The Potential Impact of COVID-19 on Aesthetic Fellowship Programs.

BACKGROUND: The COVID-19 pandemic has brought about immense change in health care. Surgical specialties in particular have had to make major adjustments because of the cancellation of nonemergent surgeries. Aesthetic surgery fellowships are uniquely affected because of the high number of elective cases and the length of the fellowship. The impact of the COVID-19 pandemic on current and upcoming aesthetic surgery fellows has not been studied. OBJECTIVE: The aim of this article was to study the potential impact of the COVID-19 pandemic on both American Society for Aesthetic Plastic Surgeons-endorsed and nonendorsed aesthetic fellowship programs. METHODS: A 23-question anonymous web-based survey was sent to aesthetic surgery fellowship directors with an active program in the United States. Surveys were collected from April 18, 2020, through May 14, 2020, with Qualtrics and then analyzed with Microsoft Excel. A 7-question follow-up survey was sent to directors, and a 23-question survey was sent to aesthetic surgery fellows. Data for these surveys were collected from June 6, 2020, through August 18, 2020. The surveys asked questions pertaining to adjustments and impact on current fellow training, as well as possible impact on fellows starting in 2020 and 2021. RESULTS: There was a 65.5% (19 of 29) response rate for the initial director survey, a 31% (9 of 29) rate for the director follow up survey, and a 28% (9 of 32) rate for the fellow-specific survey. All directors and fellows reported that the pandemic had some impact on aesthetic fellow training. A total of 5.3% of directors reported that they believe COVID-19 would have a "significant impact" on their fellows becoming well-trained aesthetic surgeons, whereas 66.7% of fellows reported that it will have a "mild impact." Predicted impact on future fellows was not as significant. CONCLUSION: Telemedicine, educational efforts, and standardization of guidelines can be increased to minimize loss of training due to COVID-19. Ongoing evaluation and shared experiences can assist fellowships in customizing programs to provide well-rounded education during the pandemic.

Dissection Technique for Abdominoplasty: A Prospective Study on Scalpel versus Diathermocoagulation (Coagulation Mode).

BACKGROUND: The purpose of this study was to evaluate the effect of the dissection technique on outcomes and complications after a full abdominoplasty, comparing 2 different techniques used to raise the abdominal flap: the steel scalpel and the diathermocoagulation device on coagulation mode. METHODS: A prospective study was performed at a single center from January 2009 to December 2011 of patients submitted to abdominoplasty with umbilical transposition. Two groups were identified: group A, abdominoplasty performed with steel scalpel/knife; and group B, abdominoplasty performed with diathermocoagulation on coagulation mode. Several variables were determined: general characteristics, time until drain removal, daily and total volume of drain output, length of hospital stay, operative time, readmission, reoperation, emergency department visits, and local and systemic complications. RESULTS: A total of 119 full abdominoplasties were performed in women (group A, 39 patients; group B, 80 patients). There were no statistically significant differences between groups with respect to general characteristics, except for body mass index, comorbidities, and weight of the surgical specimen; there were no differences for operative time, systemic complications, hematoma, and necrosis incidence. The scalpel group had a highly significant reduction of 54.56% on total drain output, and a 2.65 day reduction on time to drain removal and no reported cases of seroma or healing problems (difference of 81.25% and 90.00%, respectively, between the 2 groups). CONCLUSIONS: Performing abdominal dissection with scalpel had a beneficial effect on patient recovery, as it reduced time requested for drain removal, total drain output, and incidence of seroma and wound healing problems.

Reconstrucción de la mama: ¿qué hacer cuando la reconstrucción primaria falla? / Breast reconstruction: what to do when primary reconstruction failure?

La reconstrucción de la mama, aunque muy perfeccionada y segura, está colmada de complicaciones. Se presentan casos ilustrativos y directrices cuando la reconstrucción inicial falla, de acuerdo con nuestra experiencia de 30 años en el tema. El uso de expansores en el pecho después de la irradiación no se recomienda debido a la alta incidencia de fracasos. La radioterapia después de la reconstrucción del seno con un implante produce contractura capsular; y después de la reconstrucción con colgajo TRAM, produce fi brosis y retracción de la mama reconstruida. La cada vez mayor recurrencia del cáncer de mama después de la tumorectomía y la radiación se maneja con mastectomía con preservación de piel, y a menudo con una mastectomía profi láctica contralateral. Se describe la utilidad y el diseño del colgajo tóraco-abdominal epigástrico y Mid TRAM

Reconstruction of the Breast, although more sophisticated and safer, is fraught with complications. Illustrative cases and guidelines are presented when the initial reconstruction fails based on our 30-year experience in the subject. The use of expanders on post-irradiated chest is not recommended because of the high incidence of failures. Radiation therapy after breast reconstruction with an implant produces capsular contracture; and after TRAM fl ap reconstruction, produces fi brosis and shrinkage of the reconstructed breast. The increasing of breast cancer recurrence after lumpectomy and radiation is managed by non-skin sparing completion mastectomy, and often with a contralateral prophylactic mastectomy. The utility and design of the thoraco-epigastric and Mid Abdominal TRAM fl ap is described

Morphometric study (macroscopic and microscopic) of the lower abdominal wall.

