Background: Resident aesthetic clinics (RACs) have gained increasing popularity since the ACGME’s increase in minimum aesthetic surgery requirements. While plentiful studies have demonstrated that RAC’s have successful surgical outcomes, limited literature is available guiding the practical aspects of operating a successful RAC such as balancing case type and volume and effective resident education. Here we present valuable lessons learned from the successful two-phase restructuring of one institution’s RAC. Phase 1 effective July 1, 2018, included new faculty leadership, a formal aesthetic education curriculum, and limiting liposuction and abdominoplasty consults. Phase 2 effective January 1, 2021, consisted of obtaining increased block time, adding junior residents to the rotation, and an industry sponsored implant program. Methods: A retrospective chart review was performed on all 336 patients who underwent a total of 676 procedures in our institution’s RAC from Jan 1, 2011, to Sept 1, 2022. Procedure type and volume were compared before and after the two phases of the restructurings on July 1, 2018, and January 1, 2021. The faculty leader spearheading the clinic restructuring was interviewed to discuss the approach to problems encountered in running a RAC. Results: Of the 235 patients who underwent a total of 507 procedures from January 1, 2011, to July 1, 2018, there was a roughly equal distribution of facial and body contouring cases with limited (14%) breast aesthetic exposure. Between phases 1 and 2, 50 patients underwent 98 procedures over 30 months. 1B shows the effect of limiting body contouring consults to increase the share of facial aesthetics cases performed from 44% to 56%. After phase 2 changes, a balance was achieved among facial, body, and breast cases over the following 20 months. The specific educational challenges that motivated each aspect of the restructuring are presented. Conclusion: Through the context of our institutional RAC, we underscore tangible solutions to educational, financial, and logistic challenges RACs may face. We specifically highlight how to provide residents with more equal exposure to different aesthetic procedures and how to effectively maximize clinic infrastructure to reach targets for surgical procedures.

Background: Patients are increasingly accessing consumer-style health information from a variety of web-based platforms. This study aims to assess a popular audio-visual platform for its quality of information in orthognathic procedures. Methods: We queried YouTube on August 12th, 2021 for 20 videos, by both relevance and view count, under each of 3 search terms: (1) “orthognathic surgery,” (2) “LeFort I osteotomy,” and (3) “sagittal split osteotomy.” Each video was characterized by date of upload, time since upload, video duration, video type, and video author. Videos were further characterized by type of video (1) creator and (2) category. The provider-validated instrument DISCERN was applied to each video to assess content quality and bias. Results: Of 60 videos marked for review, 46 were included for analysis. The most common category of video was operative ( n = 18, 36.1%), while the most common creator type was non-physician medical professional ( n = 14, 30.4%). Hospital or physician advertisement videos had the greatest video power index (26 297 ± 44 556), while medical education videos had the least (13 ± 9). Significant differences were found across both video type and video creator in viewership ( P = .008 and .003, respectively) and video power index ( P = .010 and .007), but not duration ( P = .796 and .059). DISCERN scores ranged from 16 to 80 and were subdivided into 5 categories: very poor (16-28), poor (29-41), fair (42-54), good (55-67), and excellent (68-80). Average DISCERN scores for all 46 videos were 17.9 ± 4.9 for reliability, 14.2 ± 4.0 for quality, and 34.3 ± 9.0 for overall. Conclusions: YouTube videos on orthognathic surgery were of overall poor quality. These videos were rated best in relevance to the search parameter and description of treatment but were least helpful in describing alternatives to the treatment and uncertainties about the procedure. Videos created by patients and about patient experiences were rated best for content that was reliable, high quality, and low bias.

