Elbert E. Vaca

The Ethics of Sharing Plastic Surgery Videos on Social Media: Systematic Literature Review, Ethical Analysis, and Proposed Guidelines

Summary: Recent videos shared by plastic surgeons on social media applications such as Snapchat, Instagram, and YouTube, among others, have blurred the line between entertainment and patient care. This has left many in the plastic surgery community calling for the development of more structured oversight and guidance regarding video sharing on social media. To date, no official guidelines exist for plastic surgeons to follow. Little is known about the ethical implications of social media use by plastic surgeons, especially with regard to video sharing. A systematic review of the literature on social media use in plastic surgery was performed on October 31, 2016, with an emphasis on ethics and professionalism. An ethical analysis was conducted using the four principles of medical ethics. The initial search yielded 87 articles. Thirty-four articles were included for analyses that were found to be relevant to the use of social media in plastic surgery. No peer-reviewed articles were found that mentioned Snapchat or addressed the ethical implications of sharing live videos of plastic surgery on social media. Using the four principles of medical ethics, it was determined that significant ethical concerns exist with broadcasting these videos. This analysis fills an important gap in the plastic surgery literature by addressing the ethical issues concerning live surgery broadcasts on social media. Plastic surgeons may use the guidelines proposed here to avoid potential pitfalls.

Postoperative temporal hollowing: Is there a surgical approach that prevents this complication? A systematic review and anatomic illustration

BACKGROUND Temporal hollowing is a common complication following surgical dissection in the temporal region. Our objectives were to: (1) review and clarify the temporal soft tissue relationships - supplemented by cadaveric dissection - to better understand surgical approach variations and elucidate potential etiologies of postoperative hollowing; (2) identify if there is any evidence to support a surgical approach that prevents hollowing through a systematic review. METHODS Cadaveric dissection was performed on six hemi-heads. A systematic review of the literature was undertaken to identify surgical approaches with a decreased risk of postoperative hollowing. RESULTS A total of 1212 articles were reviewed; 19 of these met final inclusion criteria. Level I and II evidence supports against the use of a dissection plane beneath the superficial layer of the deep temporal fascia or through the intermediate temporal fat pad. Level II evidence supports preservation of the temporalis muscle origin - no evidence is available to support other temporalis resuspension techniques. For intracranial exposure, refraining from temporal fat pad dissection (Level I Evidence) and use of decreased access approaches such as the minipterional craniotomy (Level I Evidence) appear to minimize temporal soft tissue atrophy. CONCLUSIONS This study highlights the significance of preservation of the temporal soft tissue components to prevent hollowing. Preserving the temporalis origin and avoiding dissection between the leaflets of the deep temporal fascia or through the intermediate temporal fat pad appear to minimize this complication.

Labial Incompetence in Mobius Syndrome: LeFort I Impaction Case Report and Review of Management Strategies

Difficulty with speech intelligibility in Mobius syndrome patients due to bilabial incompetence is common yet rarely discussed. We present a patient with Mobius syndrome who underwent counterclockwise LeFort I impaction to improve her labial competence. In addition, we present a literature review of management strategies for labial incompetence correction in Mobius patients. At 7-year follow-up after LeFort 1 impaction, the patient reports improvement in speech intelligibility, specifically regarding the ability to pronounce bilabial consonants. This is the first published report of LeFort I impaction to improve labial competence and bilabial consonant pronunciation in a Mobius syndrome patient.

Quantification of strain in a porcine model of skin expansion using multi-view stereo and isogeometric kinematics

Tissue expansion is a popular technique in plastic and reconstructive surgery that grows skin in vivo for correction of large defects such as burns and giant congenital nevi. Despite its widespread use, planning and executing an expansion protocol is challenging due to the difficulty in measuring the deformation imposed at each inflation step and over the length of the procedure. Quantifying the deformation fields is crucial, as the distribution of stretch over time determines the rate and amount of skin grown at the end of the treatment. In this manuscript, we present a method to study tissue expansion in order to gain quantitative knowledge of the deformations induced during an expansion process. This experimental protocol incorporates multi-view stereo and isogeometric kinematic analysis in a porcine model of tissue expansion. Multi-view stereo allows three-dimensional geometric reconstruction from uncalibrated sequences of images. The isogeometric kinematic analysis uses splines to describe the regional deformations between smooth surfaces with few mesh points. Our protocol has the potential to bridge the gap between basic scientific inquiry regarding the mechanics of skin expansion and the clinical setting. Eventually, we expect that the knowledge gained with our methodology will enable treatment planning using computational simulations of skin deformation in a personalized manner.

Improving tissue expansion protocols through computational modeling

Tissue expansion is a common technique in reconstructive surgery used to grow skin in vivo for correction of large defects. Despite its popularity, there is a lack of quantitative understanding of how stretch leads to growth of new skin. This has resulted in several arbitrary expansion protocols that rely on the surgeons personal training and experience rather than on accurate predictive models. For example, choosing between slow or rapid expansion, or small or large inflation volumes remains controversial. Here we explore four tissue expansion protocols by systematically varying the inflation volume and the protocol duration in a porcine model. The quantitative analysis combines three-dimensional photography, isogeometric kinematics, and finite growth theory. Strikingly, all four protocols generate similar peak stretches, but different growth patterns: Smaller filling volumes of 30 ml per inflation did not result in notable expander-induced growth neither for the short nor for the long protocol; larger filling volumes of 60 ml per inflation trigger skin adaptation, with larger expander-induced growth in regions of larger stretch, and more expander-induced growth for the 14-day compared to the 10-day expansion protocol. Our results suggest that expander-induced growth is not triggered by the local stretch alone. While stretch is clearly a driver for growth, the local stretch at a given point is not enough to predict the expander-induced growth at that location. From a clinical perspective, our study suggests that longer expansion protocols are needed to ensure sufficient growth of sizable skin patches.

