Saba Motakef

Emerging Paradigms in Perioperative Management for Microsurgical Free Tissue Transfer: Review of the Literature and Evidence-Based Guidelines.

Background: Microsurgical free tissue transfer has become an increasingly valuable technique in reconstructive surgery. However, there is a paucity of evidence-based guidelines to direct management. A systematic review was performed to define strategies to optimize perioperative management. Methods: A systematic review of the literature was performed using key search terms. Strategies to guide patient management were identified, classified according to level of evidence, and used to devise recommendations in seven categories: patient temperature, anesthesia, fluid administration/blood transfusion, vasodilators, vasopressors, and anticoagulation. Results: A total of 106 articles were selected and reviewed. High-level evidence was identified to guide practices in several key areas, including patient temperature, fluid management, vasopressor use, anticoagulation, and analgesic use. Conclusions: Current practices remain exceedingly diverse. Key strategies to improve patient outcomes can be defined from the available literature. Key evidence-based guidelines included that normothermia should be maintained perioperatively to improve outcomes (level of evidence 2b), and volume replacement should be maintained between 3.5 and 6.0 ml/kg per hour (level of evidence 2b). Vasopressors do not harm outcomes and may improve flap flow (level of evidence 1b), with most evidence supporting the use of norepinephrine over other vasopressors (level of evidence 1b). Dextran should be avoided (level of evidence 1b), and pump systems for local anesthetic infusion are beneficial following free flap breast reconstruction (level of evidence 1b). Further prospective studies will improve the quality of available evidence.

Cryolipolysis for fat reduction and body contouring: safety and efficacy of current treatment paradigms.

Background: Cryolipolysis is a nonsurgical technique for localized fat reduction. With the increased risk of complications from more invasive methods such as liposuction, cryolipolysis presents a promising method for nonsurgical body contouring. This study presents a systematic review of the available clinical data, with an emphasis on the efficacy, methods, safety, and complications of cryolipolysis. Methods: To identify clinical studies that assessed outcomes of cryolipolysis, a systematic review of the MEDLINE and Cochrane databases was performed with the search algorithm cryolipolysis OR cool sculpting OR fat freezing OR lipocryolysis. Results: The primary literature search returned 319 articles. After inclusion criteria were applied and additional articles were idenfied via manual review of article references, 19 studies were selected for review. Average reduction in caliper measurement ranged from 14.67 percent to 28.5 percent. Average reduction by ultrasound ranged from 10.3 percent to 25.5 percent. No significant impact on lipid levels or liver function tests after cryolipolysis treatments was noted in any study. Only mild, short-term side effects, such as erythema, swelling, and pain, were noted. Paradoxical adipose hyperplasia was described in one patient. Conclusions: Cryolipolysis is a promising procedure for nonsurgical fat reduction and body contouring and presents a compelling alternative to liposuction and other, more invasive methods. This procedure appears to be safe in the short term, with a limited side effect profile, and results in significant fat reduction when used for localized adiposities. It remains unclear whether posttreatment manual massage and multiple treatments in the same anatomic area enhance the efficacy of cryolipolysis.

Facial Feminization: Systematic Review of the Literature

Background: Facial feminization surgery encompasses a broad range of craniomaxillofacial surgical procedures designed to change masculine facial features into feminine features. The surgical principles of facial feminization surgery can be applied to male-to-female transsexuals and anyone desiring feminization of the face. Although the prevalence of these procedures is difficult to quantify, because of the rising prevalence of transgenderism (approximately one in 14,000 men) along with improved insurance coverage for gender-confirming surgery, surgeons versed in techniques, outcomes, and challenges of facial feminization surgery are needed. This review is designed to critically appraise the current facial feminization surgery literature. Methods: A comprehensive literature search of the Medline, PubMed, and EMBASE databases was conducted for studies published through October of 2014 with multiple search terms related to facial feminization. Data on techniques, outcomes, complications, and patient satisfaction were collected. Results: Fifteen articles were selected and reviewed from the 24 identified, all of which were either retrospective or case series/reports. Articles covered a variety of facial feminization procedures. A total of 1121 patients underwent facial feminization surgery, with seven complications reported, although many articles did not explicitly comment on complications. Satisfaction was high, although most studies did not use validated or quantified approaches to address satisfaction. Conclusions: Facial feminization surgery appears to be safe and satisfactory for patients. Further studies are required to better compare different techniques to more robustly establish best practices. Prospective studies and patient-reported outcomes are needed to establish quality-of-life outcomes for patients. However, based on these studies, it appears that facial feminization surgery is highly efficacious and beneficial to patients.

