Lorne K. Rosenfield

Looking at plastic surgery through Google Glass: part 1. Systematic review of Google Glass evidence and the first plastic surgical procedures.

Background: Google Glass has the potential to become a ubiquitous and translational technological tool within clinical plastic surgery. Google Glass allows clinicians to remotely view patient notes, laboratory results, and imaging; training can be augmented via streamed expert master classes; and patient safety can be improved by remote advice from a senior colleague. This systematic review identified and appraised every Google Glass publication relevant to plastic surgery and describes the first plastic surgical procedures recorded using Google Glass. Methods: A systematic review was performed using PubMed National Center for Biotechnology Information, Ovid MEDLINE, and the Cochrane Central Register of Controlled Trials, following modified Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Key search terms “Google” and “Glass” identified mutually inclusive publications that were screened for inclusion. Results: Eighty-two publications were identified, with 21 included for review. Google Glass publications were formal articles (n = 3), editorial/commentary articles (n = 7), conference proceedings (n = 1), news reports (n = 3), and online articles (n = 7). Data support Google Glass’ positive impact on health care delivery, clinical training, medical documentation, and patient safety. Concerns exist regarding patient confidentiality, technical issues, and limited software. The first plastic surgical procedure performed using Google Glass was a blepharoplasty on October 29, 2013. Conclusions: Google Glass is an exciting translational technology with the potential to positively impact health care delivery, medical documentation, surgical training, and patient safety. Further high-quality scientific research is required to formally appraise Google Glass in the clinical setting.

The error of omission: a simple checklist approach for improving operating room safety.

Summary: The primary goal of patient safety must go hand in hand with the goal of producing reliably good aesthetic and functional results. The implementation of a proactive checklist improves operating room communication and takes the necessary step toward reducing the often neglected errors of omission. These steps are necessary if we are to ultimately achieve our goal of improving safety comprehensively in the operating room.

High Tension Abdominoplasty 2.0

Traditionally, the primary goal of any abdominoplasty has always been to excise the central lower abdominal excess skin or pannus and plicate the abdominal fascia through a suprapubic incision. Unfortunately, this traditional abdominoplasty may often fall short of this goal: a scar that may ride too high; persistent skin and lipodystrophy at the pubis, thighs, flanks, and hips; and unfortunately a consistent incidence of midline skin necrosis or wound dehiscence. High lateral tension abdominoplasty addresses these shortfalls. It may be defined as a more complete treatment of the lower trunk aesthetic unit from the abdomen to the pubis, hips, and thighs, with a greater overall aesthetic result and margin of vascular safety. This article outlines the techniques and tools to accomplish these superior results safely and consistently.

Discussion: Methicillin-Resistant Staphylococcus aureus Infections: A Comprehensive Review and a Plastic Surgeon's Approach to the Occult Sites.

Background: Up to 20 percent of the general population is persistently colonized with Staphylococcus aureus, and 1 to 3 percent of the population is colonized with community-acquired methicillin-resistant S. aureus. Currently, the knowledge of methicillin-resistant Staphylococcus aureus carriage sites other than the nose, and their effect on surgical site infections in cosmetic surgery, is lacking. Methods: A comprehensive literature review using the PubMed database to analyze prevalence, anatomical carrier sites, current screening and decontamination protocols and guidelines, and methicillin-resistant S. aureus in cosmetic surgery was performed. The senior author’s (L.R.) methicillin-resistant S. aureus infection experience and prevention protocols were also reviewed. Results: Nasal swabs detect only 50.5 percent of methicillin-resistant S. aureus colonization, and broad screening has noted the presence of methicillin-resistant S. aureus in the ear canal and umbilicus. Decolonization protocols within the orthopedic and cardiothoracic surgery literature have reduced rates of methicillin-resistant S. aureus surgical-site infections. There are no decolonization guidelines for plastic surgeons. Since instituting their decolonization protocol, the authors have had no cases of methicillin-resistant S. aureus infection in nearly 1000 cosmetic surgery procedures. Conclusions: There are very limited, if any, Level I or II data regarding methicillin-resistant S. aureus screening and decolonization. As the sequelae of a surgical-site infection can be disastrous, expert opinions recommend that plastic surgeons vigorously address methicillin-resistant S. aureus colonization and infection. The authors have developed and recommend a simple decolonization protocol that includes treatment of the umbilicus, ear canal, and nares to limit surgical-site infection and improve surgical outcomes.