Google Ranking of Plastic Surgeons Values Social Media Presence Over Academic Pedigree and Experience

BACKGROUND Patients increasingly rely on online resources to make healthcare decisions. Google dominates the search engine market; first-page results receive most of the web traffic and therefore serve as an important indicator of consumer reach. OBJECTIVES Our objective was to analyze the respective importance of physician academic pedigree, experience, and social media presence on plastic surgeon Google first-page search result placement. METHODS A Google.com search was conducted in the top 25 United States metropolitan areas to identify the top 20 websites of board-certified plastic surgeons. Social media presence was quantified by tracking the number of followers on Facebook, Twitter, and Instagram for every surgeon as well as medical school and year of graduation. The primary outcome was website ranking in the first page of Google search results. To identify the independent predictors of presence on the front page, we performed a multivariate logistic regression. RESULTS Total number of social medial followers was associated with Google front-page placement (P < 0.001), whereas medical school ranking and years in practice were not (P = 0.17 and 0.39, respectively). A total 19.6% of plastic surgeon practices in our study cohort still had no social media accounts whatsoever. CONCLUSIONS For the past few decades, plastic surgery practices relied on referrals, word of mouth, and the surgeons reputation and academic pedigree to attract new patients. It is now clear that this practice-building model is being rapidly supplanted by a new paradigm based on social media presence to reach potential patients.

Abstract 84: Modeling Tissue Expansion with Isogeometric Analysis

RESULTS: DCM showed markedly better gross incorporation than all other groups at 30 and 60 days, and were the only implants to contract upon direct electrical stimulation. Histologically, the commercially available ADM’s demonstrated encapsulation at both 30 and 60 days, and StratticeTM showed peripheral hypercellularity and central acellularity, whereas native decellularized matrices showed integration. DCM CD-31 immunofluorescence revealed a developed microvascular network at 60 days, whereas AlloDerm®, DCD and defect demonstrated less neovasculature. StratticeTM showed no vascular ingrowth whatsoever. Native matrices showed evidence of MHC-positive myocytes within the peripheral regions of the implants at 30 and 60 days in a chronologically increasing fashion. Defect alone, AlloDerm® and StratticeTM demonstrated no such MHC signal at any time point. At 30 days, it was impossible to isolate enough RNA from our StratticeTM implants for qPCR analysis. Equally at 30 days, DCM showed no significant difference to control in terms of COX-2 expression, whereas AlloDerm® and DCD showed a significant increase from control (p≤0.05) and also expressed significantly more TNF-α than DCM (p≤0.01). At 60 days, DCM expression of COX-2 and TNF-α was significantly inferior to all other implants. There was significantly less collagen1a gene expression in DCM as compared to AlloDerm® at 30 days, and at 60 days significantly less than in StratticeTM (p≤0.05) and DCD (p≤0.01). Alpha-smooth muscle actin expression was significantly elevated in AlloDerm® at 60 days compared to DCM, and connective tissue growth factor was more highly expressed in all matrices when compared to DCM. MyoD expression was significantly higher than control in DCM at both 30 and 60 days.

Abstract: Ethics and Professionalism with Snapchat Use in Plastic Surgery

INTRODUCTION: Recent data suggests 42 percent of surgeons report their patients are seeking aesthetic surgery to improve their appearance on Instagram and other social media.1 Despite the rising influence of Instagram in plastic surgery, few academic publications address Instagram, let alone evaluate its utilization in plastic surgery. We thus set out to systematically answer the following two questions: 1) what plastic surgery-related content is being posted to Instagram, and 2) who is posting this content?

Conical Modification of Forearm Free Flaps for Single-Stage Reconstruction After Total Orbital Exenteration

Background: Orbital exenteration is a significant reconstructive challenge for plastic surgeons. Options described for these defects range from healing by secondary intention to free tissue transfer. The authors present our preferred reconstruction of orbital defects with free forearm-based flaps, which provides quality soft tissue and orbital contouring in 1 stage to consistently allow placement of bone-anchored implants for eventual orbital prosthesis. Methods: This conical shape of the orbit is deconstructed into a “Pac-Man” type shaped flap that leaves adequate depth for a prosthesis. A retrospective chart review was performed of 2 separate patients receiving orbital exenteration reconstruction by the senior author (MFE). Results: Two patients presented with adenoid cystic carcinoma of the orbit. Both patients underwent nonlid sparing orbital exenteration with adjuvant chemotherapy and radiation. Each patient subsequently developed delayed wound healing after prior local flap reconstruction. Vascularized radial forearm flaps in a Pac-Man shape were used in both patients. Both patients were discharged from the hospital on postoperative day 3. No partial or total flap loss was encountered. To date, each patient has undergone planning for osseointegrated implants. Conclusion: The authors present a simplified method of orbital reconstruction that provides high-quality vascularized tissue for resurfacing in 1 stage. This type of open-cavity flap reconstruction avoids the need for flap debulking procedures and facilitates 2-stage placement of osseointegrated implants.