BACKGROUND:Plastic surgeons have a variety of treatment options for perioral rejuvenation, including chemical peels, energy-based skin-tightening devices, microneedling, microcoring, fat grafting, fillers, neuromodulators, and surgical lip lifts. OBJECTIVES:The aim of the current study was to determine the effect of perioral phenol-croton oil peeling on philtrum length in patients undergoing primary facelift. METHODS:A retrospective cohort study was performed on Caucasian females undergoing primary facelift with perioral heavy formula phenol-croton oil peels (33% phenol, 1.1% croton oil). Propensity matching was performed with BMI and age for comparison to control patients undergoing facelift without adjunct peel. Mirror Medical Imaging Software was used to estimate pre- and postoperative philtrum length for each patient from the nadir of the cupid's bow to the subnasale. Mann-Whitney and independent t-tests were used to compare the percentage change in philtrum height amongst and between cohorts. RESULTS:The study cohort consisted of 100 female primary facelift patients (50 with perioral peel, 50 without perioral peel). The patients had a mean age of 67.0 years and a mean BMI of 24.6 kg/m2, and the mean [standard deviation] follow-up for first appointment at least 3 months postoperatively was 6.4 [3.3] months (range, 3.0-16.1 months). Peel patients had significantly shorter philtrum lengths postoperatively, with a mean shortening of 9.3% [4.6%] (P < .001). Control patients had no difference in philtrum length postoperatively (P > .05). CONCLUSIONS:Phenol-croton oil peeling is a powerful tool for tightening skin and softening rhytides in the perioral region. This study demonstrated an additional, previously unreported benefit of average philtrum length shortening of nearly 10%. These findings are gratifying because philtrum lengthening is a classic finding in the aging face. LEVEL OF EVIDENCE: 3 (THERAPEUTIC):

BACKGROUND: Utilization of peninsular buccal flaps for primary cleft palate repair is well-documented in the literature. However, there is no report on the application of an island flap for primary cleft palate repair. This study aims to reveal the clinical application of an axial neurovascular propeller buccinator myomucosal flap. METHODS: An anatomical study was performed by injection into the buccal pedicle of twenty-two fresh hemifacial cadavers. Additionally, we analyzed palatal healing and flap outcomes in twenty-five primary cleft palate reconstructions utilizing thirty-six pedicled propeller flaps. RESULTS: Cadaver study: the mean buccal artery diameter was 1±0.3 mm, the neurovascular pedicle entered the flap 11.4±2.9 mm anterior to the pterygomandibular raphe (1/6 th the length of the flap), and the buccal artery advanced inside the flap as much as 66.8%±6.0% of the total flap length. Clinical experience: all reconstructions were performed using a modified Furlow palatoplasty. Mean age of patients was 15.3 months and mean maximum cleft width was 11.7 mm. Eleven cases utilized bilateral flaps. The flap always reached the contralateral pillar, and the buccal nerve was always preserved. 11.11% flaps (4/36) underwent scar revision, and 5.56% flaps (2/36) were lost. Follow-up period was 11.3 months. CONCLUSION: This study suggests the utilization of axial neurovascular pedicled propeller buccinator myomucosal flaps is a safe and reliable option in primary cleft palate reconstruction. Our anatomical dissections and clinical outcomes reveal the consistent and robust nature of buccal neurovascular pedicle, and our modified surgical technique allows for preservation of the buccal nerve.