Abstract Background In 2014, the Plastic Surgery Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME) increased minimum aesthetic surgery requirements. Consequently, the resident aesthetic clinic (RAC) has become an ever more important modality for training plastic surgery residents. Objectives To analyze demographics and long-term surgical outcomes of aesthetic procedures performed at the Johns Hopkins and University of Maryland (JH/UM) RAC. A secondary objective was to evaluate the JH/UM RAC outcomes against those of peer RACs as well as board-certified plastic surgeons. Methods We performed a retrospective chart review of all patients who underwent aesthetic procedures at the JH/UM RAC between 2011 and 2020. Clinical characteristics, minor complication rates, major complication rates, and revision rates from the JH/UM RAC were compared against 2 peer RACs. We compared the incidence of major complications between the JH/UM RAC and a cohort of patients from the CosmetAssure (Birmingham, AL) database. Pearson's chi-square test was used to compare complication rates between patient populations, with a significance set at 0.05. Results Four hundred ninety-five procedures were performed on 285 patients. The major complications rate was 1.0% (n = 5). Peer RACs had total major complication rates of 0.2% and 1.7% (P = .07 and P = .47, respectively). CosmetAssure patients matched to JH/UM RAC patients were found to have comparable total major complications rates of 1.8% vs 0.6% (P = .06), respectively. At JH/UM, the minor complication rate was 13.9%, while the revision rate was 5.9%. Conclusions The JH/UM RAC provides residents the education and training necessary to produce surgical outcomes comparable to peer RACs as well as board-certified plastic surgeons. Level of Evidence: 3

PURPOSE: Recent research found the epidermal Lgr6 stem cell population to be progressively depleted under mechanical tension, with a paralleled increase in the Lgr6 descendant population.1 This study aims to determine if there is a reversal of tension-induced skin growth characteristics, specifically if the Lgr6 stem cell population recovers after tension is removed. Our results will guide future research in therapeutic interventions for optimal skin recovery following tension, such as seen with bariatric surgery and the resulting excess skin from rapid weight loss. METHOD: Genetic Lgr6-EGFP-Cre-ERT2;tdTomato mice (EGFP=Lgr6, tdT=Lgr6 descendants) underwent controlled expansion (E) of the back skin. A tissue expander was surgically placed under the back skin on day zero, rested for 7 days, expanded over 10 days with a total of 24 mL saline, rested for 14 days, then deflated of saline at post-injection day 14 (PI-14) or deflation day zero (DF-0). Skin over the expander was resected, embedded in paraffin, and sectioned at 4µm. Cell populations were defined using immunofluorescence and quantified by relative expression and cell counting (ImageJ). Control mice underwent expander surgery but did not undergo saline expansion (non-expanded, NE). NE and E mice (n=3 each) were compared for PI-14, DF-14, and DF-56. We used two-tailed t-test with alpha set at 0.05. RESULTS: Relative expression of EGFP decreased from NE to both DF-14 (p=0.0474) and DF-56 (p=0.0477), while relative expression of tdT increased from NE to DF-56 (p=0.0125). EGFP+ cells decreased from NE to PI-14, DF-14, and DF-56 (p=0.0114 for all), while tdT+ cells increased from NE to PI-14, DF-14, and DF-56 (p=0.0086, p=0.0133, p=0.00002). Proliferating cells (Ki67+) increased from NE to PI-14, DF-14, and DF-56 (p=0.00007, p=0.00001, p=0.0417), but decreased from DF-14 to DF-56 (p=0.0278). Of the proliferating cell population, the [Ki67+tdT+] population increased from NE to DF-56 (p=0.0002). Cytokeratin 5 (K5) relative expression increased from NE to PI-14, DF-14, and DF-56 (p=0.0109, p<0.00001, p<0.00001). The number of epidermal keratinocyte layers increased from NE to PI-14, DF-14, and DF-56 (p<0.00001, p<0.00001, p=0.0043), with a decrease from DF-14 to DF-56 (p=0.0020). CONCLUSION: The epidermal Lgr6 stem cell population remained severely depleted following discontinuation of mechanical tension. Conversely, both the Lgr6 descendent population and K5 stem cell expression continued to increase while under tension and following release of tension. A prolonged history of discontinued tension revealed that the majority of the proliferating cell population was from Lgr6 progeny. Together, these observations suggest that in skin with a history of tension: (1) the Lgr6 population is permanently depleted, (2) the majority of the epidermis will be from Lgr6 progeny, and (3) Lgr6 progeny and K5 stem cells will be preferentially and progressively activated over Lgr6 stem cells to maintain the epidermis. Overall, these results imply that specific stimuli will prioritize responses from specific stem cell populations, and possibly to the detriment of an existing stem cell population. REFERENCES: 1. Xue Y, Lyu C, Taylor A. Mechanical Tension Mobilizes Lgr6+ Epidermal Stem Cells to Drive Skin Growth. [provisionally accepted ahead of print February 23, 2022]. Sci Adv.

