Body Contouring in Massive Weight Loss Patients Receiving Venous Thromboembolism Chemoprophylaxis: A Systematic Review.

Venous thromboembolism (VTE) events are the leading cause of morbidity and mortality in plastic surgery. Currently, there is no consensus regarding the use of VTE chemoprophylaxis in the context of the risk for bleeding following specific body contouring procedures. Furthermore, there is increasing popularity of these procedures in the massive weight loss (MWL) patient population, who may be at higher risk due to multiple risk factors. The purpose of this study was to stratify the incidence of VTE and bleeding events among individual, specific body contouring procedures in MWL patients receiving chemoprophylaxis. METHODS: A systematic review was designed according to PRISMA guidelines. We screened all articles published between 1988 and 2018 reporting chemoprophylaxis status, VTE, and bleeding events in MWL patients undergoing body contouring procedures. RESULTS: Thirty-one publications were reviewed. The VTE incidence for any procedure was too low to reach significance. Overall, hematoma incidence in single-procedure patients (8.7%) was significantly higher than concomitant-procedure patients (4.2%, P < 0.01). However, when stratified into operative and nonoperative hematomas, no significant difference between single- and concomitant-procedure groups overall was demonstrated for either category. Individually, only thighplasty patients had a higher rate of operative hematomas when undergoing thighplasty alone (5.3%) compared with thighplasty with concomitant procedures (0.6%, P < 0.05). CONCLUSIONS: Overall, MWL patients undergoing single body contouring procedures (among abdominoplasty, belt lipectomy, thighplasty) were found to have a higher risk of hematoma compared with those undergoing combined contouring procedures. However, stratified hematoma data revealed no differences in overall risk between single- and multiple-procedure operations.

Routine Postoperative Antibiotics After Tissue Expander Placement Postmastectomy Does Not Improve Outcome.

PURPOSE: In an attempt to reduce the incidence of infectious complications after tissue expander-based breast reconstruction, the routine administration of postoperative antibiotics regimen is common in many practices. In recent years, there has been a plethora of reports scrutinizing the prophylactic use of postoperative antibiotics in this setting. The aim of this study was to determine the efficacy of prolonged administration of postoperative antibiotics compared with perioperative-only antibiotic administration for prophylaxis after tissue expander placement for immediate mastectomy reconstruction. METHODS AND MATERIALS: A retrospective chart review of all patients who underwent immediate tissue expander placement after mastectomy at our institution from June 2005 to September 2018 was performed. All patients in the study received perioperative intravenous antibiotics 30 to 60 min preoperatively and for 24 hours postoperatively. Patients were divided into 2 groups. Patients in group A did not receive antibiotics beyond the perioperative period. Patients in group B received oral antibiotics for at least 7 days postoperatively in addition to the perioperative intravenous antibiotics. The 2 groups were compared for demographics and prevalence of risk factors such as radiation, chemotherapy, smoking, and diabetes. The incidence of complications such as infection, wound complications, hematoma, seroma, capsular contracture, loss of tissue expander, and reoperations was assessed. SUMMARY OF RESULTS: A total of 529 patients were included in the study, of which 241 were in group A and 288 were in group B. The total number of breasts reconstructed in group A was 398, whereas in group B, it was 466 breasts. Patients were followed up to 5 months postoperatively in each group. There were no statistically significant differences in the demographic and patient characteristics among the 2 groups. The incidence of infection in group A was 23.24% and in group B was 21.53% (P = 0.412). The incidence of other complications follows the same trend when comparing group A versus B. CONCLUSIONS: This retrospective study shows that the routine use of postoperative antibiotics after tissue expander placement for immediate mastectomy reconstruction does not result in reduction in the incidence of common complications or improvement of clinical outcomes.

The Effect of Obesity, Bariatric Surgery, and Operative Time on Abdominal Body Contouring Outcomes.

