Enhancing Patient Outcomes in Aesthetic Breast Implant Procedures Using Proven Antimicrobial Breast Pocket Irrigations: A 20-Year Follow-up.

BACKGROUND: Capsular contracture (CC) remains the most common complication of implant-based aesthetic and reconstructive breast surgery. With subclinical infection proven to be the primary etiology, antimicrobial breast pocket irrigation has been recommended as the key step to reduce CC but has not been universally adopted. OBJECTIVES: The purpose of this study was to review the rates of CC observed when applying proven antimicrobial breast pocket irrigations. METHODS: Data from patients undergoing cosmetic breast augmentation were recorded prospectively from 1997 to 2017. The irrigation was performed with either a Betadine-containing (50% Betadine or "Betadine triple") or a non-Betadine triple antibiotic regimen. The database was assessed to determine the type of implant used, the incidence of CC, and possible contributing factors. The degree of CC was recorded according to the Baker classification. RESULTS: A 20-year prospective data collection yielded 2088 patients with 4176 implants; of these patients, 826 had textured implants and 1262 had smooth implants. The incidence of Grade III/IV CC was found to be 0.57% in all patients undergoing primary breast augmentation (1.21% in textured implants and 0.16% in smooth implants). CONCLUSIONS: This study constitutes the largest and longest review of CC in a controlled, single-surgeon setting. The incidence of CC is low and reinforces the efficacy/utility of antimicrobial breast pocket irrigation. Both the Betadine and non-Betadine antibiotic regimens were found to be effective, with the Betadine regimen being preferred. Universal adoption of Betadine-containing antimicrobial breast pocket irrigation is recommended to reduce CC and other device-associated infections.

The Role of Adipose Tissue in Hair Regeneration: A Potential Tool for Management?

Human adipose tissue (AT) is a rich and easily harvestable source of stem cells and various growth factors (GFs). It has been widely used hitherto for facial rejuvenation and volumization. Increasing evidence shows that dermal adipocytes are intricately associated with hair follicles (HFs) and may be necessary to drive follicular stem cell activation. Early published data have shown encouraging preliminary results for the use of adipocytes and their stem cells as a treatment option for hair growth. The aim of this review study is to analyze published literature on the effect of fat on hair growth and to summarize the current evidence.

9 Tips and Pearls for Safer Performance of Dermatological Procedures during Covid-19 Pandemic.

SARS-CoV2 pandemic has affected dermatologypractice greatly. In view of the risk of transmission, physicians need to devise methods to perform procedures in a safer way. Our institute has adopted a number of innovative safety precautions steps, which are being outlined here.

Non-Surgical Rhinoplasty: The Ascending Technique and a 14-Year Retrospective Study of 2130 Cases.

INTRODUCTION: Non-surgical rhinoplasty or liquid/filler rhinoplasty is one of the fastest-growing cosmetic procedures worldwide. While several papers have been published on this topic, there has been no standardization of the technique. Most techniques advise injection in a top-down manner, similar to a traditional rhinoplasty. We present our ascending technique performed in 2130 cases. This constitutes one of the largest series published on this subject. METHODS: Patient records were retrospectively analysed from 2006 to 2019. All patients were injected with hyaluronic acid fillers. We employed an ascending approach which consisted of four sites: nasal tip, columellar base, dorsum (including supratip) and radix. The tip was first set at the appropriate projection and rotation and then the dorsum adjusted to meet it. RESULTS: Since 2006, 2130 patients underwent non-surgical rhinoplasty; 2023 patients were female (95%), and 107 were male (5%). The proportions by site injected were tip 95%, columella 58%, dorsum 83%, radix 62%. Sixty-two percent (1321) repeated the procedure after 1 year. Two percent of patients had persistent tip redness which recovered. There was no skin necrosis or ocular complications. CONCLUSIONS: In non-surgical rhinoplasty, all modifications are being done by pure addition, unlike surgical rhinoplasty. In this scenario, the risk of over-projecting the tip is higher. Hence, we believe it is important to set the tip at the desired projection and size and then raise the dorsum accordingly to match. Our high satisfaction rate over 2130 patients validates the efficacy of this ascending technique. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors - www.springer.com/00266 .

