Jordan P. Farkas

Thromboembolic Risk Assessment and the Efficacy of Enoxaparin Prophylaxis in Excisional Body Contouring Surgery

Background: There is a paucity of evidence within the plastic surgery literature concerning risk stratification and management of patients with respect to thromboembolic disease. A retrospective chart review was conducted to examine whether the Davison-Caprini risk-assessment model could stratify patients undergoing excisional body contouring surgery, allowing prophylaxis to be managed in an evidence-based manner. Methods: Three hundred sixty excisional body contouring patients at the University of Texas Southwestern Medical Center in Dallas, Texas, under the senior authors’ (J.M.K. and R.J.R.) care were reviewed. Patients were stratified into groups according to the risk-assessment model and into groups based on procedure. Patient characteristics were investigated for their effects on thromboembolic risk. Complications of enoxaparin administration were analyzed. The data were analyzed using appropriate statistical procedures. Results: The highest risk patients had a significantly increased rate of venous thromboembolism when compared with lower risk patients. Body mass index greater than 30 and hormone therapy use were associated with a significantly increased venous thromboembolism rate. Enoxaparin administration was associated with a statistically significant decrease in deep venous thrombosis in circumferential abdominoplasty patients. Enoxaparin administration was associated with higher bleeding rates. Conclusions: Low-molecular-weight heparin may affect the incidence of postoperative thrombotic complications in some surgical populations. In this study, patients who scored greater than four risk factors were at significant risk for venous thromboembolism. Enoxaparin significantly decreased deep venous thrombosis risk in patients undergoing circumferential abdominoplasty. This demonstrates the need for a multicenter, prospective, randomized study to examine various thromboembolic therapies and associated possible complications in these patients.

Preventing and managing dry eyes after periorbital surgery: A retrospective review

Background: Dry eye syndrome is a common sequela associated with periorbital surgery. As more patients seek periorbital rejuvenation, understanding the pathophysiology, diagnosis, and treatment of this condition perioperatively is essential for managing patient expectations and maximizing outcomes. Methods: A retrospective review of charts for 202 consecutive patients (180 women and 22 men) who underwent upper and/or lower blepharoplasty was performed. Additional facial cosmetic procedures were performed in 91 percent of patients. Data were collected identifying associated risk factors and the incidence of persistent dry eye symptoms. Key elements of perioperative care are described and algorithms for detection of those at risk, prevention, and management are outlined. Results: Dry eyes persisting longer than 2 weeks after surgery were noted in 22 patients (10.9 percent) and longer than 2 months in only four patients (2 percent). In most cases, dry eyes resolved with conservative management, including artificial tears, lubrication, topical and systemic steroids, and night taping. One patient (0.5 percent of all studied patients) eventually needed surgical correction of lower eyelid retraction after failure of the punctate plug. Persistent chemosis occurred in 15 patients (68.2 percent) who had symptomatic dry eyes (p < 0.01). Conclusion: Recognizing and addressing risk factors before surgery and an algorithmic approach to prevention and management of patients undergoing periorbital surgery are essential for minimizing the occurrence of dry eye syndrome.

Refinements in abdominoplasty: a critical outcomes analysis over a 20-year period.

Background: The use of liposuction combined with abdominoplasty has been controversial. The combination of techniques has been associated with an increased rate of venous thromboembolism and wound-healing complications. Through improvements in venous thromboembolism prophylaxis, refinements in liposuction techniques, and an understanding of anatomy, this cumulative risk has decreased, although the negative stigmata persist. This study describes the evolution of abdominal body contouring through a critical review of a single surgeons 20-year experience with abdominoplasty. This clinical outcome analysis will highlight the significant contributions that have led to the improvement in the safety and efficacy of this technique. Methods: A retrospective review of patients undergoing abdominoplasty procedures was performed. Patient demographics and procedural information, including postoperative course and complications, were recorded. Preoperative and postoperative photographs were scored by blinded evaluators for aesthetic result and scar quality. Results: Two hundred fifty patients undergoing abdominoplasty from 1987 to 2007 were included in the study. The use of a “superwet” liposuction technique in combination with abdominoplasty significantly decreased intraoperative blood loss (p < 0.04) and length of hospital stay (p < 0.05). Liposuction volume and region had no significant effect on abdominoplasty outcome, although refinements in operative technique, including abdominal and flank ultrasound-assisted liposuction, high superior tension, and limited abdominal undermining, did improve the postoperative aesthetic score. Venous thromboembolic events significantly decreased with aggressive venous thromboembolism prophylaxis (p < 0.001). Conclusions: The technical evolution of a single surgeons 20-year experience demonstrates that liposuction can be safely and effectively combined with abdominoplasty. Preoperative trunk analysis, intraoperative surgical refinements including superwet technique and ultrasound-assisted liposuction, and perioperative venous thromboembolism prophylaxis significantly improve the outcome of abdominoplasty.