BACKGROUND: Abdominal body contouring procedures are associated with the highest rates of complications among all aesthetic procedures. Patient selection and optimization of surgical variables are crucial in reducing morbidity and complications. OBJECTIVES: The purpose of this single-institution study was to assess complication rates, and to evaluate BMI, operative time, and history of bariatric surgery as individual risk factors in abdominal body contouring surgery. METHODS: A retrospective chart review was performed of all patients who underwent abdominoplasty, circumferential lower body lift, fleur-de-lis panniculectomy (FDL), and circumferential FDL between August 2014 and February 2020. Endpoints were the incidence of venous thromboembolism, bleeding events, seroma, infection, wound complications, and reoperations. Univariate statistical analysis and multivariate logistic regressions were performed. Covariates in the multivariate logistic regression were BMI, procedure time, and history of bariatric surgery. RESULTS: A total of 632 patients were included in the study. Univariate analysis revealed that longer procedure time was associated with infection (P = 0.0008), seroma (P = 0.002), necrosis/dehiscence (P = 0.01), and reoperation (P = 0.002). These associations persisted following multivariate analyses. There was a trend toward history of bariatric surgery being associated with minor reoperation (P = 0.054). No significant increase in the incidence of major reoperation was found in association with overweight or obese patient habitus, history of bariatric surgery, or prolonged procedure time. BMI was not found to be an individual risk factor for morbidity in this patient population. CONCLUSIONS: In abdominal body contouring surgery, surgery lasting longer than 6 hours is associated with higher incidence of seroma and infectious complications, as well as higher rates of minor reoperation.

Aesthetic Surgical Enhancement of the Upper Lip: A Comprehensive Literature Review.

BACKGROUND: The recent rise in popularity of minimally invasive facial aesthetic procedures has resulted in the overall heightened patient interest in lip rejuvenation. There is a variety of techniques and modifications for surgical upper lip enhancement described in the literature but no single method is considered optimal. The aim of this literature review is to provide a comprehensive analysis of the studies dealing with surgical upper lip enhancement and evaluate their short- and long-term outcomes, as well as complication profiles. METHODS: A comprehensive review of the published literature through July of 2019 was performed. The PUBMED and Cochrane databases were searched for all English language articles on aesthetic surgical enhancement of the upper lip. Only articles dealing with the aesthetic aspect of the upper lip subunit were included. Preoperative assessment, patient selection and technique execution were assessed. Data were abstracted on all postoperative complications and outcomes. RESULTS: Overall, 52 articles were screened for inclusion, of which 17 met the inclusion criteria. The total number of patients treated in these studies was 2265. The average follow-up period was 30 months. The most commonly used surgical method across the studies was the subnasal lip lift (93.6%). The bull's horn excision pattern was utilized to perform the subnasal lip lift in 71.7% of the cases, and the wavy ellipse excision was used in 18.1% of patients. Lip advancement by vermillion border excision pattern was the technique of choice for 49 patients (2.2%). Across all patients the most common complication was a non-aesthetically appealing result or adverse scarring with a mean incidence of 7.23%. Overall, the studies reported improvement in the aesthetic appearance of the upper lip after surgical enhancement, along with few but promising reports of high patient satisfaction. There is a relative paucity of high-quality data regarding complication profiles, patient selection, indications and contraindications. CONCLUSIONS: This review provides an overview of several techniques and modifications for upper lip enhancement. It highlights the paucity of high-quality data on their application and optimizing patient selection. Promising satisfaction rates and relatively low complication rates suggest a more prominent role for surgical cheiloplasty in facial rejuvenation. LEVEL OF EVIDENCE III: 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 .

Safety of Rivaroxaban for Postoperative Venous Thromboembolism Prophylaxis Following Abdominal Body Contouring Surgery: 600 Patients.

