Drs Rohrich, Sinno, and Afrooz provide a useful, richly illustrated yet succinct book that earns a welldeserved place on the bookshelf of plastic surgeons, facial plastic surgeons, cosmetic dermatologists, and dermatologic surgeons around the world. There are many cosmetic surgery books available; however, this one sets itself apart with its elegance, finesse, and comprehensiveness. The book includes a broad and dizzying array of chapters (93 in all), ranging in subjects from procedures that are frequently performed by dermatologists (fillers, neurotoxins, fat grafting, peels, and resurfacing) to those that are perhaps addressed only rarely (breast reduction and revision rhinoplasty). The chapter format is standardized, with each chapter including preoperative planning; operative steps; and, of course, photographs, illustrations, and videos for key components of the techniques. The authors chose to consciously eschew the traditional lengthy narrative approach to surgical texts, opting instead for bullet points that highlight key steps and concepts. This is a welcome change and is likely a trend that will be emulated by others in the future.

Paul N. Afrooz, MD Mark G. Albert, MD Marcelo Cunha Araujo, MD Mokhtar Asaadi, MD Alexander Aslani, MD Sherrell J. Aston, MD Daniel C. Baker, MD Lawrence S. Bass, MD Christopher T. Chia, MD Erez Dayan, MD Daniel A. Del Vecchio, MD Alfredo E. Hoyos, MD Jeffrey M. Kenkel, MD Christopher Khorsandi, MD William Lao, MD Richard D. Lisman, MD Patrick Mallucci, MD Timothy J. Marten, MD Constantino G. Mendieta, MD Foad Nahai, MD Pat Pazmiño, MD Mario Pelle-Ceravolo, MD Tracy M. Pfeifer, MD David P. Rapaport, MD Rod J. Rohrich, MD Douglas M. Senderoff, MD George Skouras, MD Henry M. Spinelli, MD Douglas S. Steinbrech, MD W. Grant Stevens, MD James M. Stuzin, MD Mark Sultan, MD Steven Teitelbaum, MD Spero J. Theodorou, MD Charles H. Thorne, MD Jennifer L. Walden, MD Holly C. Wall, MD Simeon Wall Jr., MD Richard Warren, MD WELCOME

BACKGROUND:Lower eyelid blepharoplasty has continued to evolve with ongoing debate regarding optimal techniques. Despite large case series publishing excellent results and minimal complications, the true longevity of these procedures remains unclear.OBJECTIVES:The aim of this study was to determine how thoroughly the aesthetic surgery literature assesses the longevity of lower blepharoplasty.METHODS:A 20-year comprehensive literature review from 1997 to 2017 was conducted. The titles and abstracts of 180 articles were reviewed, yielding 86 potential publications; 49 studies met inclusion criteria and were analyzed.RESULTS:A total of 10,698 patients were included for analysis. Reported follow-up ranged between 1 week and 192 months. Mean follow-up was 14.8 months for the 29 studies (59.2%) that reported these data. Pooled analysis of complication rates demonstrated 0.77% (n = 82) reoperation, 0.37% (n = 39) scleral show, 0.25% (n = 27) lid malposition, and 0.24% (n = 25) ectropion rates, among others. Forty-four studies (89.8%) published postoperative photographs with a total of 141 unique postoperative time points that were supported with photographic evidence (mean: 15.3 months; range: 1 week-192 months). In this series, for only 10 patients (0.094%) were postoperative photographs available at time points beyond 24 months.CONCLUSIONS:Lower eyelid blepharoplasty is a powerful procedure with seemingly minimal morbidity despite its technical demands. The longevity of this procedure is poorly supported with photographic evidence in the literature. Studies do not adequately report or represent their follow-up to capture long-lasting results. Standardized reporting of results is needed to ensure that anyone seeking this treatment can be adequately counseled.LEVEL OF EVIDENCE 4:

There are several advantages of lateral SMASectomy in comparison with traditional elevation. First, because the procedure does not require traditional SMAS flap elevation, there is less concern about tearing of the superficial fascia. Second, the potential for facial nerve injury is lower because most of the deep dissection is over the parotid gland. If the SMASectomy is performed anterior to the parotid, the deep fascia will similarly provide protection for the facial nerve branches as long as the resection of the superficial fascia is done precisely and the deep fascia is not violated. Third, because SMAS flaps have not been elevated, they tend to hold suture fixation more strongly, and the potential for postoperative dehiscence and relapse of contour is decreased.