BACKGROUND: Abdominoplasty using a more superficial plane of dissection has several advantages. Previous studies described a trilaminar structure (superficial and deep fat compartments separated by the Scarpa fascia) in the lower abdominal wall. This study aimed to gain a clearer understanding of compartment dominance and changes with increasing adiposity. METHODS: The study was performed on the surgical specimens of 41 female patients submitted to a full abdominoplasty. A morphometric study was performed on 82 sides to evaluate the thickness of the fat layers at predetermined locations (point A over the external oblique muscle and point B over the rectus abdominis muscle). A histologic study was performed in 31 samples to analyze the structure of the fat compartments and Scarpa fascia. RESULTS: A trilaminar structure was always present, and the Scarpa fascia did not become vestigial with increasing adiposity. Total thickness at point B was significantly higher than that at point A; this difference was mainly attributable to the superficial compartment. The deep fat compartment was always thinner than the superficial, corresponding to 25 percent of total thickness in point A and 23 percent in point B. It was less susceptible to an increase in thickness in cases of obesity. Histologic analysis demonstrated constant morphology, with an average Scarpa fascia thickness of 0.29 mm (point A) and 0.28 mm (point B). CONCLUSIONS: This study demonstrates a trilaminar structure with superficial compartment dominance and Scarpa fascia presence irrespective of adiposity in the lower abdominal wall. The deep fat compartment has a minor contribution to the lower abdominal wall thickness.

Scarpa fascia preservation during abdominoplasty: randomized clinical study of efficacy and safety.

BACKGROUND: Scarpa fascia preservation has been suggested as a way of reducing complications associated with conventional abdominoplasty. A prospective randomized study was conducted to evaluate the effect on results and complications of preserving the Scarpa fascia during a full abdominoplasty. METHODS: This was a single-center study conducted from August of 2009 to February of 2011. Patients were assigned randomly to one of two procedures: classic full abdominoplasty (group A) or a similar type of abdominoplasty except for the preservation of the Scarpa fascia and the deep fat compartment in the infraumbilical area (group B). Four surgeons were involved in the study. Several variables were determined: general characteristics, time to suction drain removal, total volume of drain output, length of hospital stay, systemic complications, local complications, and aesthetic result. RESULTS: A total of 160 full abdominoplasties were performed in women (group A, 80 patients; group B, 80 patients) equally divided by the four involved surgeons. There were no statistically significant differences between groups with respect to general characteristics, complications (except for the seroma rate), and aesthetic result. The Scarpa fascia preservation group had a highly significant reduction of 65.5 percent on the total drain output, 3 days on the time to drain removal, and 86.7 percent on the seroma rate. CONCLUSION: Preservation of the Scarpa fascia during an abdominoplasty had a beneficial effect on patient recovery, as it reduced the total drain output, time to drain removal, and seroma rate without compromising the aesthetic result.

Neck rejuvenation--anatomy and clinical correlation.

The restoration of the aesthetic contour of the neck is a challenging but important component of facial rejuvenation. Numerous techniques have been developed to improve the aesthetic outcome. We plan to give an overview of anatomic principles and their clinical correlation.

Scarpa fascia preservation during abdominoplasty: a prospective study.

BACKGROUND: Preservation of the Scarpa fascia has been suggested as a way of lowering complications associated with conventional abdominoplasty. Objective evidence regarding this strategy is lacking. The purpose of this investigation was to evaluate the effect of preserving the Scarpa fascia in the infraumbilical area during a full abdominoplasty. METHODS: A prospective study was performed at a single center from November of 2005 to November of 2007 of the patients submitted to abdominoplasty with umbilical transposition. Two groups were identified: group A, classic full abdominoplasty; and group B, full abdominoplasty with preservation of infraumbilical Scarpa fascia. Several variables were determined: age, body mass index, previous surgical procedures, comorbid conditions, specimen weight, time to suction drain removal, total volume of drain output, and length of hospital stay. RESULTS: A total of 208 full abdominoplasties were performed (group A, 143 patients; group B, 65 patients). There was no statistically significant difference between groups with respect to body mass index, previous abdominal operations, comorbid medical conditions, or weight of the surgical specimen (p > 0.05). The group with preservation of the Scarpa fascia had an average reduction of the total amount of drain output of more than 50 percent (p < 0001). This group also had an average reduction of 2.0 days until the time to drain removal (p < 0.001) and 1.9 days of the hospital stay (p < 0.001). CONCLUSION: Preservation of the Scarpa fascia during abdominoplasty has a beneficial effect on patient recovery, as it reduces the total drain output, time to drain removal, and length of hospital stay.

