Nathaniel L. Villanueva

Staying Safe during Gluteal Fat Transplantation

Summary: Gluteal augmentation with fat transplantation is increasing in demand but has been associated with a concerning number of fatality reports. Despite these reports, various surgeons have safely performed gluteal fat transplantation on a large number of patients with no reported mortality. The important aspects of safely performing gluteal fat transplantation are reviewed. Proper patient selection, favorable instrumentation, patient positioning, proper technique, and knowledge of anatomy are critical to improving the safety of this procedure. Adherence to these key principles should allow a reduction in mortality from this procedure, which would safely allow its continued offering in the setting of increasingly high demand.

Technical Refinements in Autologous Hand Rejuvenation.

Summary: The aging hand is characterized by skin changes and soft-tissue deflation, which leads to rhytides, dermal atrophy, and distinct anatomical structures. Soft-tissue deflation and prominent hand anatomy can be corrected with volume augmentation using dermal fillers or lipofilling. Fat transfer volumizes the hand with prolonged durability and efficacy, autologous tissue replacement, and possible dermal regeneration. The senior author’s (R.J.R.) technique for hand rejuvenation is described, which uses minimal access and blunt dissection to effectively augment the soft-tissue compartments of the hand. This approach addresses the prominent aged anatomy of the hand, providing excellent contour and aesthetic outcomes.

Review of Maxillofacial Hardware Complications and Indications for Salvage.

From 2002 to 2006, more than 117,000 facial fractures were recorded in the U.S. National Trauma Database. These fractures are commonly treated with open reduction and internal fixation. While in place, the hardware facilitates successful bony union. However, when postoperative complications occur, the plates may require removal before bony union. Indications for salvage versus removal of the maxillofacial hardware are not well defined. A literature review was performed to identify instances when hardware may be salvaged. Articles considered for inclusion were found in the PubMed and Web of Science databases in August 2014 with the keywords maxillofacial trauma AND hardware complications OR indications for hardware removal. Included studies looked at human patients with only facial trauma and miniplate fixation, and presented data on complications and/or hardware removal. Fifteen articles were included. None were clinical trials. Complication data were presented by patient, fractures, and/or plate without consistency. The data described 1,075 fractures, 2,961 patients, and 2,592 plates, nonexclusive. Complication rates varied from 6 to 8% by fracture and 6 to 13% by patient. When their data were combined, 50% of complications were treated with plate removal; this was consistent across the mandible, midface, and upper face. All complications caused by loosening, nonunion, broken hardware, and severe/prolonged pain were treated with removal. Some complications caused by exposures, deformities, and infections were treated with salvage. Exposed plates were treated with flaps, plates with deformities were treated with secondary procedures including hardware revision, and hardware infections were treated with antibiotics alone or in conjunction with soft-tissue debridement and/or tooth extraction. Well-designed clinical trials evaluating hardware removal versus salvage are lacking. Some postoperative complications caused by exposure, deformity, and/or infection may be successfully treated with plate salvage. We propose an algorithm using this review and clinical expertise. We also propose that a national databank be created where surgeons can uniformly compile their patient information and examine it in a standardized format to further our understanding of clinical management.

Implications of Facial Asymmetry in Rhinoplasty

Summary: Many rhinoplasty patients present with a chief complaint of nasal deviation and are unaware of any inherent facial asymmetries; however, recognizing and discussing the interrelation between the deviated nose and facial asymmetry is an important consideration in surgical planning. The objective of this study was to evaluate whether a surgeon’s subjective assessment of facial analysis in the setting of nasal deviation correlates with objective anthropometric measurements. In addition, this study sought to further quantify the frequency of facial asymmetry associated with nasal deviation to highlight important anatomical trends for the rhinoplasty surgeon. Finally, this study presents the senior author’s (R.J.R.) method of addressing a deviated nose on an asymmetric face. In this study, the authors demonstrated that nasal deviation is closely related to facial asymmetry. Furthermore, the authors demonstrated that objective facial analysis closely correlates to anthropometric facial measurements. In addition, the wide side of the face correlates to the short side of the face and the nose tends to deviate away from the wide side of the face. During surgical correction of the deviated nose in the setting of facial asymmetry, the surgeon’s goal should be to obtain nasal symmetry and center the nose on a line between the mid glabella and the mid Cupid’s bow. This may reduce the perception of a facial asymmetry, leading to increased patient satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Gluteal Augmentation and Contouring with Autologous Fat Transfer: Part I

Gluteal augmentation with autologous fat transfer is an increasingly popular procedure that has the ability to transform a patients entire body silhouette and gluteal appearance. Proper patient selection, preoperative evaluation, and planning are critical to the success of the procedure. Using the preoperative planning, surgical technique, and postoperative care described, the procedure can be performed safely with powerful and consistent results and avoidance of complications associated with gluteal fat transfer.

Commentary on: Cosmetic Liposuction: Preoperative Risk Factors, Major Complication Rates, and Safety of Combined Procedures

We were excited to read the publication on liposuction and the safety of combined procedures which contains the largest prospective, multi-institution, single database series published to date.1 The study uses the CosmetAssure insurance database to evaluate the incidence and risk factors of significant complications following liposuction alone and in combination with other procedures. Recently, the CosmetAssure database has proven to be a valuable resource for prospectively gathering important outcomes data for various procedures.2-8 One of the limitations of using this database is that it only captures major complications requiring emergency room visits, hospital admission, and reoperations. Despite this limitation, the risk factors for major complications are important to identify. These allow plastic surgeons and patients alike to review patient specific risks for a procedure contributing valuable information necessary to make an informed decision regarding surgery. Female gender, higher body mass index (BMI), surgery performed in a hospital or combined procedures were all independently associated with increased complication rates in patients undergoing liposuction. The types of complications which were identified were hematomas, pulmonary dysfunction, surgical infections, and confirmed venous thromboembolism (VTE). BMI was demonstrated to be a risk factor for surgical site infections, pulmonary complications, and VTE. This data is consistent with previously reported findings regarding the effect of BMI on risk of complications during aesthetic procedures.9-11 When selecting patients to undergo either liposuction alone or in combination with other procedures, it is important to recognize and discuss this increased risk of complications in overweight patients. This may lead to a recommendation regarding preoperative weight loss or modification of the planned procedures for the patient’s safety. Counseling on diet modification, with the help of a nutritionist, exercise, and lifestyle changes are essential for improving outcomes on all patients presenting for body contouring procedures, but especially for morbidly obese patients.12 Many obese patients have increased insulin resistance or diabetes requiring medications for glycemic control. The data from this study found that diabetics had higher risks of complications although it was not statistically significant. Prior to any surgical procedure we require that patients demonstrate excellent glycemic control by having a Hemoglobin A1C of less than 6.5.13 Also, patients with higher BMI may require higher lipoaspirates which can lead to larger fluid shifts. It is our practice to use a super-wet technique (1:1, wetting solution to lipoaspirate) and we monitor hemodynamic parameters (blood pressure, heart rate, and urine output) on all patients undergoing large volume liposuction overnight in order to ensure adequate resuscitation.14-18 Obesity is a known risk factor for VTE.8 As such, in our practice we use the Caprini score for risk stratification to identify patients that should receive thromboembolic prophylaxis19-21 In addition, we routinely use intermittent

Review of 3-dimensional Facial Anatomy: Injecting Fillers and Neuromodulators

Summary: To achieve consistent results utilizing facial injectables, practitioners must understand the pertinent anatomy of the forehead, temple, cheek, nose, and perioral areas. A detailed understanding of facial blood vessels, nerves, and musculature is essential for safe and effective placement of fillers and neuromodulators.