Effects of Common Laser Treatments on Hyaluronic Acid Fillers in a Porcine Model

BACKGROUND Injectable hyaluronic acid fillers (HAFs) and laser/light procedures have become increasingly popular for noninvasive facial rejuvenation in many cosmetic practices. However, the effect of laser/light treatments on HAFs is unknown. OBJECTIVE Our objective was to examine the effect of laser/light treatments on HAFs in a porcine model. METHODS The abdomens of 6 Yorkshire pigs were injected with 3 different HAFs: Restylane (Medicis, Scottsdale, AZ), Perlane (Medicis), and Juvéderm (Allergan, Santa Barbara, CA). Two weeks after injection, the injection sites were treated with 1 of 7 common laser/light ablative or nonablative devices. Following laser treatment, 8-mm punch biopsies were collected from the treated tissue and fixed for histopathologic evaluation. Sections were stained with hematoxylin-eosin and alcian blue stains for identification of the preinjected HAF. RESULTS The filler was identified in different areas of the dermis in different sections. The Sciton intense pulsed 560 nm filter (Sciton, Palo Alto, CA), the Sciton Nd: YAG, Lux1540 (Palomar Medical Technologies, Burlington, MA), or ActiveFX (Lumenis, Yokneum, Israel) treatments showed no sign of interaction with superficial or deep dermal filler. No evidence of morphologic changes to the filler or the surrounding tissues was observed. Obvious interaction between the HAFs and the laser injury was demonstrated in sections treated with the deep ablative systems fractional erbium 2940 (Profractional; Sciton) and DeepFX CO(2), (Lumenis). However, no uncharacteristic tissue injury or morphologic change in the filler was appreciated in any of the preinjected specimens. CONCLUSIONS Injected HAFs were unaffected by the nonablative laser/light and superficial ablative treatments. The more aggressive deeper laser treatments demonstrated laser/filler interaction and may have a clinical effect on the longevity of the filler and/or efficacy of laser treatments. Novel ablative fractional lasers have the capability of deep dermal penetration, and this should be taken into consideration when planning to use them in combination with soft tissue fillers for noninvasive facial rejuvenation.

Effects of carving plane, level of harvest, and oppositional suturing techniques on costal cartilage warping.

Background: Cartilage warping has plagued reconstructive and cosmetic rhinoplasty since the introduction of extra-anatomical cartilage use. With the present level of knowledge, there is no evidence of the warping properties with respect to cartilage harvest and suture techniques and level of rib harvest. This report aims to improve understanding of costal cartilage warping. Methods: The sixth through tenth costal cartilages were harvested from six fresh cadavers aged 54 to 90 years. Warping characteristics were followed with respect to level of harvest (i.e., sixth versus seventh), carving orientation, and oppositional suturing. Digital photography of the specimens was performed at various time points (immediately, 1 hour, and 1 month postoperatively). Results: All specimens showed signs of warping beyond 1 hour of carving that continued in a linear fashion to 1 month. There was no statistical difference in the amount of warping specific to the level of harvest, orientation, or with or without oppositional suturing (p < 0.05). Conclusions: Cartilage warping remains a problematic obstacle in nasal reconstruction and revision rhinoplasty, but costal cartilage remains the workhorse graft and is an excellent autologous option. Our findings are the first to be described in the literature regarding warping characteristics of costal cartilage with regard to the level of harvest, orientation of carving, and oppositional suturing techniques in a cadaveric model.

TUNEL assay to characterize acute histopathological injury following treatment with the active and deep FX fractional short-pulse CO2 devices.

BACKGROUND This is a report of the histopathological evaluation of the acute damage profile in human skin following treatment with two novel short-pulsed fractional carbon dioxide resurfacing devices used independently and in combination in vivo. METHODS The panni of eight abdominoplasty patients were treated with either the Active FX, the Deep FX (Lumenis Ltd., Yokneum, Israel), or a combination of the two (Total FX) prior to the start of the excisional surgical procedure. Multiple combinations of energies, pulse widths, and densities were evaluated for each device. After surgical removal (two to five hours), each pannus was immediately biopsied and samples were processed for histopathological evaluation. RESULTS The Active FX system resulted in extensive epidermal injury with wide shallow ablation craters that, at higher fluences, extended through the basement membrane of the epidermis into the papillary dermis. The Deep FX fractional treatment caused deep microcolumns of ablation penetrating up to 3 to 4 mm from the epidermal surface into the deep reticular dermis with a variable rim of coagulated collagen surrounding each ablation column. CONCLUSIONS The in vivo histopathological evaluation of these devices furthers our understanding of the fundamental laser/tissue interaction following treatment with each device independently and in combination.