Redefining the Ideal Buttocks: A Population Analysis.

Background: The buttocks are a key element of female beauty, with aesthetic gluteoplasty becoming one of the fastest growing plastic surgery procedures. However, there remains no clear standard for the ideal buttocks. The authors performed a population analysis of the characteristics of the ideal buttocks to guide surgical planning. Methods: Images of buttocks were digitally altered to create buttocks of varying proportions on posterior and lateral views. Waist-to-hip ratios and varying vertical proportions were studied. Data were stratified and analyzed according to age range, gender, ethnicity, and nationality of the respondents. Results: A total of 1146 responses were collected. Of 989 respondents who submitted their gluteal preferences, 482 respondents (48.7 percent) were women and 507 (51.3 percent) were men. Overall, the most attractive buttocks waist-to-hip ratio is 0.65 from the posterior view (44.2 percent of respondents). The next most attractive ratio was 0.60 (25 percent of respondents). Positioning of the lateral prominence at the inferior gluteal fold was rated by 26.3 percent of respondents as the most attractive. From the lateral view, the most attractive buttocks have a waist-to-hip ratio of 0.70 (29.8 percent of respondents), with the most prominent portion positioned at the midpoint of the buttocks (45.1 percent of respondents), which is a 50:50 vertical ratio. There were no significant differences in preferences between respondent ages, genders, or ethnicities. Conclusions: New ideal waist-to-hip ratios of 0.6 and 0.65 update the previous standards and indicate a more dramatic and “curvier” new ideal, signaling an important preference paradigm shift. The information derived from this study has the potential to guide gluteoplasty practices and techniques.

Reply: Vaginal Labiaplasty: Current Practices and a Simplified Classification System for Labial Protrusion.

Background: Vaginal labiaplasty has been described for the management of functional and aesthetic problems associated with protrusion of the labia minora. Despite increasing numbers of procedures performed, there is a paucity of data to guide treatment paradigms. This systematic review aims to establish a simple, unifying classification scheme for labial protrusion and summarize current labiaplasty techniques and practices. Methods: A systematic literature review was performed using the PubMed database. Additional articles were selected after reviewing references of identified articles. Results: The search returned 247 articles. After applying inclusion criteria to identify prospective and retrospective studies evaluating different techniques, outcomes, complications, and patient satisfaction, 19 articles were selected. Labiaplasty of the labia minora was described in 1949 patients. Seven different surgical techniques were used for labiaplasty, including deepithelialization, direct excision, W-shaped resection, wedge resection, composite reduction, Z-plasty, and laser excision. Patient satisfaction rates for each technique ranged from 94 to 100 percent. The most common postoperative complication for all techniques was wound dehiscence (4.7 percent). Key areas for perioperative patient management were defined. Conclusions: Labiaplasty is safe and carries a high satisfaction rate. However, current practices remain exceedingly diverse. The authors propose a simplified classification system based on the distance of the lateral edge of the labia minora from that of the labia majora, rather than from the introitus. Key areas for perioperative patient management include patient anesthesia, resection technique used, wound closure, and postoperative care. Further randomized studies using a standardized classification system are required to better compare different techniques and establish best practices.

