Feminizing Gender Affirming Breast Surgery: Procedural Outcomes at a Single Academic Institution.

Background: Implant-based breast augmentation is a gold standard procedure for transfeminine patients to create a more feminine-appearing chest. In many cases, ancillary procedures are performed simultaneously to achieve an optimal aesthetic result. Objectives: To determine the clinical outcomes of patients undergoing feminizing gender-affirming breast surgery in a single academic institution. Methods: A retrospective electronic chart review of feminizing gender-affirming breast surgery patients at Mayo Clinic, Rochester, from 2017 to 2022 was conducted. Patients' demographics and surgical outcomes were gathered. A survival analysis was performed to obtain the time-to-event complication rate. Results: Over 5 years, 46 patients (92 breasts) were included. The mean age was 39 years (standard deviation [SD] ±15), and most had an above-normal body mass index (BMI) (58.7%). Thirty (65%) had previous gender-affirming surgeries. The mean implant volume was 289 mL (SD ±95; 140-520). Most implants were placed in a subglandular plane (81%) with an inframammary fold incision (91.3%). All implants used were smooth, round cohesive silicone gel implants. Ancillary procedures were performed in 32 patients (69.57%). Eight patients presented complications (4 major vs 4 minor) in a median postoperative follow-up of 372 vs 392 days; at 1-month follow-up, the probability of a complication having occurred is 2.17% (95% CI: 0%-6.3%) vs 5% (95% CI: 0%-11.5%), and at 1 year, the probability is 10.21% (95% CI: 0%-20.9%) vs 12.5% (95% CI: 0%-23.4%), which remains the same up to 4 years. Conclusions: Breast augmentation with implants is a safe procedure to achieve feminization of the breast with a low rate of complications.

Most Cited Articles in Body Contouring: A Bibliometric Analysis of the Past 45 Years.

Introduction: The purpose of this study is to produce a bibliometric review of the 30 most cited articles related to 6 major domains of body contouring-abdominoplasty, thighplasty, brachioplasty, gluteoplasty, body lift, and liposuction-for resident and fellow education. Methods: The authors utilized the Web of Science Citation Index to identify the 30 most cited articles related to surgery for body contouring published from 1975 to 2020. Articles were classified according to their level of evidence, type of study, and country of publication. Results: A total of 336 articles were reviewed to compile our list. The mean number of citations across the articles was 114.7 ± SD 86.1. The highest prevalence of the papers was published between 2000 and 2009 (n = 15, 50%). The country with the highest number of contributions was the United States (n = 22, 73%). Plastic and Reconstructive Surgery served as the main journal of publication for these papers (n = 22, 73.3%). The majority of articles were designated for clinical-type studies (n = 26, 86.7%). No basic science or prevalence study design papers were listed. In terms of level of evidence (LoE), most papers were assigned IV (n = 11, 36.7%) and III (n = 7, 23.3%). Conclusions: Our study reveals that the most cited papers in body contouring are of LoE III and IV. Although the LoE of plastic surgery research, in general, has improved, in the past decade, a call for higher quality papers remains. Overall, this analysis provides an easy, electronic starting point for residents and fellows interested in understanding the field's evolution.

Introduction : La présente étude vise à produire une analyse bibliométrique de 30 articles influents liés à six grands domaines du remodelage corporel (l'abdominoplastie, le redrapage des cuisses, la brachioplastie, la glutéoplastie, le redrapage du corps et la liposuccion) pour la formation des résidents et des étudiants en stage de perfectionnement postdoctoral. Méthodologie : Les auteurs ont utilisé l'index de citation de Web of Science pour extraire les 30 articles les plus cités sur les opérations de remodelage corporel publiés entre 1975 et 2020. Ils ont classé les articles d'après la qualité des preuves, le type d'étude et le pays de publication. Résultats : Au total, les auteurs ont analysé 336 articles pour compiler leur liste. Les articles contenaient un nombre moyen de 114,7± ÉT 86,1 citations. La plus forte prévalence d'articles a été publiée entre 2000 et 2009 (n = 15, 50 %). La majorité des articles provenaient des États-Unis d'Amérique (n = 22, 73 %), et c'est la revue Plastic and Reconstructive Surgery© qui en a publié le plus (n = 22, 73,3 %). La plupart des articles prenaient la forme d'études de type clinique (n = 26, 86,7 %). Aucun article de science fondamentale ni étude de prévalence n'a été répertorié. Pour ce qui est de la qualité des preuves, la plupart des articles ont obtenu un classement de IV (n = 11, 36,7 %) et de III (n = 7, 23,3 %). Conclusions : L'étude révèle que la qualité de preuve de la plupart des articles dans ce domaine était de III et IV. Même si la chirurgie plastique se prête moins bien aux études randomisées et contrôlées que la médecine, elle mérite des articles comportant une meilleure qualité de preuves. Grâce à la présente analyse, les résidents et les étudiants en stage de perfectionnement peuvent accéder rapidement et facilement à des concepts influents pour comprendre l'évolution du domaine par voie électronique. Termes MeSH : abdominoplastie, bibliométrie, chirurgie plastique, études transversales, liposuccion, remodelage corporel.