BACKGROUND:Over the past decade, the use of poly-4-hydroxybutyrate (P4HB) in aesthetic breast surgery has grown in popularity. Published data on long-term outcomes, however, is scarce. OBJECTIVES:The purpose of this study was to assess long-term outcomes with utilization of P4HB in various aesthetic breast procedures. METHODS:A retrospective review of all patients undergoing breast procedures with P4HB was performed by the senior author between July 2012 and March 2022. All patients with greater than 1 year of follow-up were evaluated, including demographics, surgical indications, complications, secondary procedures, and patient satisfaction. A Kruskal-Wallis test was performed to assess the stability of satisfaction over time. RESULTS:A total of 248 patients were evaluated. The mean follow-up length was 2.9 years (range, 1-9.3 years). The most common surgical indication was breast ptosis, which comprised 68% (n = 167) of patients. The overall complication rate was 8.0% (n = 20), with an unplanned reoperation rate of 2.8% (n = 7). Across the entire study population, the mean satisfaction score was 3.42 out of 4. When satisfaction scores were compared to follow-up length, Kruskal-Wallis test demonstrated no statistical differences (H = 18.2, P = .89, degrees of freedom [df]= 2), suggesting stability of satisfaction over time. CONCLUSIONS:This study presents the senior author's entire experience with P4HB across a wide range of aesthetic breast procedures. With an average follow-up length of almost 3 years, P4HB appears to be a both safe and effective tool to support soft tissue in aesthetic breast surgery. Further, high patient satisfaction appears stable. LEVEL OF EVIDENCE: 4:

The preoperative evaluation plays an important role in optimizing outcomes and minimizing morbidity for patients undergoing blepharoplasty. This article provides a detailed, systematic approach for the preoperative evaluation of patients undergoing upper and lower blepharoplasty. This article focuses on the critical steps of evaluating surgical blepharoplasty candidates to ensure optimal outcomes and high patient satisfaction, while minimizing risks and complications.

Editorial Decision date: January 18, 2023; online publish-ahead-of-print January 25, 2023. Aesthetic Surgery Journal Open Forum 2023, 1–2 © The Author(s) 2023. Published by Oxford University Press on behalf of the Aesthetic Society. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/ by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. https://doi.org/10.1093/asjof/ojad006 www.asjopenforum.com

The author's name Maria Siemionow was unfortunately excluded from the author group in Chapter 3. The initially published version has now been corrected.

BACKGROUND:Previous studies have compared various attributes of independent and integrated resident applicants and identified criteria for a successful match outcome. Few studies have directly examined the relative desirability of various surgical and nonsurgical specialties from the resident's perspective. To address this, the authors analyzed plastic surgery resident applicants and available positions from 2010 through 2018 and compared these data alongside four surgical and five nonsurgical specialties.METHODS:In this cross-sectional, retrospective review from the San Francisco Match and National Resident Matching Program, year, number of applicants, available positions, and specialty (integrated or independent plastic, general, or orthopedic surgery; neurosurgery; otolaryngology; anesthesiology; emergency, family, or internal medicine; and pediatrics) were examined.RESULTS:From 2010 through 2018, the number of integrated positions increased by 142%, whereas the number of integrated applicants increased only by 14.5%. The number of available independent positions decreased by 32.6%, whereas the number of independent applicants decreased by 43.9%. All surgical subspecialties demonstrated a decrease in applicants relative to positions (range 9.9% to 24.8%). Unlike the surgical specialties, the nonsurgical fields increased both their number of positions (14% to 57.2%) and number of applicants (2.2% to 44.1%). In particular, applicants to emergency, family, and internal medicine increased dramatically (17% to 44.1%).CONCLUSIONS:Applicants to plastic surgery and other surgical residencies changed minimally. The nonsurgical specialties showed a significant increase in the number of applicants, suggesting increasing interest in the nonsurgical fields. Contributing factors may include medical school pressures, lifestyle concerns, and experience with various specialties during medical school. Means of enhancing medical student exposure to plastic surgery are suggested.