Aesthetic Surgery's Tipping Point

As I reflected upon the multiple national meetings I have attended over the last few years, I realized that our specialty is, to borrow from the enlightening author Malcolm Gladwell, a millennial expression, at a “tipping point.” The subject is as difficult to discuss as it is critical, but I am emboldened by the fact that mine is the impression of almost every colleague I have spoken to, whether they were old friends, “students” in my teaching courses, or just “seatmates” in the audience. The issue is the flippant disregard for the scientific method and resultant relative lack of intellectual honesty in our specialty. If that were not enough, there is an equal amount of apathetic silence and maddening inertia with regard to this issue, not just by our leaders but by the general plastic surgical community as well. Let me use, as they say, a “hypothetical”: If a Martian, or my seventh grade son for that matter, were to sit in one of our meetings, he might very well conclude that Earth’s plastic surgeons define the scientific method as simply a presentation of positive outcomes as conclusive data for the efficacy of their techniques. Clearly, using this modus operandi, we haven’t really proved anything and, more importantly, we haven’t learned anything. Classically, panel members only present their “perfect” results, leaving the audience duly impressed but equally unenlightened. The consequence, of course, is that since the presenter has not really “proven” his work, most audience members will be wary of adopting the technique. Of greater concern, however, is the less discerning observer who hurries back to his or her office to apply the approach! Too rarely, a diligent moderator will prod the presenter, teasing out the complications, and only then empower the audience to truly evaluate a surgical technique. It is for these reasons that I now suggest some practical actions that could be taken to correct our ethical crisis:

Commentary on: Preoperative Respiratory Physiotherapy in Abdominoplasty Patients

Respiratory physiotherapy postabdominal and other major surgeries is a well-embedded practice standard. We have only to review our forefathers’ general surgical literature to find plenty of support for this preventative strategy in major abdominal surgeries.1 This article attempts to test the hypothesis that similar preoperative support may synergistically reduce postoperative pulmonary complications in the abdominoplasty patient.2 But before one delves into the specifics of this paper, it is useful to stand back and appreciate the inherent value of any paper that attempts to inaugurate strategies to reduce risks in our surgeries. It is fruitful to repeatedly murmur under one’s mask the mantra that the abdominoplasty, that aesthetic surgery, is always elective surgery. Thus, any complication is one too many. But clearly, no matter how hard we try, surgical complications will forever challenge us. However, this fact should not absolve us of our perpetual duty to deliberately choose what kinds of complication we, as surgeons, are willing to witness postoperatively: it is what I call our personal “boiling points.” Ideally, the complication should be self-limiting or easily reversible. Reciprocally, a complication that is life threatening should give us pause and probably be considered “deal-breakers.”3,4 The abdominoplasty procedure harbors one of the highest overall risk profiles and specifically, one of the most daunting and deadly: pulmonary embolism.5-7 I say daunting, because even at the mid of this late year 2017, this disease remains confounding as to its true etiology and thus elusive as to its definitive prevention. One causal hypothesis is that the abdominoplasty increases the intra-abdominal pressure (IAP) leading to stasis in the deep venous system as well as directly compromising pulmonary function.8-12 And it is the possible salutary effect of preoperative respiratory therapy on these very data points, IAP and spirometry function, in the prevention of pulmonary complications, that this paper endeavored to study. Unfortunately, the authors excluded the high risk respiratory patients, the very ones who would most likely benefit from preventive measures and most easily prove their hypothesis. But, in their defense, they do confess to the value of conducting just such a future study. Surprisingly, the authors found no difference in spirometry measurements in the perioperative period in patients who received preoperative respiratory physiotherapy relative to the control group. On the other hand, they did determine that completing one week of physiotherapy prior to abdominoplasty successfully lead to a reduction in IAP compared to a nonphysiotherapy control group. Finally, without measuring clinical outcomes, the authors could only, but correctly, infer, rather than definitively prove that this lower IAP reduction may reduce serious pulmonary complications. Still, the paper’s value is far from diminished and instead should spur us on in our efforts to reduce complications. As many of you know, I am frankly perpetually distracted

Commentary on: Incidence and Risk Factors for Major Surgical Site Infections in Aesthetic Surgery: Analysis of 129,007 Patients

The authors of this paper,1 who so enviably sit upon a veritable Sierra Madre treasure of complication data, have delivered yet another rare and unusual practice “biopsy” of our aesthetic surgery corpus. With an exhaustive analysis of almost 130,000 patient encounters, their subject of interest this time was surgical site infections (SSI). And as the authors rightfully caution, this biopsy per force, only included patients who had had infections severe enough to invoke the insurance coverage of a medical and/or surgical intervention. This explains the papers calculation of the otherwise deceivingly low overall infection incidence of 0.46% with a range of from 0.2% to 1.9%. Whereas, as is also pointed out, the veritable incidence of SSIs as reported in our literature for these same aesthetic procedures, ranges from 0.001% to 32.6%. More importantly, and with few …