Beware of the Impostors-Scalp Pathology Primer for the Hair Transplant Surgeon.

Histopathological features are important for the practicing hair transplant surgeon to ensure proper case selection, diagnosis, choice of proper treatment, and successful outcome. While the primary focus of the hair transplant surgeon is androgenetic alopecia (AGA), it is important to be aware of other conditions that can mimic AGA, whose treatment may be different. This article outlines some of these conditions such as scarring alopecias, alopecia areata, etc., and how to distinguish them. Proper identification will ensure proper treatment and avoid potential missteps in management.

Optimal Hair Transplant Recipient Site Slit Design: Minimizing Vascular Damage.

An often overlooked aspect of hair transplantation is the art of recipient site design and slit creation. There is also a lack of consensus on which technique provides the optimum coverage while minimizing vascular damage. This paper aims to provide logical arguments to determine the optimal instrument and method of slit creation, in order to ensure maximum density, optimal survival, minimal pop-out, and minimal damage to scalp vascularity. The use of semiconical blades reduces the damage to the dermis and vascular plexus as compared with rectangular blades and needles, as the depth of penetration required is lower. The use of acute angle reduces the depth of penetration for the same length of slit and decreases damage to deep plexus. Coronal slits produce less vascular damage than that of sagittal slits with the same size blades. We believe that these recommendations provide the optimum volume slits while causing minimal vascular damage.

Regenerative Medicine Treatments for Androgenetic Alopecia.

Regenerative medicine and the role of stem cells are being studied for applications in nearly every field of medicine. The pluripotent nature of stem cells underlies their vast potential for treatment of androgenic alopecia. Several advances in recent years have heightened interest in this field, chief among them are the evolution of simpler techniques to isolate regenerative elements and stems cells. These techniques are easy, outpatient procedures with immediate injection, often single session with harvest, and minimal manipulation (usually physical). This paper seeks to critically review the existing data and determine the current evidence and their role in practice.

Importance of Choke Vessels in Injectable Fillers.

Knowledge of facial anatomy is indispensable for dermatologists and plastic surgeons practicing aesthetic medicine, especially for those using fillers, as injection of fillers may be associated with serious complications such as vascular occlusion and blindness. Angiosome and choke vessels play an important role in vascular incidents occurring after filler injections. The objective of this article was to outline the anatomy and pathophysiology of choke vessels, a concept which is not well known to dermatologists.

Recommendations for Cutaneous and Aesthetic Surgeries during COVID-19 Pandemic.

BACKGROUND: Amid the coronavirus disease 2019 (COVID-19) pandemic, dermatologists must be prepared to restructure their practice of procedural dermatology and cutaneous aesthetic surgeries. The COVID-19 pandemic has presented several challenges and has ushered in several changes in practice such as teledermatology, with many physicians adopting virtual consultations and treatments. Performing procedures in the times of COVID-19 pandemic presents challenges such as risk of transmission to doctors and staff due to potential aerosolization, release of virus droplets during the procedures, and risk of virus transfer through the instruments both in the peri- and postoperative period. This can have several medical, administrative, and legal implications. OBJECTIVES: This document aimed to outline best practices that can be followed in this scenario to perform cutaneous surgeries and procedures to ensure safer skin surgery. RECOMMENDATIONS: Standard precautions include social distancing of at least 1 m, hand hygiene, appropriate use of personal protective equipment (PPE), safe injection practices, sterilization and disinfection of medical devices, environmental cleaning, and respiratory hygiene. It is generally advisable to see patients only by appointments. Each clinic should have a special area at entry for screening patients and providing sanitizers and masks. Procedures, which are of short duration, performed on nonfacial areas are considered as low risk and require donning surgical mask. Procedures involved with minimal invasiveness and bleeding, short duration procedures on the face such as injectables, chemical peels, and aerosol-generating procedures on nonfacial areas are considered moderate risk. These procedures need apron with head cover, N95 mask, face shield, double gloves, and smoke evacuator with high-efficiency particulate air (HEPA) or ultralow particulate air (ULPA) filter. Aerosol and plume-regenerating procedures (such as ablative lasers on the face), prolonged surgeries on head (such as hair transplantation), intraoral, and intranasal procedures are considered high risk. These procedures must be carried out with full body cover with surgical gown, head cover, N95 mask, face shield, double gloves, and smoke evacuator. Physicians should be aware of local epidemiological situation and adhere to the relevant guidelines issued by the relevant governmental agencies.