BACKGROUND:In 2001, Elkwood and Matarasso published an American Society of Plastic Surgeons (ASPS) member survey detailing brow lift practice patterns. Interval changes in practice patterns have not been studied. OBJECTIVES:The previous survey was revised to elucidate current trends in brow lift surgery. METHODS:A 34-question descriptive survey was distributed to a random group of 2360 ASPS members. Results were compared to the 2001 survey. RESULTS:A total of 257 responses were collected (11% response rate; ± 6% margin of error at 95% CI). The most frequent technique for the correction of brow ptosis in both surveys was the endoscopic approach. The use of hardware fixation has increased in endoscopic brow lifting, whereas the use of cortical tunnels has decreased. Although coronal brow lifting has decreased in frequency, hairline and isolated temporal lift have increased. Neuromodulators have replaced resurfacing techniques as the most common nonsurgical adjunct. Frequent use of neuromodulators has risen from 11.2% to 88.5%. Nearly 30% of current surgeons feel that neuromodulators have replaced formal brow lifting procedures to a significant degree. CONCLUSIONS:In comparing the 2001 and current ASPS member survey there has been a clear transition to less invasive procedures over time. Although the endoscopic approach was the most popular means of forehead correction in both surveys, coronal brow lifting has decreased in frequency and the hairline and temporal approaches have increased. Neurotoxins have replaced laser resurfacing and chemical peeling methods as an adjunct, and in some cases replaced the invasive procedure entirely. Possible explanations for these findings will be discussed. LEVEL OF EVIDENCE: 4:

PURPOSE: Buccal artery myomucosal (BAMM) flap has been well-described for cleft palate (CP) reconstruction. However, anatomic analysis and application of a completely islanded propeller flap have not been reported in the literature. METHODS: Anatomical study was performed using Indocyanine green, red and blue latex injected directly into the buccal pedicle of 22 fresh hemifacial cadavers. Then, clinical analysis of the senior authors’ (BBG, AR) experience with 25 consecutive primary cleft palate reconstructions utilizing a propeller islanded BAMM flap was conducted to assess palatal healing and flap outcomes. RESULTS: Mean buccal artery diameter was 0.95±0.29mm. Neurovascular pedicle entered the flap 11.38±2.87mm anterior to the pterygomandibular raphe. Buccal artery advanced inside the flap as much as 66.8%±6.0% of the total flap length. ICG angiography showed 84.8%±13.9% of the flap length was instantly vascularized through the buccal arterial system. Quantitative fluorescence scores (average normalized pixel brightness) were low in 6.84%±1.28%, intermediate 4.24%±1.48%, and high 2.58%±0.54%. Low fluorescence scores corresponded to the distal third near the oral commissure. Intermediate and high fluorescence were distributed in the proximal two thirds of the flap length. All reconstructions were performed using Furlow palatoplasty. 36 flaps were utilized in 25 patients (mean age 478d). The mean maximum cleft width was 11.7 mm. Mean BAMM flap width was 1.2 cm and 11 cases utilized bilateral flaps. The flap always reached the contralateral pillar and the buccal nerve was always preserved. Mean follow-up was 400 days. There were 2/36 flap loss. In both flap losses, pedicles were aggressively dissected. 4/36 flaps underwent revision surgery for flap debulking. CONCLUSION: This study shows that the buccal pedicle is the main blood supply to the flap and this modification allows preservation of the sensory innervation. The contralateral pillar could always be reached improving the traditional advancement and inset. Traditional extensive propeller flap dissection should be avoided in these neonates to avoid vascular compromise.

PURPOSE: Buccal artery myomucosal (BAMM) flap has been well-described for cleft palate reconstruction. However, anatomic analysis and application of a completely islanded propeller flap have not been reported in the literature. METHODS: Anatomical study was performed using Indocyanine green, red and blue latex injected directly into the buccal pedicle of 22 fresh hemifacial cadavers. Then, clinical analysis of the senior authors’ (BBG, AR) experience with 25 consecutive primary cleft palate reconstructions utilizing a propeller islanded BAMM flap was conducted to assess palatal healing and flap outcomes. RESULTS: Mean buccal artery diameter was 0.95±0.29mm. Neurovascular pedicle entered the flap 11.38±2.87mm anterior to the pterygomandibular raphe. Buccal artery advanced inside the flap as much as 66.8%±6.0% of the total flap length. All reconstructions were performed using Furlow palatoplasty. 36 flaps were utilized in 25 patients (mean age 478d). The mean maximum cleft width was 11.7 mm. Mean BAMM flap width was 1.2 cm and 11 cases utilized bilateral flaps. The flap always reached the contralateral pillar and the buccal nerve was always preserved. Mean follow-up was 400 days. There were 2/36 flap loss. In both flap losses, pedicles were aggressively dissected. 4/36 flaps underwent revision for flap debulking. CONCLUSION: This study shows that the buccal pedicle is the main blood supply to the flap and this modification allows preservation of the sensory innervation. The contralateral pillar could always be reached improving the traditional advancement and inset. Traditional extensive propeller flap dissection should be avoided in these neonates to avoid vascular compromise.