Purpose: Soft tissue losses from oncologic resection, trauma, aging, and congenital differences are a ubiquitous problem in clinical medicine. Lipotransfer of adipocytes and adipose-derived stem cells (ADSCs) has emerged as an important reconstructive strategy over the last two decades.1 Nonetheless, as currently practiced lipotransfer suffers from two major limitations (1) unpredictability of cell survival, and (2) limited long-term volume retention. Recently, we developed a nanofiber-hydrogel composite (NHC) that closely mimics the ultrastructure and macroscopic properties of adipose tissue while encouraging vascularization and soft tissue remodeling in vivo. Here, we explore the capacity of NHC to enhance survival, volume retention, and adipose tissue integrity of autologous transferred adipocytes and ADSCs. Methods: Nanofiber-hydrogel composite materials comprising of covalently linked hyaluronic acid and polycaprolactone nanofibers were prepared in fully-hydrated, beaded form. Autologous adipocytes and adipose derived stem cells were harvested from inguinal fat pads of Lewis rats, minced, and washed with PBS solution and passed through Luer lock syringes. The resulting adipose slurry -an autologous analog of human lipoaspirate-was mixed with NHC in varying ratios from 100% NHC to 100% adipose slurry. The mixtures were injected subcutaneously on the back of Lewis rats at a constant volume of 400cc per group. Volume retention and structural integrity were assessed by quantitative 3D MRI and histology. Results: Markedly improved volume retention was observed in the 100% NHC groups and the 50:50 NHC:fat groups with over 49% and over 40% of the original volume remaining at post-operation day (POD) 90, respectively. This is compared to 16.63% in the 100% fat group. Critically, the 50:50 NHC:fat group also had improved adipose tissue structure with discrete adipoctyes and fibrous septae evident as compared to the 100% fat group which had large oil droplets and vacuolar structures and a paucity of adipocytes and the 100% NHC group which showed a mixed inflammatory and fibrovascular infiltrate. Conclusions: We demonstrated improved volume retention and structural integrity of transferred autologous adipocytes and ADSCs when combined in equal ratios with biomimetic nanomaterials. The use of an autologous lipotransfer model more closely mimics the clinical scenario than immunocompromised rodent models or allogeneic human fat transfer into immunocompetent models. Given the ongoing preclinical and clinical testing of NHC, we expect that this approach will powerfully complement traditional lipotransfer to enable more predictable and durable soft tissue restoration.

Background: Various surgical techniques can be used to repair acute distal biceps tendon (DBT) tears; however, it is unknown which type of repair or implant has the greatest biomechanical strength and presents the lowest risk of type 2 failure. Purpose: To identify associations between the type of implant or construct used and the biomechanical performance of DBT repairs in a review of human cadaveric studies. Study Design: Systematic review and meta-regression. Methods: We systematically searched the EMBASE and Medline (PubMed) databases for biomechanical studies that evaluated DBT repair performance in cadaveric specimens. Two independent reviewers extracted data from 14 studies that met our inclusion criteria. The pooled data set was subjected to meta-regression with adjusted failure load (AFL) as the primary outcome variable. Procedural parameters, such as number of sutures, cortices, locking stitches, and whipstitches, served as covariates. Adjusted analysis was performed to determine the differences among implant types. The alpha level was set at .05. Results: When using no implant (bone tunnels) as the referent, no fixation type or procedural parameter was significantly better at predicting AFL. Cortical button fixation had the highest AFL (370 N; 95% CI, −2 to 221). In an implant-to-implant comparison, suture anchor alone was significantly weaker than cortical button (154 N; 95% CI, 30 to 279). Constructs using a cortical button and interference screw were not stronger (as measured by AFL) than those using a cortical button alone. The presence of a locking stitch added 113 N (95% CI, 29 to 196) to the AFL. The use of cortical button instead of interference screws or bone tunnels was associated with lower odds of type 2 failure. Avoiding locking stitches and using more sutures in the construct were also associated with lower odds of type 2 failure. Conclusion: Cortical button fixation is associated with greater construct strength than is suture anchor repair and a lower risk of type 2 failure compared with interference screw fixation or fixation without implants. The addition of an interference screw to cortical button fixation was not associated with increased strength. The presence of a locking stitch added 113 N to the failure load but also increased the odds of type 2 failure.