BACKGROUND: Reducing the incidence of venous thromboembolism (VTE) following abdominal body contouring surgery remains a top priority for patient safety. There is a lack of consensus regarding the optimal chemoprophylactic agent for postoperative VTE prophylaxis, and the role of oral anticoagulants warrants further investigation. OBJECTIVES: The aim of this multisurgeon, single-institution study was to determine the safety and efficacy of a 7-day postoperative rivaroxaban regimen for VTE prophylaxis in abdominal body contouring surgery. METHODS: A retrospective chart review was performed of all patients who underwent abdominoplasty, circumferential body lift, fleur-de-lis panniculectomy, or circumferential fleur-de-lis panniculectomy at our surgical center from August 2014 to November 2019. A 7-day postoperative course of once-daily 10 mg rivaroxaban, starting on postoperative day 1, was administered to every patient unless there was a contraindication. The 2 primary endpoints were the incidence of VTE and bleeding events. RESULTS: A total of 600 patients were included in the study. There were no deaths. There were 4 (0.7%) incidents of VTE events: 2 (0.3%) patients suffered pulmonary embolus and 2 (0.3%) patients suffered a lower-extremity deep venous thrombosis. A total of 13 (2.2%) patients suffered complications related to bleeding. Of these, operative intervention for control and evacuation was required in 7 (1.2%) patients. CONCLUSIONS: A 7-day postoperative course of once-daily rivaroxaban for VTE risk reduction in abdominal body contouring surgery is associated with a low incidence of VTE events and a low risk of bleeding complications.

The Three-Triangle Rotation Flap Technique for Aesthetic Ear Lobule Reduction.

BACKGROUND: Although the effect of normal aging on the appearance of the ear lobule is well known and defined, this often a neglected aspect of facial rejuvenation. Rhytidectomy offers a great opportunity to surgically enhance the aging earlobe. The objective of this study was to provide a step-by-step description of the execution of the three-triangle rotation flap technique for aesthetic ear lobule reduction. METHODS: The three-triangle rotation flap technique is described in a step-by-step fashion and illustrated by photographs and videos. All ear lobule reduction procedures that took place at our practice from December 2016 to February 2020 were retrospectively reviewed. RESULTS: A total of 16 patients underwent bilateral ear lobule reduction during face lift, neck lift, or both, and 7 patients underwent bilateral lobule reduction in isolation. None of the patients experienced complications, and revisions were not performed or required. CONCLUSIONS: The three-triangle rotation flap technique relies on simple principles that can be adjusted to address all shapes and degrees of true ear lobule ptosis, as well as patient desire. It is employed in isolation or synchronous with rhytidectomy. When performed during rhytidectomy, it provides lobule stability and fixation. LEVEL OF EVIDENCE V: 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 .

Four-Position Four-Entry Site Circumferential Arm Liposuction: Technique Overview and Experience.

BACKGROUND: In attempting to overcome the challenges associated with arm contouring, arm liposuction has been an area of focus in recent years. In appropriately selected patients, circumferential liposuction is the procedure of choice. The objective of this study is to describe our experience with the four-position four-entry site circumferential arm liposuction technique. METHODS: All consecutive circumferential liposuction procedures that took place at our ambulatory surgical facility from January 2015 to November 2019 were retrospectively reviewed. The four-position four-entry site circumferential arm liposuction technique is described, and photographs as well as videos are presented. RESULTS: A total of 35 patients underwent circumferential bilateral arm liposuction via the four-position four-entry site technique. All patients were female, and their average age was 43 years. The average BMI was 28.4 kg/m2, and the average follow-up was 481 days. The average volume of lipoaspirate was 1,514 ml per patient, and the average volume of aspirated fat was 1,052 ml per patient. There was no incident of infection, seroma, bleeding event or venous thromboembolism. CONCLUSIONS: For the right candidate, the four-entry site four-position circumferential arm liposuction is an efficient and reproducible technique, which produces predictable and pleasing results. 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 .

Avulsion Fat Graft Gluteoplasty: Technique Overview.

BACKGROUND: The popularity of gluteoplasty has grown significantly in recent years, and there are a variety of techniques described to address gluteal aesthetic deformities. The aim of this study was to describe the avulsion fat graft gluteoplasty technique. METHODS: A review of all consecutive patients undergone avulsion fat graft gluteoplasty from February 2018 to March 2019 was performed. Data included demographics, operative details, and clinical outcomes. RESULTS: A total of 7 patients with a minimum of 6 months follow-up were analyzed and included in the study. The avulsion fat graft gluteoplasty technique is described in a step-by-step fashion and illustrated by preoperative, postoperative, and intraoperative photographs, as well as video. The average total weight of the avulsed specimen was 372 g (range, 176-596 g) per patient. The average total volume of fat grafting was 593 mL (range, 344-900 mL) per patient. CONCLUSIONS: The avulsion fat graft gluteoplasty is a powerful technique with consistent results and low-risk profile. It provides durable lift and augmentation and produces a predictable and aesthetic scar.