Tumescent Anesthesia for Dermatosurgical Procedures Other Than Liposuction.

CONTEXT: Tumescent local anesthesia is a form of local anesthesia, which is a technique in which a dilute local anesthetic solution is injected into the subcutaneous tissue until it becomes firm and tense. Originally developed to facilitate liposuction, the use of tumescent anesthesia has expanded to other dermatological and plastic surgery procedures, as well as to other disciplines, including endocrine and vascular surgeries. For infiltration local anesthesia, the conventional dosage of lidocaine is up to 4.5 mg/kg, and that with adrenaline is up to 7 mg/kg; however, in liposuction using tumescent anesthesia, the recommended maximum dose of lidocaine with adrenaline is up to 55 mg/kg. There are several important pharmacological, pharmacokinetic, and pharmacodynamic factors that need to be considered in the administration of tumescent anesthesia leading to considerable interdisciplinary differences of opinion with respect to the maximum dose of local anesthetic permissible. Although several studies and publications have studied these issues in liposuction extensively, the role of tumescent anesthesia in other indications has not been reviewed adequately. AIMS AND OBJECTIVES: The aim of this study was to discuss the science behind tumescent anesthesia, its applications, and safety considerations in different dermatosurgical procedures other than liposuction. MATERIALS AND METHODS: For this review, a systematic literature search in PubMed, Embase, Web of Science, Cochrane Library, Central, Emcare, Academic Search Premier, and ScienceDirect was conducted for safety studies on tumescent anesthesia. CONCLUSION: Tumescent anesthesia is generally very well accepted by patients and is relatively safe at the recommended doses. Nonetheless, one must be vigilant about the signs and symptoms of LAST, as they may not manifest until several hours after the procedure. Lipid emulsion therapy should be readily available and could prove life-saving in such situations.

Aesthetic subunits of the trunk: Anatomy and behavior of skin and adipose tissue in each unit for better outcomes in liposuction.

BACKGROUND: Liposuction and abdominal contouring is one of the most common procedures performed by plastic surgeons worldwide. Surprisingly, there has been few attempts at dividing the abdomen into subunits to delineate and aid in this endeavour. We have evolved a system of abdominal aesthetic subunits which has enabled us to achieve high quality results. MATERIALS AND METHODS: A system of 8 subunits of the abdomen was evolved after analysing 1000 cases: Upper midline, upper rectus, lower rectus, pubic, Lateral abdomen, Lumbar Posterior midline and Bra Roll. RESULTS: The system was used in 2000 cases with good results. The system enabled the performance of tailored liposuction in each area, with greater accuracy, better results and fewer complications. CONCLUSION: Our success with this classification validates its use, and makes liposuction more scientific and effective.

Clinical Implications of Gluteal Fat Graft Migration: A Dynamic Anatomical Study.