Effect of Facial Feminization Surgery (FFS) on Eyelid Anatomic Features.

Facial feminization surgery (FFS) improves gender dysphoria. The brows and eyes are crucial in perceived gender, yet brow and eyelid surgeries are relatively underutilized. This study aimed to determine rates of brow and eyelid surgeries as part of FFS and characterize pre- and postoperative periocular features. We conducted a retrospective review to identify all patients with the diagnosis of gender dysphoria who underwent FFS at a single academic institution from 2019 to 2022. Thirty-four patients comprising 38 surgical cases were included. Twelve (35%) eyelid surgeries and 27 (79%) brow lifts were performed. Baseline eyelid measurements did not differ between brow lift and nonbrow lift cases. Those undergoing brow lift and eyelid surgery were older in age (p = 0.022), had a higher rate of negative canthal tilt (p = 0.050), and smaller baseline margin-reflex distance 1 (p = 0.014) than patients who had brow lift alone. Brow lift increased tarsal platform show (p ≤ 0.001) and lash-to-brow distance (p ≤ 0.001), and upper blepharoplasty increased tarsal platform show (p = 0.01). Rates of brow lift are high at our institution, and patients are appropriately selected for eyelid surgery in FFS. Brow lift and upper blepharoplasty can feminize anatomical features when using standards described for cisgender cohorts. The impact of periocular features on gender perception in transgender patients warrants further study.

Clinical evaluation of a stereotactic system for single-stage deep brain stimulation surgery under general anesthesia: technical note.

OBJECTIVE: Conventional frame-based stereotactic systems have circumferential base frames, often necessitating deep brain stimulation (DBS) surgery in two stages: intracranial electrode insertion followed by surgical re-preparation and pulse generator implantation. Some patients do not tolerate awake surgery, underscoring the need for a safe alternative for asleep DBS surgery. A frame-based stereotactic system with a skull-mounted "key" in lieu of a circumferential base frame received US FDA clearance. The authors describe the system's application for single-stage, asleep DBS surgery in 8 patients at their institution and review its workflow and technical considerations. METHODS: Eight patients underwent DBS lead insertion and IPG implantation in a single surgical preparation under general anesthesia using the system. Postoperative CT imaging confirmed lead placement. RESULTS: Eight patients underwent implantation of 15 total leads targeting the ventral intermediate nucleus (4 patients), globus pallidus internus (GPi; 3 patients), and subthalamic nucleus (STN; 1 patient). Intraoperative microelectrode recording was conducted for GPi and STN targets. Postoperative CT imaging revealed a mean ± SD radial error of 1.24 ± 0.45 mm (n = 15 leads), without surgical complications. CONCLUSIONS: The stereotactic system facilitated safe and effective asleep, single-stage DBS surgery, maintaining traditional lead accuracy standards.

Cardiac implantable electronic devices in female patients: Esthetic, breast implant, and anatomic considerations.