Postoperative Venous Thromboembolism Prophylaxis Utilizing Enoxaparin Does Not Increase Bleeding Complications After Abdominal Body Contouring Surgery.

BACKGROUND: Venous thromboembolism (VTE) chemoprophylaxis warrants an individualized, risk-stratified approach, and constitutes a relatively controversial topic in plastic surgery. OBJECTIVES: The aim of this study was to determine the safety of a 7-day postoperative enoxaparin regimen for VTE prophylaxis compared with a single preoperative dose of heparin in abdominal body contouring surgery. METHODS: This single-institution pre-post study investigated the safety of a 7-day enoxaparin postoperative regimen in abdominal body contouring procedures performed by a single surgeon from 2007 to 2018. Four procedures were included: traditional panniculectomy, abdominoplasty, fleur-de-lis panniculectomy, and body contouring liposuction. Group I patients received a single dose of 5000 U subcutaneous heparin in the preoperative period, and no postoperative chemical prophylaxis was administered. Group II patients received 40 mg subcutaneous enoxaparin in the immediate preoperative period, then once daily for 7 days postoperatively. RESULTS: A total of 195 patients were included in the study, 66 in Group I and 129 in Group II. The groups demonstrated statistically similar VTE risk profiles, based on the 2005 Caprini risk-assessment model. There were no statistically significant differences in the 2 primary outcomes: postoperative bleeding and VTE events. Group I patients had higher reoperation rates (22.7% vs 10.1%, P = 0.029), which was secondary to higher rates of revision procedures. CONCLUSIONS: A 7-day postoperative course of once-daily enoxaparin for VTE risk reduction in abdominal body contouring surgery does not significantly increase the risk of bleeding. Implementation of this regimen for postdischarge chemoprophylaxis, when indicated following individualized risk stratification, is appropriate.

Extra-articular Metacarpal Fractures: Closed Reduction and Percutaneous Pinning Versus Open Reduction and Internal Fixation.

BACKGROUND: There is no consensus on the optimal operative treatment of isolated closed metacarpal fractures as every technique is associated with advantages and shortcomings. This retrospective study aims to compare the outcomes of single metacarpal, extra-articular fractures treated with closed reduction and percutaneous pinning (CRPP) versus open reduction and internal fixation (ORIF). METHODS: The charts of all patients who underwent surgical repair of closed metacarpal fractures at our institutions from 2009 to 2016 were reviewed. 70 patients met the inclusion criteria, 44 had undergone CRPP and 26 ORIF with plate or lag screws. Subgroup analyses of all patients stratified by both fracture pattern and fracture location were performed. Additionally, subgroup analyses of outcomes based on the time from injury to surgery were conducted. Clinical outcomes included immobilization time, total active motion, stiffness, complication and reoperation rates, as well as occupational therapy referral rates and duration. Functional outcomes were determined using the Quick-DASH (Disabilities of the Arm, Shoulder and Hand) score via telephone questionnaire administered retrospectively. RESULTS: Overall, there was no significant difference in functional outcome parameters including total active motion (CRPP 91% of normal vs. ORIF 87% of normal), stiffness, therapy referrals, and complications between treatment groups. Patients treated with CRPP, regardless of fracture pattern or location, were operated on earlier than those treated with ORIF (avg. 7 days vs. 15 days). The immobilization time for patients treated with ORIF was significantly less than those treated with CRPP (19.7 vs. 30.7 days; p=0.001). This difference in the immobilization time also reflected the outcomes of the subgroup analyses based on the post-injury time of surgery. When transverse shaft fractures were examined independently as a subgroup, ORIF resulted in improved post-operative range of motion vs. CRPP (100% normal vs. 91% normal). The mean DASH score for each group was satisfactory and the difference was not statistically significant (16.3 for the CRPP and 18.7 for the ORIF group, p=0.805). CONCLUSION: Both CRPP and ORIF are viable techniques with good clinical outcomes and low complication rates. ORIF of closed metacarpal fractures allowed for earlier mobilization when compared with CRPP without compromising fracture stability, clinical or functional short-term outcomes.