Summary:Cosmetic plastic surgery procedures continue to increase in frequency, and a greater number of them now occur outside of an acute-care hospital setting. In addition, antidepressant use is also rising, with a greater number of patients taking selective serotonin reuptake inhibitors to aid in a variety of mood and anxiety disorders. Americans spend more than $86 billion each year on antidepressants, as 34 million people in the United States are taking at least one of these medications. Many side effects of selective serotonin reuptake inhibitors are well known and not clinically relevant to practicing surgeons. Hyponatremia, however, is a well-documented side effect of these medications that has received relatively little attention in the surgical literature. Postoperative hyponatremia results because of a decrease of antidiuretic hormone suppression that occurs with selective serotonin reuptake inhibitor administration. Here, the authors first review the literature reporting hyponatremia with selective serotonin reuptake inhibitor use. The authors then present two cases of severe postoperative hyponatremia after plastic surgery operations. The authors propose that patients using selective serotonin reuptake inhibitors, especially elderly patients and those undergoing procedures with expected large fluid shifts, should be tested preoperatively and postoperatively for serum sodium levels so that a diagnosis of hyponatremia may be made early and treated before a catastrophic event.CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, V.

On December 5, 2013, Dr. Longaker and Dr. Rohrich were participating in a panel moderated by Drs. Aston and Baker at the 34th Annual Meeting of “The Cutting Edge” in New York City. We looked out at a packed Grand Ballroom at the Waldorf Astoria Hotel as Dr. Aston asked how many surgeons in the audience routinely performed fat transfer during a face lift in their practice. Almost every hand went up. In response to the next several questions asking what percentage of the transferred fat survived after performing these procedures–100, 75, 50, 25, or 0 percent–the percentage of hands raised varied, with most of the audience thinking 75 percent or 50 percent of the fat survived. Two characteristics were remarkable about the audience’s response: (1) how prevalent fat transfer has become in plastic surgery; and (2) how many “unknowns” remain about fat transfer. Plastic surgeons achieve the best results after performing procedures that yield predictable and consistent outcomes. As our careers as surgeons and our practices develop and mature, we modify and refine our techniques to optimize results. Today, the state-of-the-art techniques for face lifts, rhinoplasties, microvascular surgery, hand surgery, and craniofacial surgery can consistently yield predictable results. In stark contrast, our current knowledge of fat transfer is not well developed, and many aspects of the procedure remain “unknown” and lead to unpredictable clinical outcomes. Fat transfer begins with lipoaspiration and ends with placement of the fat into another part of the body for either cosmetic or reconstructive indications. If a surgeon is performing lipoaspiration without subsequent transfer, the viability of the fat removed is not a consideration because it is discarded as medical waste. However, if the fat removed will be transferred to another site on that patient, the preservation of fat viability becomes very important. In its current form, fat transfer involves a harvesting step, followed by some form of processing, and finally placement of fat into the new location. Each of these phases of the procedure has an adverse effect on fat viability. Are the unpredictable results of fat transfer the result of diminished fat viability during the harvest, processing, and placement steps? Currently, we simply do not know the optimal techniques in each of the steps of fat transfer that yield the “best practice” for preserving fat viability and producing predictable results (Table 1).Table 1: Unresolved Questions in Fat Transfer*FAT HARVEST The techniques for fat removal by means of lipoaspiration were designed for safe and efficient removal of fat, not the preservation of aspirated fat viability for subsequent transfer. Does the technique of fat aspiration have a detrimental effect on fat viability? The answer is undoubtedly yes. Which technique of fat aspiration maximizes fat viability for subsequent transfer: the “standard” approach, power-assisted, ultrasound-assisted, or laser-assisted? Although some investigators are beginning to study this question, it remains largely unknown. What is the effect of tumescent technique with or without vasoconstrictors on the viability of aspirated fat? What is the effect of patient age on the viability of aspirated fat? What is the effect of harvest site (e.g., abdomen, outer thigh, inner thigh, hips) on the viability of aspirated fat? Preclinical work both in vitro and in vivo will have to be performed followed by randomized controlled clinical trials to answer these questions before “best practices” for fat harvest that maximize fat viability can be determined. FAT PROCESSING Following harvest, fat is generally processed before placement. This phase of the procedure is perhaps the least defined in terms of techniques. Surgeons use a wide variety of processing steps ranging from nothing to extensive steps including decanting, centrifugation, syringe exchanging, and commercial devices that wash and filter the fat. Recent publications are beginning to study the effects of each of these approaches with an eye on fat viability in vitro and in vivo. However, much more work is needed in preclinical models followed by randomized controlled clinical trials before best