INTRODUCTION: The implantation of a cardiac implantable electronic device (CIED) can have esthetic and psychological consequences on patients. We explore a heart team model for care coordination and discuss esthetic approaches for improved cosmetic outcomes in patients undergoing (CIED)-related procedures or de novo implantation. METHODS: Patients undergoing CIED surgery for approved indications between June 2015 and June 2022 were identified. Patients were included when surgical care was provided by a collaborative relationship between the primary electrophysiologist and the plastic surgeon. Patient demographics, details of the surgical procedure, information on breast implants, complications, and outcomes related to cosmesis were recorded. RESULTS: Twenty-two female patients were included in this study. The mean age was 50.2 ± 18.2 years. The mean follow-up duration was 2.2 ± 5.5 months. The top two indications for the procedure included CIED generator change (n = 9, 41%) and implantable cardioverter-defibrillator (ICD) implantation (n = 7, 32%). The most common reasons for involving plastic surgery in the procedure included surgery near breast implants (n = 10, 45%) and device displacement or discomfort (n = 8, 36%). CIED pocket position was prepectoral in 10 cases (45%), subpectoral in 11 patients (50%), and intramuscular in one patient (4.5%). The majority of the patients (20, 91%) had cosmetically acceptable results postprocedure. One patient (4.5%) had breast asymmetry on the CIED side, and another continued to have skin erosion over the CIED and leads. CONCLUSION: A heart team approach incorporating the expertize of cardiac electrophysiology and plastic surgery is essential for providing optimal care for patients with breast implants and patients requesting esthetic appeal.

Eyelid and Brow Rejuvenation: Technical Pearls and Outcomes of Upper Blepharoplasty with or without Ptosis Correction and Browlift.

BACKGROUND: Eyelid ptosis may present with upper lid dermatochalasis and brow ptosis. When indicated, ptosis correction (PC) is advocated during upper blepharoplasty (UB). Here, we aimed to report our outcomes following UB and PC. METHODS: A retrospective review of patients that underwent UB from November 2018 to March 2020 was performed. Patient demographics, clinical characteristics, and revisions were recorded. Cox regression was performed to assess predictors of revision. RESULTS: Overall, 278 patients with 533 UB were included. Mean age was 67.3 years. Mean follow-up was 8.3 months. In 169 (31.7%) cases, a browlift was performed. UB and PC were performed in 109 (20.5%) cases, of which 60 (55%) involved Müller's muscle conjunctival resection, and 49 (45%) were levator repairs. New dry eye symptoms lasting ≥3 months occurred in 4 (0.8%) cases, all of which resolved. Revision rate was 3.8% after UB (residual skin [n=11], hypertrophic scar [n=4], Herring's law-related ptosis [n=1]); versus 9.2% after UB and PC (overcorrection [n=4], residual skin [n=4], asymmetry [n=2]). Multivariable analysis demonstrated increased revision rates after UB and PC (p-value=0.008). There was no difference in revision rates between different techniques of PC. CONCLUSIONS: In our study of 278 patients presenting for dermatochalasis, up to 21% of cases required ptosis correction in addition to upper blepharoplasty. Ptosis correction is a safe procedure when combined with upper blepharoplasty, regardless of technique used. The revision rate in our series was 9.2% after the combined procedure, which is greater than the revision rate of upper blepharoplasty only, however, comparable to the literature.

Revisiting Breast Reduction Insurance Coverage: How the Schnur Scale Discriminates Against Women Based on Body Habitus.

INTRODUCTION: The Schnur scale utilizes body surface area (BSA) to determine the amount of breast tissue resection in reduction mammoplasty, resulting in a greater requirement of breast weight removal in patients with larger BSA. We aimed to demonstrate BSA variance among women with similar mastectomy weights and the range of mastectomy weights among women with comparable BSAs. METHODS: A retrospective chart review of patients who underwent mastectomy from October 2021 to June 2022 was performed. Patients were included if they underwent skin-sparing or nipple-sparing mastectomy with a minimum specimen weight of 700g. Patient's BSA, body mass index (BMI), mastectomy weight, and Schnur weight requirement (SWR) were collected. RESULTS: A total of 130 patients (194 breasts) were included. There was significant variance in mean BSA, BMI, SWR, and SWR to mastectomy weight ratio among women with similar mastectomy weights. BSA varied by as much as 0.82 units, BMI varied by as much as 32 kg/m 2, and SWR varied by as much as 1365g within the same mastectomy weight group. There was also significant variance in mastectomy weights among women with comparable BSA, especially in BSA groups>2.20, with the greatest range in mastectomy weights being 1684g. CONCLUSION: Analysis of mastectomy patients showed no predictable relationship between BSA and breast weight. There was significant variance in the BSA of patients with similar breast weights, and conversely in breast weights of patients with comparable BSA. Therefore, strict adherence to the Schnur weight requirement can prevent patients suffering with macromastia from receiving breast reductions.