Lateral orbicularis oculi muscle plasty in conjunction with face lifting for periorbital rejuvenation.

BACKGROUND: The purpose of this study was to evaluate the lateral orbicularis oculi muscle plasty as an alternative periorbital rejuvenation technique during face lift. METHODS: The authors conducted a retrospective review of patients who underwent face lifts between 2004 and 2007. Postoperative follow-up, complications, aesthetic outcome, and patient satisfaction were recorded. The patients were further divided into four groups for the analysis: lateral orbicularis oculi muscle plasty with lower blepharoplasty (group 1), lower blepharoplasty without lateral orbicularis oculi muscle plasty (group 2), lateral orbicularis oculi muscle plasty without lower blepharoplasty (group 3), and neither lateral orbicularis oculi muscle plasty nor lower blepharoplasty (group 4). RESULTS: A total of 76 patients were identified as having had a midface lift with or without lateral orbicularis oculi muscle plasty in the study period. Sixty-eight percent of the patients had a lateral orbicularis oculi muscle plasty procedure. Group 3 showed the lowest complication rate followed by group 4, but there were no statistical differences in complication rates among the study groups. The higher aesthetic result and patient satisfaction were obtained by groups 3 and 4 (p < 0.01). Group 2 had the highest complication rate and lowest overall outcomes. CONCLUSION: The authors have been able to demonstrate that lateral orbicularis oculi muscle plasty is a safe technique that may be considered a good alternative for periorbital rejuvenation and may help in avoiding lower lid incisions or extensive dissections during face lifting in some cases.

Suture suspension technique for midface and neck rejuvenation.

Seventeen patients averaging 51 years of age underwent 23 surgical procedures, including suture suspension for both midface and neck rejuvenations. A 3/0 polypropylene thread with bioabsorbable cones with multiple point fixations in addition to 2 x 0.5-cm polypropylene surgical mesh are used in this technique. The mean postoperative, follow-up time was 9 months. Of the 17 patients, 12 underwent this procedure for midface rejuvenations, 3 for facial palsy, 5 for neck aesthetic procedures, 2 for brow ptosis, and 1 for brow asymmetry. The average number of sutures used for each face was 4 and 2 were used for each neck. The authors present an anatomic study for the safe placement of sutures, the surgical technique, and a microscopic photo documentation of the fibrosis around the suture knot and cone. All patients developed temporary edema. Two patients had a moderate aesthetic improvement of the face, and 1 patient underwent resuspension of the sutures 4 months postsurgery. Overall early patient satisfaction at 9 months was 90%. This technique has the potential to be a useful and effective clinical tool for minimally invasive face and neck rejuvenations.

Promotion of incisional wound repair by human mesenchymal stem cell transplantation.

The purpose of this study was to determine the effect of transplanted human mesenchymal stem cells (hMSCs) on wound healing. In this model, full-thickness cutaneous wounds were created by incision in the skin of adult New Zealand white rabbits and treated by transplanted hMSCs into the wounds. Wound healing was evaluated by histological analysis and tensiometry over time. A total of 15 New Zealand white rabbits with 10 wounds per animal were examined in this study. Animals were treated with hMSCs and euthanised at 3, 7, 14, 21 and 80 days after manipulation. The hMSCs were labelled with a fluorescent dye (CM-DiI), suspended in phosphate-buffered saline and used to treat full-thickness incisional wounds in rabbit skin. Tensiometry and histology were used to characterise the wound-healing rate of the incisional wounds. These results showed that transplanted hMSCs significantly inhibited scar formation and increased the tensile strength of the wounds. Importantly, MSCs from genetically unrelated donors did not appear to induce an immunologic response. In conclusion, human mesenchymal stem cell therapy is a viable approach to significantly affect the course of normal cutaneous wound healing and significantly increase the tensile strength.

Mastectomy with breast reconstruction in previously augmented patients: indications for implant removal.