practices for fat processing that maximize fat viability can be determined. FAT PLACEMENT This part of the procedure is arguably the most damaging to the fat. Surgeons are beginning to determine the effects of shear, pressure, and flow during injection on fat viability. However, the optimal aliquot volume with each deposit of fat into the recipient site maximizing fat survival and take at the recipient site remains unknown. In addition, what size cannula or needle should be used for injections, and does a precisely controlled mechanical approach to pressure, flow, and aliquot size for fat deposition make a difference? Investigators are now developing technology to address these questions, but much more work needs to be done before we can identify best practices for fat placement that maximizes fat viability. RECIPIENT SITE Whether one transfers fat into the face, breast, or any other recipient site for either cosmetic or reconstructive indications, what is the optimal technique for preserving fat viability and maximizing take? Does the increased blood supply to the soft tissue of the face yield increased fat transfer take compared with the breast? Does externally expanding the breast recipient site lead to more predictable results with fat transfer? Should one pretunnel with a cannula to create channels for subsequent fat transfer? What is the best way to approach fat transfer into an irradiated site in the head and neck or breast? The idea of optimizing the recipient site to maximize fat transfer take is rapidly evolving, and scientists are now actively studying the most fat-friendly microenvironment or niche for the transplanted cells with a goal of maximizing viability. For example, future techniques may include combining angiogenic factors with antiapoptotic agents to preserve the viability of transplanted fat when placed into the recipient site. The transplanted cells are hypoxic following the ex vivo period for processing and they are placed into a wound environment following injection, so it makes sense to develop a fat-friendly microenvironment and macroenvironment at the recipient site to maximize fat survival following placement. STEM CELLS Although adipocytes are used in the vast majority of fat transfer cases, surgeons are beginning to study the strategy of “mixing in” adipose-derived stromal/stem cells, so-called cell-assisted lipotransfer. The concept of cell-assisted lipotransfer is that adipose-derived stromal/stem cells may produce angiogenic factors and prosurvival factors, and/or differentiate into adipocytes following transplantation. If this is the case, combining adipocytes with adipose-derived stromal/stem cells may maximize fat viability and yield predictable results. As with the other aspects of fat transfer described above, much more work needs to be done in both preclinical models and clinical trials before we can answer whether or not adipose-derived stromal/stem cells mixed-in with adipocytes maximizes clinical fat viability and outcomes. EFFECT ON SKIN Although the previous sections focused on fat preservation and soft-tissue volume, less in known about the effect of fat transfer on overlying skin. This question is perhaps more relevant for the face than for other recipient sites. Does the fat have an effect on the overlying skin? If so, does it promote collagen synthesis and angiogenesis and does this make a difference in the clinical appearance of the skin? What is the effect of fat transfer on irradiated skin? These are important questions, and plastic surgeons must study this area rigorously if we are making claims regarding skin rejuvenation following fat transfer. REGENERATIVE MEDICINE In addition to its ability to provide an autologous soft-tissue filler for cosmetic or reconstructive indications, fat is an abundant (and renewable!) source of mesenchymal multipotent cells. Although the exact cell lineage and identity of the stromal cells found in fat remain elusive, these cells can be differentiated into multiple types of mesenchymal-derived cells (e.g., fat, bone, cartilage, ligament, tendons). Furthermore, adipose-derived cells have been used to engineer new tissue in both preclinical and clinical studies. Finally, adipose-derived stromal/stem cells can be reprogrammed into induced pluripotent cells that can be differentiated into every cell type in the body. Given the relative abundance and ease of harvest, the increasing use of adipose-derived stromal/stem cells for regenerative medicine places the plastic surgeon in a prominent role for regenerative medicine. We must leverage our ability to safely obtain relatively large volumes of fat with techniques that maximize adipose-derived stromal/stem cell viability and become the key clinicians at the center of operative tissue engineering. That we will see plastic surgeons harvesting fat for tissue engineering indications in orthopedic; cardiac; vascular; general; ear, nose, and throat; urology; and neurosurgery cases in the next 5 years is not too far-fetched. If we do not maintain our leadership in techniques for fat harvest, there is no doubt that our roles will be replaced by competing specialties. CONCLUSIONS There is an enormous clinical appetite for fat transfer in both small-volume (e.g., face) and large-volume (e.g., breast, buttock) indications, but unpredictable results in terms of fat take at the recipient site remain a problem. Plastic surgeons must determine the optimal strategies for preserving fat viability during fat harvest, processing, and placement. In addition, we must study the effects of recipient-site preparation and the roles of adipose-derived stromal/stem cell mix-in with adipocytes in maximizing fat viability. Only by rigorous preclinical and clinical studies will these questions be answered.