Revisiting Nasal Reconstruction After Mohs Surgery: A Simplified Approach Based on the Liberal Application of Local Flaps.

INTRODUCTION: Nasal reconstruction after oncologic resection often constitutes a technically demanding task. The aim of this study was to investigate our experience with nasal reconstruction after Mohs micrographic surgery using the following 3 well-established, versatile, and reliable techniques: the bilobed flap, nasolabial flap, and forehead flap. METHODS: A single-surgeon retrospective chart review of all patients undergone a bilobed, nasolabial, or forehead flap for nasal reconstruction after Mohs micrographic surgery from 2003 to 2017 was conducted. Data collected for analysis included demographics and defect characteristics. Revisions and complications were analyzed. RESULTS: A total of 83 patients were included in the study; 52 patients underwent bilobed, 17 patients nasolabial, and 14 patients forehead flaps. All defects involved the middle and lower nasal zones. There was a significant difference in the defect size between the 3 groups (P < 0.001). The mean diameters were as follows: 1.37 cm for the bilobed, 2.22 cm for the nasolabial, and 3.46 cm for the forehead flap groups. Liberal utilization of the bilobed and nasolabial flaps achieved reconstruction of defects larger than typically described in the literature. Reconstruction of all defects, including support for successful restoration of mucosal lining and cartilage when indicated, was achieved. An algorithm dealing with defects larger than 0.5 cm in the middle and distal nasal zones was devised. CONCLUSIONS: In this study, the liberal application of the 3 flaps was described based on an individualized treatment approach. The algorithm provides a simplified approach for larger nasal defects in the middle and lower thirds.

Surgeons' Dilemma: Treatment of Implant-Associated Infection in the Cosmetic Breast Augmentation Patient.

BACKGROUND: Augmentation mammaplasty is the most common plastic surgical procedure performed in the USA. The management of severe implant-associated infection is a challenge, and the traditional two-stage treatment is associated with significant limitations. The aim of this literature review is to provide a comprehensive analysis of all studies dealing with the management of severe infection or implant exposure following cosmetic breast augmentation. METHODS: The PubMed and Cochrane databases were searched through February 2018 for studies on the management of severe infection and threatened or actual implant exposure following primary augmentation mammaplasty. Search terms used were "breast implant," "breast prosthesis," "breast augmentation," "breast augmentation complications," "infected implant," "implant salvage" and "implant exposure." RESULTS: Five articles met inclusion criteria. There was inconsistency in the reporting of several key factors, such as the antibiotic regimens employed, culture sensitivities, time from diagnosis to treatment, implant characteristics, as well as the precise treatment of the capsule and pocket. A total of 58 implants were treated, of which 37 (63.8%) were exposed in the setting of infection and 21 (36.2%) were infected without exposure. One-stage implant salvage was employed in 31 implants and was successful in all. The capsular contracture rate with this approach was 6.5%. Antibiotic-alone, non-operative treatment was employed in the salvage of 22 implants, with success and capsular contracture rates of 77.3 and 13.6%, respectively. In the setting of severe periprosthetic infection in the absence of implant exposure, antibiotic-alone treatment was successful in the salvage of 13 out of 14 implants (92.9%). CONCLUSIONS: The inconsistency and paucity of the data in the literature preclude definitive conclusions with regard to the optimal management of the threatened implant following augmentation mammaplasty. Given the excellent salvage rates in this setting, a more prominent role and liberal utilization of implant salvage are proposed. 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 .

Severe Delayed Hemorrhage After Cosmetic Rhinoplasty in the Setting of Maxillary Vascular Malformation.

Late epistaxis after rhinoplasty is a rare but potentially life-threatening occurrence. This case report concerns a 20-year-old woman who had severe epistaxis 5 and 10 days after a closed rhinoplasty with internal osteotomies and who ultimately required transcatheter arterial embolization for definitive control of the hemorrhagic source. Arterial hypervascularity, with signs of arteriovenous malformation, of the midface at the level of the piriform aperture and maxilla was seen on angiography.

Bilateral Sciatic Neuropathy following Gluteal Augmentation With Autologous Fat Grafting.