Background: The efficacy of minimally invasive techniques for addressing isolated sagittal craniosynostosis decreases with age; thus, timely referral is critical. We sought to identify a screening tool using data from well-child visits. We hypothesized that many infants with sagittal craniosynostosis, but no macrocephaly based on growth chart plotting, in fact have a relative macrocephaly. Methods: All infants with CT and surgically/pathologically confirmed isolated sagittal craniosynostosis were identified. Growth chart data was collected (head circumference (HC), weight, crown-to-toe-length, and World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) percentiles and deviation ( z-scores)). Relative macrocephaly was defined as head circumference >2SD from size (weight and/or length). Results: Initial pilot screen indicated that WHO growth chart data has utility as a screening tool. Subsequent retrospective case-control study with area under the curve (AUC) analysis revealed that HC:length ratio ≥0.71 is indicative of isolated sagittal craniosynostosis as young as 1 week of age, while HC:length ratio ≥0.67 represents the maximization of sensitivity (0.89) and specificity (1.00) as early as 2 weeks old. Prospective internal validation with logistic regression demonstrated that at ages 1 to 2 months greater discriminatory value HC:length ratio was observed. Conclusions: When length is added to head circumference as a screening tool we may identify an abnormal growth pattern beginning as early as 1 week. This represents an opportunity to design an automated alert easily programed into the electronic medical records and may prompt pediatricians to refer patients to craniofacial surgeons early.

Background: In 2000, Matarasso et al. performed a survey of American Society of Plastic Surgeons members’ face lift practice patterns. Since that publication, the aesthetic marketplace has changed dramatically, as have ancillary face lift techniques. In an attempt to detail these changes, we repeated that original survey, adding questions to address more recent technical issues and advances. The goal of this report was to define current face lift practice patterns, compare current patterns to the previous ones, and define recent advances. Methods: A 38-question survey assessing face lift techniques, perioperative management, complications, and concomitant procedures was electronically distributed to a random cohort of American Society of Plastic Surgeons members. Data were recorded and statistically analyzed utilizing the Pearson chi-square test. Results: A total of 251 forms were returned and analyzed. Details of demographics, face lift techniques, ancillary procedures, perioperative care, and complications are presented. Current results were compared to the previously published society member practice patterns delineated in the 2000 Plastic and Reconstructive Surgery publication. Conclusions: The basic approach of American Society of Plastic Surgeons members to the face lift operation has not changed dramatically over the past 20 years. The development of operative adjuncts, however, has been positive, including fat grafting techniques, concomitant use of skin resurfacing, and means of minimizing blood loss with tranexamic acid. In certain instances, respondents do not follow evidence-based guidelines for perioperative care. Finally, common complications of practicing members appear to coincide with published retrospective reviews.