1305 On December 5, 2013, Dr. Longaker and Dr. Rohrich were participating in a panel moderated by Drs. Aston and Baker at the 34th Annual Meeting of “The Cutting Edge” in New York City. We looked out at a packed Grand Ballroom at the Waldorf Astoria Hotel as Dr. Aston asked how many surgeons in the audience routinely performed fat transfer during a face lift in their practice. Almost every hand went up. In response to the next several questions asking what percentage of the transferred fat survived after performing these procedures—100, 75, 50, 25, or 0 percent—the percentage of hands raised varied, with most of the audience thinking 75 percent or 50 percent of the fat survived. Two characteristics were remarkable about the audience’s response: (1) how prevalent fat transfer has become in plastic surgery; and (2) how many “unknowns” remain about fat transfer. Plastic surgeons achieve the best results after performing procedures that yield predictable and consistent outcomes. As our careers as surgeons and our practices develop and mature, we modify and refine our techniques to optimize results. Today, the state-of-the-art techniques for face lifts, rhinoplasties, microvascular surgery, hand surgery, and craniofacial surgery can consistently yield predictable results. In stark contrast, our current knowledge of fat transfer is not well developed, and many aspects of the procedure remain “unknown” and lead to unpredictable clinical outcomes. Fat transfer begins with lipoaspiration and ends with placement of the fat into another part of the body for either cosmetic or reconstructive indications. If a surgeon is performing lipoaspiration without subsequent transfer, the viability of the fat removed is not a consideration because it is discarded as medical waste. However, if the fat removed will be transferred to another site on that patient, the preservation of fat viability becomes very important. In its current form, fat transfer involves a harvesting step, followed by some form of processing, and finally placement of fat into the new location. Each of these phases of the procedure has an adverse effect on fat viability. Are the unpredictable results of fat transfer the result of diminished fat viability during the harvest, processing, and placement steps? Currently, we simply do not know the optimal techniques in each of the steps of fat transfer that yield the “best practice” for preserving fat viability and producing predictable results (Table 1).

This article discusses removing a portion of the superficial musculoaponeurotic system (SMAS) in the region directly overlying the anterior edge of the parotid gland, called a lateral SMASectomy. Excision of the superficial fascia in this region secures mobile anterior SMAS to the fixed portion of the superficial fascia overlying the parotid. It is a rapid, safe, and reproducible operation, providing the versatility of traditional SMAS flap undermining and the safety and rapidity of SMAS plication in carefully selected patients.

Summary: Aesthetic analysis in facial rejuvenation has traditionally been subordinate to technical solutions. While concerns regarding correction of facial laxity, a reduction in the depth of the nasolabial fold, and improvement of both the jowl and the jawline are worthy goals in rhytidectomy, the aesthetic concept of restoring facial shape to a more youthful appearance is equally important. Restoring facial shape in face lifting requires an understanding of how the face ages and then the formulation of a treatment plan that is individualized for the patient. Re-establishment of facial contour is significantly influenced by the re-elevation of descended facial fat through superficial musculoaponeurotic system manipulation; it can be approached through a variety of technical solutions. Underlying skeletal support affects not only the appearance of the face in youth but also how the face ages and influences the operative plan in terms of the requirements for fat repositioning. Formulating a treatment plan that is patient specific and based on the artistic goals as influenced by skeletal support is the key element for consistency in restoring facial shape in face lifting.