Analysis of Sexual Dimorphic Features of the Jawline and Chin in White Celebrity Faces.

BACKGROUND: The jawline greatly influences facial shape and contributes to facial dimorphism. Analysis of lower facial shape and sexual dimorphic differences in contemporary attractive white faces can advance the goals of lower facial aesthetics and facial gender-affirming surgery (FGAS). METHODS: Full-face, front-view photos of 47 white female and 21 white male celebrities were included from a list generated using GQ magazine's Highest Paid Models issue, People Magazine's Beautiful issue (1991-2022), and celebrities featured on lifestyle websites. Facial landmarks were detected through a facial analysis program using Vision framework and MATLAB. After converting pixel distances to absolute distances, lower face measurements were compared between males and females. RESULTS: The mean lower facial height was 6.08 cm in females and 7.00 cm in males (P value<0.001). The mean bigonial width was 11.21 cm in females and 12.30 cm in males (P value<0.001). The ratio of facial height to lower facial height was 2.98 in females and 2.76 in males (P value<0.001), signifying that symmetry in facial thirds is more prevalent in attractive female faces, while a longer lower face is more common in attractive male faces. The greatest differences in female and male facial contours were at gonial angles and chin. CONCLUSIONS: Analysis of contemporary white celebrity faces demonstrated significantly wider and longer lower facial measurements in males. The overall contour of the female lower face was more tapered at the gonial angles and chin compared to males. These results are important when planning lower facial rejuvenation or FGAS, as lower face size and proportions influence perceived gender and attractiveness.

Analysis of Hairline and Forehead Sexual Dimorphic Aesthetics in 60 Celebrities Using Artificial Intelligence.

Upper facial third morphometrics are an important consideration in aesthetic facial surgery and facial gender-affirming surgery. Although there are generally accepted sexual dimorphic differences, an in-depth analysis of forehead morphometrics in attractive individuals is lacking. Methods: Thirty white female and 30 white male celebrities were included. Three full-face front-view photographs of each celebrity were evaluated by a facial analysis program, using Vision framework and MATLAB. After converting pixel distances to absolute distances, midline and lateral forehead heights were calculated and compared between men and women. Results: Forehead height was similar between attractive men and women, but forehead width was shorter in women. Analysis of forehead height at various points along the hairline demonstrated that forehead measurements above the lateral brow and brow peak were significantly greater in men. Mean forehead height above the lateral eyebrow was 3.51 cm in women and 4.16 cm in men (P = 0.017). Forehead height above the eyebrow peak was 4.34 cm in women and 5.55 cm in men (P < 0.001). Medial forehead height was similar between men and women, indicating that the greatest difference in attractive male and female foreheads is in the lateral forehead and forehead width. Conclusions: Analysis of attractive white celebrities demonstrated no significant differences in central forehead heights between men and women. Forehead width and lateral forehead height were significantly smaller in women, with an overall downward slanting contour. Male hairlines were more horizontal and slanting upward laterally. These results have implications in facial rejuvenation and facial gender-affirming surgery.

Facial Morphometrics in Black Celebrities: Contemporary Facial Analysis Using an Artificial Intelligence Platform.

The diversity of patients pursuing facial aesthetic and facial gender-affirming surgery (FGAS) is increasing, yet there is a paucity of objective guidelines to facilitate surgical decision-making in patients of color. We conducted a quantitative analysis of black celebrities using standardized frontal photos of 21 female and 21 male celebrities. Celebrities were chosen from popular entertainment magazines and websites, including People Magazine, the Internet Movie Database (IMDb), Cosmopolitan, and Essence. For each celebrity, 100 facial landmarks were detected through a facial analysis artificial intelligence (AI) program. Black males had greater facial height, bizygomatic width, lower facial height, and bigonial width than females. However, the facial height to bigonial width ratio was similar between genders and approximated the golden ratio (1.618). Female faces demonstrated a greater mid-face height to total facial height proportion, and males had a greater lower facial height proportion. Females exhibited an upward-slanted medial brow and shorter total eyebrow length, nose height, and alar width. Forehead height above the lateral brow was greater in males, while central forehead height was similar to females. This is the first study that has utilized AI to provide ethnicity-specific facial morphometrics relevant to facial rejuvenation and FGAS in the black population.