PURPOSE: In 2001, Elkwood and Matarasso conducted an American Society of Plastic Surgeons (ASPS) member survey detailing browlift practice patterns. Despite significant changes in approach in the past twenty years, no survey has been performed since. METHODS: A 34-question descriptive survey was electronically distributed to a random group of 2,360 ASPS members. Results were then compared to the 2001 survey. RESULTS: A total of 257 responses were collected (11% response rate; ±6% margin of error at 95% CI). The most frequent technique for the correction of brow ptosis in both surveys was the endoscopic approach. The use of hardware fixation has increased in endoscopic browlifting while the use of cortical tunnels has decreased. While coronal browlifting has decreased in frequency, hairline and isolated temporal lift have increased. Neuromodulators have replaced resurfacing techniques as the most common non-surgical adjunct. Frequent use of neuromodulators has risen from 11.2% to 88.5%. Nearly 30% of current surgeons feel that neuromodulators have replaced formal browlifting procedures to a significant degree. CONCLUSION: In comparing the 2001 and current ASPS member survey there has been a clear transition to less invasive procedures over time. While the endoscopic approach was the most popular means of forehead correction in both surveys, coronal brow lifting has decreased in frequency while the hairline and temporal approaches have increased. Neurotoxins have replaced laser resurfacing and chemical peeling methods as an adjunct, and in some cases replaced the invasive procedure entirely. Possible explanations for the above will be discussed.

This article provides a review of available evidence with regard to short-term complications in facelift surgery. The article reviews both the most common complications and less common, but well-described ones. The goal is to offer objective means to minimize postoperative complications and a guide for treatment when they occur.

Background:. Scalp thinning over a cranioplasty can lead to complex wound problems, such as extrusion and infection. However, the details of this process remain unknown. The aim of this study was to describe long-term soft-tissue changes over various cranioplasty materials and to examine risk factors associated with accelerated scalp thinning. Methods:. A retrospective review of patients treated with isolated cranioplasty between 2003 and 2015 was conducted. To limit confounders, patients with additional scalp reconstruction or who had a radiologic follow-up for less than 1 year were excluded. Computed tomography or magnetic resonance imaging was used to measure scalp thickness in identical locations and on the mirror image side of the scalp at different time points. Results:. One hundred one patients treated with autogenous bone (N = 38), polymethylmethacrylate (N = 33), and titanium mesh (N = 30) were identified. Mean skull defect size was 104.6 ± 43.8 cm2. Mean length of follow-up was 5.6 ± 2.6 years. Significant thinning of the scalp occurred over all materials (P < 0.05). This was most notable over the first 2 years after reconstruction. Risk factors included the use of titanium mesh (P < 0.05), use of radiation (P < 0.05), reconstruction in temporal location (P < 0.05), and use of a T-shaped or “question mark” incision (P < 0.05). Conclusions:. Thinning of the native scalp occurred over both autogenous and alloplastic materials. This process was more severe and more progressive when titanium mesh was used. In our group of patients without preexisting soft-tissue problems, native scalp atrophy rarely led to implant exposure. Other risk factors for scalp atrophy included radiation, temporal location, and type of surgical exposure.

Summary: Superficial vein thrombosis has traditionally been considered a disease of the lower extremity. Less frequently it can affect the breast, chest wall, penis, or upper extremity. Cases involving upper extremities are usually associated with intravascular access, and the vast majority remain self-limiting. This case report presents a 63-year-old patient who had acute extensive thrombosis of cephalic and basilic venous systems following resection of a desmoid tumor from the flank. This was likely related to intraoperative positioning and resulted in severe symptoms mimicking deep vein thrombosis and carpal tunnel syndrome. Additionally, diagnostic tools available to the hand surgeon that allow prompt diagnosis, management, and prevention are discussed.