Background: The modified lateral superficial musculoaponeurotic system (SMAS)-ectomy is an evolution of the technique described by Baker. This modification of the lateral SMASectomy improves and simplifies the procedure by addressing the SMAS and platysma in one surgical procedure. Methods: A rectangle of SMAS and platysma, parallel to the nasolabial fold (1 cm inferior to the zygomatic arch, 4 to 5 cm below the jaw line, and 3 cm wide), was marked. This plane was undermined anteriorly with blunt dissection, leaving the facial nerve deep to the deep cervical fascia. After excision of the rectangle, the defect was closed, leading to a correction of the neck, jowl, and nasolabial folds. Superolateral elevation of the inferior portion of the flap in particular addresses the problem of neck laxity and platysma redundancy. Results: A total of 359 patients have undergone this procedure performed by the senior author (N.W.). Conclusion: This technique gives pleasing, durable results, with minimal morbidity.

Neck Lift By Joel J. Feldman. Pp. 450. Quality Medical Publishing, St. Louis, Mo., 2006. Price: $395. Neck Lift is the culmination of Joel Feldman’s 30 years of experience performing both reconstructive and cosmetic surgery on the neck. The entire book is a testimony to his clear thinking and analysis of a complicated, often confusing subject. The illustrations by Amanda Behr are superb, simple, and precise. The 12 chapters discuss basic concepts, anatomy, surgical technique, and the more complicated and controversial subplatysmal surgery, at which Dr. Feldman is a master. One of the best chapters covers anatomy. It is the most thorough and clear description of aesthetic neck anatomy I have ever read. The chapter’s exhaustive bibliography of 163 references is invaluable and shows the time, thought, and effort put into this book. I especially enjoyed the chapters on incisions and earlobe shaping, two critical areas often overlooked in rhytidectomy. In his Preface, Dr. Feldman admits that his approach to neck lifting is unconventional. Although Dr. Feldman and I do not share the same surgical approaches, our concepts and goals are the same. Clearly, his technique works well for him. In the chapter on subplatysmal surgery, I was pleased to read Dr. Feldman state, “I don’t perform digastric shaves very often, a few times a year at most.” The chapter on resecting submandibular salivary gland bulges is very thorough and honest. After reading the descriptions of the complexities and potential complications, I was convinced I would never resect a submandibular gland for cosmetic reasons. Neck Lift is certainly Dr. Feldman’s masterpiece, and reading it was truly stimulating. As I have stated at several national meetings, this is a book for resident, young, and seasoned plastic surgeons alike. Even if you never perform corset platysmaplasty, you will be educated and enlightened by the book. It should be in every cosmetic surgeon’s library.FigureDaniel C. Baker, M.D.

The author discusses his view that the risks of aggressive subplatysmal surgery are not balanced by substantial benefits. He emphasizes that aesthetic standards for neck contouring should not be based upon unrealistic criteria for the "youthful neck" but modified according to each patient's unique physiognomy. He stresses the need for reporting of large case series, standardized evaluation and surgical technique, and accurate data on complications of aggressive subplatysmal surgery before surgeons embrace these radical contouring techniques.

New York, N.Y.; and New Orleans, La. From the Institute of Reconstructive Plastic Surgery, Manhattan Eye, Ear, and Throat Hospital, and the Louisiana State University Health Science Center. Received for publication July 12, 2004; revised September 23, 2004. Daniel C. Baker, M.D., Ernest S. Chiu, M.D., 65 East 66th Street, New York, N.Y., [email protected]