Using Artificial Intelligence to Quantify Sexual Dimorphism in Aesthetic Faces: Analysis of 100 Facial Points in 42 Caucasian Celebrities.

Background: Sexual dimorphism has been studied in the faces of average populations and worldwide celebrities; however, a focused analysis of attractive Caucasian faces has not been conducted. Objective: The study harnesses the power of artificial intelligence (AI) to efficiently analyze these facial patterns in attractive Caucasian male and female celebrities. Methods: Twenty-one male and 21 female Caucasian celebrities were selected based on popular editorial rankings, modeling agencies, and casting directors from 2017 to 2022. Frontal photographs of celebrities aged 23 to 42 without facial animation were selected. One hundred facial landmarks were identified using semi-automatic image analysis software consisting of modified Apple Vision (Cupertino, CA) machine-learning algorithms with additional custom landmarks. Measurements were converted to absolute distances by fixing subjects' white-to-white corneal diameters to the validated average in Caucasians. Results: Attractive females had significantly greater upper and middle facial proportions, more uniformly divided facial thirds, and greater canthal tilt compared with males. Attractive males had significantly greater facial height, bizygomatic and bigonial widths, medial and total brow lengths, and alar width than females. The golden ratio (1.618) was observed in the ratio of facial height to bigonial width in females (1.613), and attractive males closely approximated that ratio (1.566). There were no significant differences in interpupillary distances, eyebrow angles, or horizontal palpebral fissure lengths. No faces in either sex exhibited scleral show. Conclusions: The study is the first to utilize AI in quantifying key sexual dimorphisms among Caucasian celebrity faces. Identifying these contemporary patterns may provide valuable considerations in planning facial aesthetic and gender affirmation surgery.

Predictors of Surgical Versus Medical Management of Eyes in the Setting of Orbital Fracture at an Academic Level I Trauma Center.

We present clinical and imaging predictors of ocular injuries that required medical management versus surgical intervention in cases of orbital fractures. From 2014 to 2020, a retrospective review of patients with orbital fractures who received ophthalmologic consultation and computed scan (CT) analysis at a level I trauma center was performed. Inclusion criteria were patients with confirmed orbital fracture on CT and ophthalmology consultation. Patient demographics, associated injuries, comorbidities, management, and outcomes were collected. Two hundred and one patients and 224 eyes (11.4% bilateral orbital fractures) were included. Overall, 21.9% of orbital fractures presented with a significant concomitant ocular injury. Associated facial fractures were present in 68.8% of eyes. Management included surgical treatment in 33.5% of eyes and ophthalmology-directed medical treatment in 17.4%. On multivariate analysis, clinical predictors of surgical intervention were retinal hemorrhage (OR=4.7 (1.0-21.0), P =0.0437), motor vehicle accident injury (OR=2.7 (1.4-5.1), P =0.0030) and diplopia (OR=2.8 (1.5-5.3), P =0.0011). Imaging predictors of surgical intervention were herniation of orbital contents (OR=2.1 (1.1-4.0), P =0.0281) and multiple wall fractures (OR=1.9 (1.01-3.6), P =0.0450). Predictors of medical management were corneal abrasion (OR=7.7 (1.9-31.4), P =0.0041), periorbital laceration (OR=5.7 (2.1-15.6), P =0.0006), and traumatic iritis (OR=4.7 (1.1-20.3), P =0.0444). We demonstrated a 22% incidence of concomitant ocular trauma in orbital fracture patients at our level I trauma center. Predictors of the surgical intervention included multiple wall fractures, herniation of orbital contents, retinal hemorrhage, diplopia, and motor vehicle accident injury. These findings emphasize the importance of a multidisciplinary team in managing ocular and facial trauma.

Surgical and Patient-Reported Outcomes of Open Perforator-Preserving Anterior Component Separation for Ventral Hernia Repair.