INTRODUCTION Cranial vault surgery in children with ventricular shunts is more complex due to the possible interference of shunt location with surgical planning and increased risk of shunt related complications. The study evaluated the management of ventricular shunts during cranial vault remodeling (CVR) and subsequent outcomes and complications following CVR. METHODS An IRB-approved retrospective chart review was performed including patients who underwent CVR in presence of a ventricular shunt. Measured outcomes were number of shunt revisions following CVR, 30-day complication rate, 3-month complication rate, and post-CVR Whitaker classification. Finally, a review of the literature was performed, and our results were compared to previous reports. RESULTS Eleven patients met the inclusion criteria. Ventricular shunt was not exposed in 18%; exposed and not revised in 54%; exposed and left on a bone peninsula in 18% and simultaneously exposed and revised in 18%. Two patients experienced complications within 30-days. Three additional patients experienced complications within 3-months. An average of 2.2 shunt revisions per patient were performed following CVR. Whitaker classification was I in 7 patients, II in 1 patient and III in 2 patients. Shunt revision rate for patients undergoing CVR for hydrocephalic macrocephaly was on average of 1.2 and 1.9 for shunt-induced craniosynostosis in literature. CONCLUSIONS Cranial vault abnormalities in the presence of a ventricular shunt can be effectively treated with CVR. The presence of a shunt does not seem to interfere with final head shape. While leaving the shunt unexposed may appear less morbid, shunt related complications can still occur with this approach.

Background: Rebound bleeding during facelift surgery is a major cause of facelift hematomas. Subcutaneous infiltration of tranexamic acid (TXA) combined with lidocaine and epinephrine was recently retrospectively shown to decrease rebound bleeding. No study has prospectively examined the effect of subcutaneous TXA on intraoperative and postoperative bleeding during facelift surgery. Objectives: The aim of this study was to prospectively demonstrate that TXA combined with local anesthesia safely reduces the effects of rebound bleeding, reduces operative time, and decreases postoperative drainage. Methods: This was a prospective, single-surgeon, case-control study performed between July 2019 and March 2020. Thirty-nine patients (35 female and 4 male; mean age, 64.9 years; age range, 49-80 years) underwent facelift surgery alone or in combination with facial rejuvenation procedures. All patients were injected subcutaneously with 1 or 2 mg/mL TXA + 0.5% lidocaine/1:200,000 epinephrine. Patient demographics, TXA dose, time to hemostasis, drain output, and minor and major complications were recorded. Results: The mean time to hemostasis was 6.4 minutes for the left and right sides each. Average postoperative day (POD) 0 drain outputs were 13.9 mL (left) and 10.1 mL (right). Average POD 1 drain outputs were 15.1 mL (left) and 15.6 mL (right). Drains were removed from all patients on POD 1 or 2. There were 2 minor complications (flap necrosis plus infection, marginal mandibular neuropraxia) and no major complications. Conclusions: TXA safely and effectively decreased bleeding, operating room time, and drain output compared with traditional local anesthetic techniques. Our future goal is to determine if epinephrine can be completely removed from the local anesthetic and replaced with TXA for facelift surgery.

Background: The ability to quantitatively analyze how we look at a face and determine if this changes following facial surgery should be of interest to the plastic surgeon. Eye tracking technology (ETT) provides the ability to record where observers fixate when viewing a facial image, enabling quantitative data to be obtained comparing pre- and postoperative changes. Objectives: The authors sought to investigate ETT as a novel outcome assessment tool, determining if facial rejuvenation surgery shifts attention away from the prominent signs of aging, and if so, where this attention shifts. Methods: Twenty-five volunteers viewed 32 randomized frontal, oblique, and lateral images of 11 patients pre- and post-facelift. An eye movement monitoring system recorded the observer's eye position, net dwell time, fixation count, fixation time, and revisits into predefined areas of interest. Data were grouped and analyzed by angle and areas of interest. Paired t tests were employed to detect significant differences in pre- and post-images. Results: On frontal images, less dwell time, fixations, and revisits were noted on the bottom third, forehead, perioral region, and neck (P<0.05). On the lateral view, less visual attention was given to the neck, upper third, and perioral region, with more time in the cheek, nose, and middle third (P<0.05). On oblique images, less attention was given to the neck and upper lid with more aimed at the middle third of the face (P<0.05). Conclusions: ETT provides quantitative data post-facial rejuvenation. Facial aesthetic surgery does alter where observers look when viewing a face, decreasing the time spent inspecting the prominent signs of aging.