As gluteal augmentation continues to gain in popularity among patients seeking aesthetic enhancements, a thorough knowledge of the postoperative complications associated with this procedure is crucial. This case report concerns a 31-year-old woman who suffered bilateral foot drop secondary to sciatic neuropathy and as a result was wheelchair-bound for several months, following gluteal autologous fat grafting in the Dominical Republic. One year later, the patient had persistent left foot drop and sensory deficits. This is a devastating but seldom reported complication that all plastic surgeons need to be aware of when performing this operation.

Surgical resection and scarification for chronic seroma post-ventral hernia mesh repair.

BACKGROUND: The aim of this report is to present a new surgical approach in the definitive management of challenging cases of abdominal wall seroma following herniorrhaphy with mesh. CASE REPORT: We describe the case of a 56-year-old male with a 4-year history of a complex abdominal wall seroma. He had undergone fluid aspiration twice without success. On physical examination, the mass was supraumbilical and measured 15×10 cm. Computer tomography (CT) scan revealed a complex encapsulated formation overall measuring 10.1×17.3×17.3 cm in AP, transverse, and craniocaudal dimensions, respectively. In this case complete resection was not safe due to the anatomic relationship of the posterior aspect of the pseudocapsule and the mesh. Intraoperatively, the anterior and lateral aspects of the pseudocapsule were resected and an argon beam was used to scarify the residual posterior pseudocapsule and prevent recurrence. This technique was successful in preventing reaccumulation of the seroma. CONCLUSIONS: Capsulectomy and scarification of the remnant pseudocapsule is an acceptable and safe surgical option for complex chronic abdominal wall seromas.

Noncosmetic benefits of single-incision laparoscopic sigmoid colectomy for diverticular disease: a case-matched comparison with multiport laparoscopic technique.

BACKGROUND: Single-incision laparoscopic (SIL) colectomy has gained significant momentum with anticipated benefit of improved cosmesis. Feasibility and safety of SIL colectomy have been shown; however, benefits are not well defined. The purpose of this study is to directly compare outcomes of SIL sigmoid colectomy for diverticular disease with standard multiport laparoscopic (LAP) technique. METHODS: SIL sigmoid colectomy cases performed for diverticular disease between August 2009 and July 2011 were case matched for age, gender, body mass index, American Society of Anesthesiologists score, previous abdominal operation, and need to mobilize the splenic flexure and compared with an equal number of LAP cases. Data analyzed included operative time, estimated blood loss, procedure conversion, incision length, length of hospital stay (LOS), 30-d hospital readmission, and postoperative pain scores. RESULTS: Twenty patients were analyzed in each group with no significant differences found in the six case-matching criteria. Operative time, conversions, estimated blood loss, surgical site infection, and hospital readmissions were similar. The mean incision length for both groups was 5cm (P=0.72). LOS was 3.7d for the SIL group, which was >1d shorter than that for the LAP group (5.0d; P<0.05). Pain score at post-anesthesia care unit discharge and total amount of narcotic pain medication delivered in the post-anesthesia care unit was significantly less in the SIL group (P<0.05), as was maximum visual analog scale pain score on postoperative day 1 and postoperative day 2 (P≤0.01). CONCLUSIONS: SIL sigmoid colectomy is associated with noncosmetic benefits, including a reduction in early postoperative pain and decreased LOS. These findings may be related to reduced abdominal wall trauma.

Severe type IV hypersensitivity to 'black henna' tattoo.

A 16-year-old Bangladeshi girl presented with a 9-day history of an extensive pruritic, erythematous, papulovesicular skin eruption to both forearms. Appearance was 5 days following application of a home-made henna preparation. Examination revealed ulceration and scabbing along the whole henna pattern and early keloid formation. A diagnosis of type IV delayed hypersensitivity reaction superimposed by infection was initially made. As in this case, home-made henna preparations commonly combine commercial henna with black hair dye, paraphenylenediamine (PPD). PPD, widely known as 'black henna', darkens the pigment and precipitates the drying process. PPD is a potent contact allergen associated with a high incidence of hypersensitivity reactions. Despite treatment the patient was left with extensive keloid scarring in the pattern of the henna tattoo.