key areas for perioperative patient management include patient anesthesia, resection technique used, wound closure, and postoperative care. Further randomized studies using a standardized classification system are required to better compare different techniques and establish best practices.