Background: The reported incidence of hematoma following male rhytidectomy ranges from 7.9 to 12.9 percent. In 1976, it was demonstrated that postoperative hypertension is a key etiologic factor in hematoma formation and postoperative use of Thorazine was recommended to control blood pressure. This study analyzes the incidence of hematoma after male rhytidectomy at one institution after a strict and aggressive perioperative blood pressure control regimen was iniated. Methods: From 1.982 to 2002, 985 patients with a mean age of 61 years (range, 49 to 72),ears) underwent rhytidectomy. Thirty-six patients required surgical evacuation of expanding hematoma after rhytidectomy. Operative procedures were performed by more than 100 different plastic surgery attending surgeons, residents, and fellows. Results: The overall incidence of hematoma during this study period was 4.24 percent. Age, medical history, medications, style of anesthesia, rhyddectomy technique and combination of-procedures, and length of operation were not independent risk factors for determining who was more likely to develop a hematoma. Thirty-three percent of the patients requiring Surgical evacuation had systolic blood pressure greater than 150 mmHg and diastolic blood pressure greater than 90 mmHg preoperatively, intraoperatively, and postoperatively. Over a 30-year period, the incidence of hematoma requiring surgical evacuation has decreased From 8.7 percent to 3.97 percent after initiation of-a strict perioperative blood pressure control regimen. Conclusion: Despite the lower incidence of hematoma following male rhytidectomy today as compared with 30 years ago, the incidence in men (3.97 percent) remains higher than that in women (I to 3 percent).

Daniel C. Baker, MD Foad Nahai, MD Hamid Massiha, MD Patrick Tonnard, MD Dr. Baker: The first patient is a 48-year-old fashion consultant who wants to correct her neck and jowl laxity (Figure 1). Although her hair is quite short, she is planning to let it grow and wear it up off her face. Many of her friends and clients have undergone face lift surgery and have significant scars behind their ears; she would like to avoid this. Dr. Massiha, how would you treat this patient? Figure 1 This 48-year-old fashion consultant is requesting correction of her neck and jowl laxity. Dr. Massiha: She has some asymmetry, and the right side of her face is smaller than the left. The asymmetry may require another procedure, such as fat grafting. She has a type 1 or 2 deformity1 and would be an ideal candidate for a short scar face lift. Dr. Baker: Would you do a SMAS flap, plication, or some type of suspension technique? Dr. Massiha: I would dissect the SMAS and platysma as one unit and pull it up. Whatever SMAS is in excess, I would remove. I would treat the left side more aggressively than the right, and maybe that would improve the asymmetry. I like using a SMAS platysma unit, but if I could not dissect the cheek part of the SMAS because it was too thin or too thick, I would create a skin flap in the upper part of the face and blend it with the SMAS platysma flap of the lower face, namely below the level of the lips inferiorly. Dr. Baker: Dr. Nahai, the submental area seems a little full. How would you address that? Dr. Nahai: I agree with Dr. Massiha that this woman would be a good candidate for a short scar …

Since its introduction in 1992, endoscopic brow lift has gained tremendous recognition because it has been promoted as a novel technique to correct brow ptosis as well as glabella rhytids in a minimally invasive manner with fewer complications than the classic coronal brow lift method. In this retrospective study, 628 endoscopic brow lift procedures performed over a 5-year period (1997-2001) at Manhattan Eye Ear and Throat Hospital were reviewed. The number of endoscopic brow lift procedures performed at this institution has declined 70 percent. The purpose of this study was to elucidate the causes of this striking trend by soliciting the opinions of 21 New York plastic surgeons on their current brow ptosis management. The response rate was 84 percent (21 of 25 surgeons contacted). Currently, 25 percent of the interviewed plastic surgeons perform endoscopic brow lift regularly, 50 percent of the plastic surgeons perform endoscopic brow lift occasionally, and 25 percent of the participants no longer perform endoscopic brow lift. While most patients (70 percent) were satisfied with their results, only 50 percent of the plastic surgeons were pleased with the long-term results (after more than 2 years of follow-up). Observed postsurgical complications of endoscopic brow lift included alopecia, hairline changes, infected hardware, brow asymmetry requiring surgical revision, prolonged forehead/brow paresthesia, frontal branch nerve paralysis, and scalp dysesthesia. These complications were similar to those resulting from open brow lifts. Seventy-one percent of the surveyed New York plastic surgeons routinely administered botulinum toxin type A (Botox) within 6 months of the endoscopic brow lift procedure. Possible explanations for the decline in the overall number of endoscopic brow lift procedures include the following: (1) the selection criteria for the ideal endoscopic brow lift patients are currently more limited; (2) other techniques equal or surpass endoscopic brow lift in effectiveness and predictability; and (3) endoscopic brow lift is ineffective in the majority of patients. There is no single superior surgical procedure for brow ptosis management available at this time.