BACKGROUND: The intraoperative mortality and overall complication rate for gluteal augmentation with fat transplantation is unacceptably high. The current controversy among experts regarding safety is whether fat should be placed within the gluteus muscle or limited to only the subcutaneous space. The purpose of the present study was to test the hypothesis that under certain pressures, fat injected within the gluteal muscle can actually migrate out of the muscle and into a deeper plane containing critical neurovascular structures, by means of the process of deep intramuscular migration. METHODS: A total of eight human cadaver dissections were performed. Four hemibuttocks were selected for intramuscular fat injection. The patterns of subfascial fat migration were evaluated in three of these hemibuttocks by direct visual inspection and in one hemibuttock by endoscopic evaluation. Four other hemibuttocks were selected for subcutaneous or suprafascial fat injection. RESULTS: Proxy fat was found to migrate through the muscle and into the deep submuscular space with each intramuscular injection. With subcutaneous injection, no proxy fat was found during dissection in the intramuscular septae or submuscular space. CONCLUSIONS: The intramuscular insertion of fat, which up to this point has been considered reasonable to perform in the superficial muscle and even recommended in the literature, is now deemed to be an inexact and risky surgical technique. This technique, because of the migratory nature of injected fat, should be avoided from further use in fat transplantation to the gluteal region.

Logic of Hair Transplantation.

Hair transplant is a seemingly illogical process wherein we are using a small number of hairs to cover a large area of baldness. This is possible if one understands the logic of this equation. Understanding the pattern of hair distribution, and the sequence of balding, helps us learn the limitations of this technique and give the best possible results to the patient. In this article, we aim to give an understanding of all the processes associated with hair transplantation and the logic behind the same.

Radial Artery Forearm Flap Anomaly: A Rare Anomaly and the Importance of the Proximal Exploratory Incision.

During a free radial forearm flap harvest, we encountered a variant anatomy of the arterial system. The brachial artery was found to travel with the median nerve and bifurcate 10 cm below the antecubital fossa, under cover of the pronator teres. The radial artery then emerged from the pronator and continued on its usual path. This anomaly has been reported only once thus far. We report this case to highlight our practice of always starting with a proximal exploratory incision to identify the anatomy before raising the flap, which is what enabled us to adapt to this variation with a satisfactory outcome.

Forequarter Replantation and the Lessons Learnt.

The literature on major upper limb replantation, especially those proximal to the elbow, is inadequate. An 18-year-old man presented to us with a left forequarter amputation. A replantation was attempted with a view to salvaging function and avoiding prosthesis. The procedure was technically challenging with a number of issues not highlighted in previous reports, particularly bony stabilization. The procedure was initially successful, with good perfusion. However, with time, the limb showed sepsis and had to be abandoned. We report this case to add to the literature on replantation at the shoulder level in the hope that this procedure may be reported successfully in the future.

Smart apps for the smart plastic surgeon.

Smartphones have the ability to benefit plastic surgeons in all aspects of patient care and education. With the sheer number of applications available and more being created everyday, it is easy to miss out on apps which could be of great relevance. Moreover, the range of android applications available has not been extensively discussed in the literature. To this end, we have compiled an exhaustive list of android smartphone applications, which we feel can help our day to day functioning. The apps have been extensively reviewed and neatly described along with all their potential uses. In addition, we have made an effort to highlight 'non-medical' or efficiency apps which can improve departmental functioning. These apps have not been described in prior articles, and their functionality might not be known to all. We believe that the technology savvy plastic surgeon can make maximum use of these apps to his benefit.

Postoperative venous thromboembolism prophylaxis by general surgeons in a developing country: a survey.

Venous thromboembolism (VTE) is the most common preventable cause of hospital death. Several audits in the west have demonstrated that appropriate thromboprophylaxis is not being offered to a large number of surgical patients. Similar audits are lacking in the Indian population, and a perception exists among Indian surgeons that Indian patients are not susceptible to VTE. Hence we undertook a survey to analyze the existing knowledge and practice of VTE prophylaxis amongst general surgeons in India. A questionnaire-based survey was conducted on 100 active general surgeons. We found that 97% of surgeons had encountered VTE in their practice, and 49% had encountered mortality from pulmonary embolism. 64% of surgeons do not routinely score patients preoperatively for their VTE risk, and only 33% reported the presence of an institute-based protocol for the same. There was a wide disparity in the prophylaxis methods used for each risk group, particularly in the moderate-risk group. These findings suggest the need for adoption of institute-based protocols for prophylaxis and the evolution of Indian guidelines for VTE prophylaxis.