BACKGROUND: Abdominal wall reconstruction is challenging for surgeons and may be life altering for patients. There are scant high-quality studies on patient-reported outcomes following abdominal wall reconstruction. We assess long-term surgical and patient-reported outcomes of perforator-preserving open anterior component separation (OPP-ACS) following large ventral hernia repair. METHODS: A retrospective review of patients with large ventral hernia defects who underwent OPP-ACS performed by the authors (B.A.S., M.J.T.) was conducted between 2015 and 2019. Demographics, surgical history, operative details, outcomes, and complications were extracted. A validated questionnaire, Carolinas Comfort Scale (CCS), was used to assess postoperative quality of life. RESULTS: Twenty-two patients (12 males and 10 females) with a mean age and BMI of 60.9 ± 10 years and 28.9 ± 4.8 kg/m2, respectively, were included. Mean follow-up was 28.5 ± 16.3 months. All had prior abdominal surgery; 15 (68%) for abdominopelvic malignancy, 3 (14%) for previous failed hernia repair, and 8 (36%) had history of abdominopelvic radiation. Overall, 16 (73%) hernias were in the midline, 4 (18%) in the right lower quadrant, 1 (4.5%) in the right upper quadrant, and 1 (4.5%) in the left lower quadrant. Mean hernia defect surface area was 145 ± 112 cm2. A total of 9 patients (40.9%) underwent bilateral component separation, whereas 13 (59.1%) had unilateral. Bioprosthetic mesh was used in all patients as underlay. Mean mesh size and thickness were 545.6 ± 207.7 cm2 and 3.4 ± 0.5 mm, respectively. One patient presented with a minor wound dehiscence, and two presented with seromas not requiring aspiration/evacuation. One patient had hernia recurrence 22 months after surgery. One patient was readmitted for partial small bowel obstruction and one required wound revision. A total of 14 (65%) patients responded to the CCS questionnaire. At 12 months, mean score for all 23 items was 0.29 ± 0.21 (0.08-0.62), which corresponds to absence or minimal symptoms. CONCLUSION: The OPP-ACS is a safe surgical option for large, complex ventral hernias. Our cases showed minimal complication rate and hernia recurrence, and our patients reported significant improvement in life quality.

Craniomaxillofacial Trauma: The Past, Present and the Future.

Reconstruction of facial trauma has seen a significant evolutionary leap in the last 100 years. The current surgical management of facial fractures was made possible by the efforts and creativity of pioneer surgeons, advances in anatomic understanding, and the continued development of biomaterials and imaging technologies. Virtual surgical planning (VSP) and 3-dimensional printing (3DP) are being incorporated into the management of acute facial trauma. The integration of this technology at the point of care is rapidly expanding globally. This article reviews the history of the management of craniomaxillofacial trauma, current practices, and future directions. The use of VSP and 3DP in facial trauma care is highlighted with a description of EPPOCRATIS, a rapid point-of-care process incorporating VSP and 3DP at the trauma center.

Editorial: A Tribute to Mediterranean Pioneers in Facial Plastic and Craniomaxillofacial Surgery.

BACKGROUND: Physicians from the Mediterranean civilization were profoundly instrumental in the early development and contemporary advancement of the craniomaxillofacial field. These feats are scarcely studied or acclaimed. In this editorial, the authors explore the contributions of these major Mediterranean pioneers. METHODS: A literature review on the subject was performed using PubMed, Scopus, Embase, and Mayo Clinic Libraries. RESULTS: Mediterranean medicine has recognized and managed craniomaxillofacial pathologies from as early as the 10th century. The first inscriptions were authored by Abu Alkasem al-Zahrawi and Serefeddin Sabuncuoglu. Starting in the 15th century, Leonardo da Vinci shed light on anatomy and esthetics at a time where Gasparo Tagliacozzi spearheaded maxillofacial techniques. The field during the Renaissance was dominated by Hippocrates Asclepiades. Varaztad Kazanjian revolutionized the armamentarium necessitated by mass emergencies during the World War. In the 20th century, Paul Tessier redefined the limits of craniomaxillofacial treatment by using facial osteotomies and developing refined surgical instruments. Modern day Sam Hamra, Enrico Robotti, and Daniel Labbé continue to lead educational and innovative fronts of the field. CONCLUSIONS: This essay highlights some important historical contributions to the fields of craniomaxillofacial and facial plastic surgery by pioneer surgeons from around the Mediterranean.

Brow and Eyelid Rejuvenation: Trends from the 100 Most Cited Articles over 30 Years.