Plastic Surgery Resident-Run Cosmetic Clinics: A Survey of Current Practices

Background The recently increased minimum aesthetic surgery requirements set by the Plastic Surgery Residency Review Committee of the Accreditation Council for Graduate Medical Education highlight the importance of aesthetic surgery training for plastic surgery residents. Participation in resident aesthetic surgery clinics has become an important tool to achieve this goal. Yet, there is little literature on the current structure of these clinics. Objectives The authors sought to evaluate current practices of aesthetic resident-run clinics in the United States. Methods A survey examining specific aspects of chief resident clinics was distributed to 70 plastic surgery resident program directors in the United States. Thirty-five questions sought to delineate clinic structure, procedures and services offered, financial cost to the patient, and satisfaction and educational benefit derived from the experience. Results Fifty-two questionnaires were returned, representing 74.2% of programs surveyed. Thirty-two (63%) reported having a dedicated resident aesthetic surgery clinic at their institution. The most common procedures performed were abdominoplasty (n = 20), breast augmentation (n = 19), and liposuction (n = 16). Most clinics offered neuromodulators (n = 29) and injectable fillers (n = 29). The most common billing method used was a 50% discount on surgeon fee, with the patient being responsible for the entirety of hospital and anesthesia fees. Twenty-six respondents reported feeling satisfied or very satisfied with their resident aesthetic clinic. Conclusions The authors found aesthetic chief resident clinics to differ greatly in their structure. Yet the variety of procedures and services offered makes participation in these clinics an effective training method for the development of both aesthetic surgical technique and resident autonomy.

Abstract: Fat Grafting to Improve Results of Facelift

M oday, O cber 1, 2018 with Fitzpatrick Skin Types II and III. Subjects received 3 combination treatments completed 30 days apart. Standardized photographs were taken at baseline and each followup. Improvement in wrinkles, texture and pigmentation was determined by masked, qualitative assessment of photographs at 90 days after last treatment compared to baseline. Clinician and Subject Global Aesthetic Improvement Scales (CGAIS, PGAIS), and a Patient Satisfaction Questionnaire were completed at 90 days after last treatment.

Establishing Milestones for Facial Injectables in Plastic Surgery Residency Training: Four-Year Follow-Up

The Milestone Project was established by the American Council of Graduate Medical Education (ACGME) in an effort to provide a framework for Clinical Competency Committees, guide curriculum development, and support assessment practices at residency training programs.1 The milestones are designed to provide residents with performance standards, facilitate and guide self-directed learning, and direct feedback for professional development.1 The Plastic Surgery Milestone Project established milestones for 18 core areas.2 While milestones were established in a number of key areas, such as head and neck, maxillofacial trauma, and facial aesthetics, specific milestones were not established for measuring facial injectables skills and knowledge. According to the most recent data released by the American Society for Aesthetic Plastic Surgery (ASAPS), 4,597,886 procedures were performed with botulinum toxin (eg, Botox and Dysport) and 2,494,814 procedures were performed with soft tissue fillers (eg, Radiesse and Juvederm) in 2016, making these the top two cosmetic, nonsurgical procedures.3 Despite this, Hashem et al have found that both residents and program directors are not confident in their ability to perform facial aesthetic procedures.4 A 2015 analysis of 818 plastic surgery residents found that the bottom 10th percentile of residents did not achieve case minimums for botulinum toxin and dermal fillers.5 Because of the rising importance of these procedures and the reported need for added training, specific milestones were established for the residency training program at the Loma Linda University (LLU) Department of Plastic Surgery for facial injectables, and their outcomes were assessed with a survey (Appendix A, available online as Supplementary Material at www. aestheticsurgeryjournal.com). Milestones were established by the senior author (S.G.) for the measurement of facial injectables skills with the following key objectives, in line with those advocated by the ACGME:

Polyostotic Juvenile Ossifying Fibroma: An Exceptionally Rare Case

Accurate and early diagnosis of benign fibroosseous lesions is important because the treatment and resulting outcomes of each differ. Juvenile ossifying fibromas typically occur in young patients and grow rapidly with a high recurrence rate. Their monostotic nature has previously differentiated these tumors from other fibroosseous lesions. We describe an interesting and extremely rare case of polyostotic juvenile ossifying fibromas in a 14-year-old boy with involvement of the maxilla and mandible. The available literature on juvenile ossifying fibromas is also briefly reviewed. When diagnosing a polyostotic fibroosseous lesion, it is important to not exclude the possibility of juvenile ossifying fibromas because this may warrant a different treatment.

Abstract: Liposomal Bupivacaine in Implant-Based Breast Reconstruction: Patient Outcomes and Economics

PURPOSE: The purpose of this study is to evaluate the role of liposomal bupivacaine in postoperative pain control following implant-based breast reconstruction, the effect of liposomal bupivacaine on postoperative opioid consumption and opioid related adverse events, and the effect of liposomal bupivacaine on length of hospital stay.