Surgeons performing breast reconstruction in previously augmented patients can either leave the preexisting implant in place and incorporate the implant into the reconstruction, or remove the implant, usually performing an implant exchange. The focus of this study is to identify indications for implant removal in previously augmented patients undergoing mastectomy with breast reconstruction. We performed a retrospective chart review of patients who underwent breast reconstruction from 1997-2007 at University of Alabama, Birmingham Medical Center. Of these patients, 54 had previous augmentation with silicone or saline implants. Twenty-two of these underwent bilateral breast reconstruction, making a total of 76 reconstructed breasts. Patients were followed for a mean of 2.1 years (range 0.1-5.1 years). The mean body mass index was 23.0 (range 18-30). Implants were explanted in all but one patient. Reasons for implant removal or exchange included subglandular position (n = 39), aged silicone implant (n = 50), rupture or leak (n = 24), implant exposure (n = 1), and infection (n = 1). Some patients had more than one reason for explantation. We recommend removal of preexisting implants for patients who have implants in a subglandular position, ruptures or leaks, site infections, implant exposures, capsular contractures, pain, indolent seromas, aged silicone implants, poor cosmesis, plans for or history of radiotherapy, and close proximity of tumor to implant. We also remove implants to respect patient preferences and to achieve symmetry in our reconstruction. Consequently, we find in our practice that most of previously augmented patients who undergo breast reconstruction will also undergo implant removal.

Distally based superficial sural fasciomusculocutaneous flap: a reliable solution for distal lower extremity reconstruction.

The objective of this study is to present a simple and rapid approach to elevate a consistent superficial sural fasciomusculocutaneous flap and show its clinical applications. All the patients with lower limb defects who underwent reconstruction using the distally based fasciomusculocutaneous sural flap were included in the study. The flap was elevated with a cuff of gastrocnemius muscle under the skin paddle, and the distal pedicle was dissected until 5 cm over the lateral malleolus. The donor site is primarily closed or skin-grafted. From March 2004 to August 2006, this distally based superficial sural fasciomusculocutaneous flap was applied to nine patients. All the defects resulted from traumatic injuries of the distal third of the leg, ankle, or foot, combined with bone or tendon exposure. Two flaps developed minor distal skin necrosis that recovered uneventfully with conservative therapy. The other flaps had an adequate postoperative evolution with good blood supply, contour, and function. The superficial sural fasciomusculocutaneous flap is a simple and consistent alternative for distal lower limb reconstruction, particularly when microsurgery is not available.

Ischemic complications in pedicle, free, and muscle sparing transverse rectus abdominis myocutaneous flaps for breast reconstruction.

Muscle sparing and perforator flaps techniques for breast reconstruction have focused in reducing the donor site morbidity. Theoretically this may result in a less robust blood supply to the flap. The purpose of this study was to assess flap ischemic complications with the pedicle, free, and the different muscle sparing transverse rectus abdominis myocutaneous (TRAMs) flaps for breast reconstruction and determine the factors associated with these complications. A total of 301 consecutive patients that underwent 399 breast reconstructions were retrospectively reviewed. Patient, oncologic, and reconstruction data were recorded. A flap ischemic complication scale was design including: wound healing problems, skin flap necrosis, fat necrosis, partial flap loss, and total flap loss. Analysis of donor site complications, bilateral and unilateral reconstructions were also performed. There were 147 pedicle TRAM and 154 free TRAM with the following subgroup distribution: MS-0 = 102; MS-1 = 37; and MS-2 = 15 patients. The groups were comparable in relation to age, comorbidities, cancer stage, and treatment. The overall complication rate after reconstruction had no statistical differences between the groups. The variables related to flap ischemia were statistically lower in the free TRAM. Mild and severe fat necrosis were the indicators with a statistical difference. The MS-0 group had lower ischemic complications and fat necrosis than the pedicled group, but no differences were observed for the MS-1 and MS-2 groups. The same results were seen in the unilateral reconstructions but not in the bilateral ones. No differences in donor site bulging or hernia were observed between the groups. In our study, the free TRAM flap demonstrated lower ischemic complications than the pedicle TRAM. A trend for decreased flap blood supply when more muscle is preserved and less number of perforators are used with a constant tissue volume was observed.

Open repair of ventral incisional hernias.

Despite advances in many fields of surgery, incisional hernias still remain a significant problem. There is a lack of general consensus among surgeons regarding optimal treatment. A surgeon's approach is often based on tradition rather than clinical evidence. The surgeon's treatment plan should be comprehensive, with attention focused not merely on restoration of structural continuity. An understanding of the structural and functional anatomy of the abdominal wall and an appreciation of the importance of restoring dynamic function are necessary for the successful reconstruction of the abdominal wall.