Background and Objective: Various periorbital rejuvenation techniques have been introduced over the last 3 decades. This study highlights important milestones in the evolution of periorbital rejuvenation surgery by identifying the 100 most-cited articles in this field. Material and Methods: The Web of Science citation index was used to identify the 100 most-cited articles concerning periorbital rejuvenation. Articles published in English from January 1989-April 2020 describing periorbital rejuvenation-related surgical techniques, facial aging, and anatomy were included. The terms "lower blepharoplasty", "upper blepharoplasty", "browlift", "browplasty", "endobrow lift", "endoscopic brow", "Foreheadplasty", "lower eyelid anatomy", "upper eyelid anatomy", "forehead lift", "eyelid rejuvenation", "canthopexy", "canthoplasty", "eyelid fat pad", "orbital fat pad", "tear trough", and "eyelid bags" were entered into the citation search. Web of Science Core Collection was the database used for the search. A manual review of the initial 159 studies was performed. Articles describing reconstructive or non-invasive techniques, injectable fillers, lasers, and neurotoxins were excluded. Of the 100 most-cited articles, the publication year, specialty journal, the corresponding author's primary specialty, the focus of the article, the corresponding author's country of residence, the type of study, and the level of evidence were analyzed. Results: The mean number of citations per article was 75 ± 42. There were more articles published from 1989-1999 (n = 53) than later decades. Most articles originated from the USA (n = 82) and were published in plastic surgery journals (n = 81). Plastic surgery was the primary specialty of the corresponding authors (n = 71), followed by oculoplastic surgery (n = 22). Most articles (n = 69) reported on surgical techniques. Of the clinical studies (n = 69), 45 (79%) provided level IV evidence. Conclusions: Of the 100 most-cited studies on periorbital rejuvenation, studies focusing on periorbital anatomy, aging, and surgical techniques comprised the most-cited publications. An anatomically based approach accounting for age-related changes in the periorbital structures is paramount in the field of contemporary periorbital rejuvenation.

Cosmetic considerations for placement of deep brain stimulation pulse generator: the submammary subfascial approach.

INTRODUCTION: Deep brain stimulation (DBS) is an effective treatment for a number of debilitating neurological diseases. However, the placement of an implantable pulse generator (IPG) can lead to significant cosmetic concerns for some patients. METHODS: We present a subfascial technique of DBS IPG implantation under the breast using a more concealed scar location. The technique is illustrated in a female patient who favored a more aesthetic placement of the DBS to treat essential tremor. Relevant literature of this approach from both breast augmentation and cardiac pacemaker implantation was reviewed. RESULTS: An excellent cosmetic outcome was demonstrated, and reviewing the literature, implanting under the pectoralis major fascia has the potential benefit of reducing complication rates associated with silicone implant placement in the plastic surgery literature when compared to other planes. CONCLUSIONS: The subfascial implantation of IPG was described. This plane, which is used routinely in breast augmentation, has the potential to decrease complication rates compared to placement in the subglandular plane. An inframammary incision provides patients with concerns about the scar and stigmata associated with an infraclavicular location of DBS generator a better cosmetic outcome.

Point of Care Virtual Surgical Planning and 3D Printing in Facial Feminization Surgery.

The use of virtual surgical planning (VSP) and three-dimensional printing (3DP) technologies in the routine facial feminization surgery practice has gained a significant popularity over the past few years. The clinical applications of them are claimed to improve safety, accuracy, and efficiency of facial feminization surgeries. In this article, we review and discuss the current applications of VSP and 3DP in different facial feminization procedures.

Virtual Planning and 3D Printing in the Management of Acute Orbital Fractures and Post-Traumatic Deformities.

Virtual surgical planning (VSP) and three-dimensional (3D) printing have advanced surgical reconstruction of orbital defects. Individualized 3D models of patients' orbital bony and soft tissues provide the surgeon with corrected orbital volume based on normalized anatomy, precise location of critical structures, and when needed a better visualization of the defect or altered anatomy that are paramount in preoperative planning. The use of 3D models preoperatively allows surgeons to improve the accuracy and safety of reconstruction, reduces intraoperative time, and most importantly lowers the rate of common postoperative complications, including over- or undercontouring of plates, orbital implant malposition, enophthalmos, and hypoglobus. As 3D printers and materials become more accessible and cheaper, the utility of printing patient-specific implants becomes more feasible. This article summarizes the traditional surgical management of orbital fractures and reviews advances in VSP and 3D printing in this field. It also discusses the use of in-house (point-of-care) VSP and 3D printing to further advance care of acute orbital trauma and posttraumatic deformities.