Comparison of Limited-Undermining Lipoabdominoplasty and Traditional Abdominoplasty Using Laser Fluorescence Imaging

BACKGROUND Body contouring that involves abdominoplasty and/or liposuction is a common cosmetic surgery procedure. Although single-staged lipoabdominoplasty has gained popularity, safety concerns remain. OBJECTIVES The authors compared abdominal flap perfusion and overall complication rates for traditional abdominoplasty and limited-undermining lipoabdominoplasty. METHODS Eighteen abdominoplasty patients were evaluated in a prospective study. All patients were nonsmokers and lacked major comorbidities. The control group (n = 9) underwent traditional abdominoplasty with wide undermining. The study group (n = 9) underwent abdominoplasty with limited undermining as well as liposuction of the abdominal flap. The groups were similar with respect to age and body mass index. Patients received follow-up for an average of 97 days. Fluorescence imaging was utilized for perfusion studies. Results and complications were documented, and statistical significance was ascertained via the Student t test. RESULTS Neither group had major complications or revisions. Minor complications included an exposed suture, resulting in delayed wound healing, in the control group. A patient in the study group had a small area of fat necrosis and a small seroma, neither of which required further treatment. No significant difference in abdominal flap perfusion was found between the control (57%) and study (50%) groups based on fluorescence levels relative to a designated baseline reference marker. CONCLUSIONS Results of the study indicate that no significant differences exist between the 2 operations with respect to the rates of abdominal flap perfusion or complications. LEVEL OF EVIDENCE 3.

Micro-island damage with a nonablative 1540-nm Er:Glass fractional laser device in human skin.

Background and objectives  Fractional photothermolysis produces micro‐islands of thermal injury to the skin while preserving areas among treated tissue sites in order to promote wound healing. Histological changes associated with single and multiple passes of the 1540‐nm Er:Glass fractional laser were examined using in vivo human skin.

The Science and Theory behind Facial Aging

Summary: The etiology of age-related facial changes has many layers. Multiple theories have been presented over the past 50–100 years with an evolution of understanding regarding facial changes related to skin, soft tissue, muscle, and bone. This special topic will provide an overview of the current literature and evidence and theories of facial changes of the skeleton, soft tissues, and skin over time.

TUNEL Assay for Histopathologic Evaluation of Irreversible Chromosomal Damage following Nonablative Fractional Photothermolysis

Background: Fractional photothermolysis is extremely popular in skin rejuvenation and remodeling procedures. However, the extent of thermal cellular injury beyond the borders of the coagulated microcolumns produced with fractional phototherapy is undefined. Methods: Six abdominoplasty patients were pretreated with the Lux1540 Fractional Erbium device (Palomar, Inc., Burlington, Mass.) at various clinical laser settings. After tissue excision, the panni were immediately biopsied. Biopsy specimens were fixed in formalin, embedded in paraffin, sectioned, and evaluated with the terminal deoxynucleotidyl transferase–mediated deoxyuridine triphosphate nick end labeling (TUNEL) procedure for cellular necrosis/apoptosis. Tissue was sectioned horizontally and longitudinally to help define the depth and distribution of the microcolumns of injury in a three-dimensional plane. Results: The extent of cellular necrosis/apoptosis at variable depths within the epidermis and dermis was demonstrated successfully with the TUNEL technique. After the Lux1540 treatment, TUNEL-positive nuclei were identified in a vertically oriented fashion that extended from the epidermis into the papillary and reticular dermis, highlighting the areas of injury. The TUNEL-positive nuclei defined lesions that were approximately 175 to 225 &mgr;m in diameter and penetrated to variable depths (200 to 900 &mgr;m), depending on the fluence used for treatment (18 to 100 mJ). Conclusions: TUNEL immunofluorescent labeling provided an accurate assessment of cellular damage within and surrounding the microthermal zones of coagulated collagen with respect to column depth and width. Because of its specificity, the TUNEL assay can be a useful adjunct to other histologic stains used to characterize cellular damage and matrix denaturation in skin treated with any fractional ablative or nonablative laser device.