Local Infiltration of Tranexamic Acid With Local Anesthetic Reduces Intraoperative Facelift Bleeding: A Preliminary Report

BACKGROUND

Rebound bleeding as a result of loss of epinephrine effect is a common problem encountered during facelift surgery. Tranexamic acid (TXA) is an anti-fibrinolytic agent whose safety and efficacy in reducing bleeding are well documented. We have found that local infiltration of TXA combined with a lidocaine with epinephrine solution during facelift surgery has been effective in decreasing rebound bleeding and the time required to gain hemostasis.

OBJECTIVES

The authors sought to share their local infiltration protocol of TXA combined with epinephrine solution in facelift.

METHODS

Patients who underwent facelift received subcutaneous injection of TXA-lidocaine 0.5% solution following the authors' protocol. After completing both sides of the facelift and the submental platysmaplasty, the first and second sides were sequentially closed. The time to gain hemostasis on each side prior to closure was prospectively measured.

RESULTS

Twenty-seven consecutive patients who underwent facelift surgery received local infiltration of TXA-lidocaine solution. In 23 of the 27 patients, the time required for hemostasis was prospectively recorded. The mean age was 62.1 years (±9.3) and all were females. The average time spent achieving hemostasis on the right, left, and both sides of the face was 6.5 (±2.7), 6.3 (±2.1), and 12.9 (±4.2) minutes, respectively. The total surgical time saving is approximately 25 to 60 minutes. Although primary facelift [13.6 (± 4.3)] exhibited a longer time of hemostasis compared with the secondary group [10.2 (± 2.8)], this was not statistically significant (P = 0.09).

CONCLUSIONS

Local infiltration of TXA with local anesthetic prior to a facelift appears to decrease bleeding, operative time, and postoperative facelift drainage output.

Level of Evidence: 4.

Facelift Surgery Following Superficial Parotidectomy: Is it Safe?

INTRODUCTION

Patients who have previously undergone superficial parotidectomy may also seek facelift surgery for facial aging and rejuvenation. These patients present unique challenges compared to a standard facelift patient. Most concerning is the location of facial nerve branches, which may be superficial and displaced. In addition, significant contour deformities and abnormal scar patterns may be present. The purpose of the study is to review our series of patients and assess potential morbidity and safety of facelift surgery in superficial parotidectomy patients.

METHODS

A retrospective case series was performed reviewing all patients who underwent facelift surgery following superficial parotidectomy from 2000 to 2017. Data were collected for: postoperative facial nerve deficit, soft tissue contour and scar deformities, facelift technique, ancillary soft tissue augmentation procedures and pre- and postoperative photographs. An evidence-based treatment algorithm to address specific problems in this patient population was developed.

RESULTS

A total of seven patients were identified who underwent facelift surgery following parotidectomy. Patients underwent one of the standard SMAS procedure on the non-parotidectomy side, and surgical modifications were made to address the parotidectomy side; soft tissue augmentation was performed in two patients. Precautions to identify the facial nerve and prevent injury, including nerve monitoring and stimulation, were utilized in all seven patients. No permanent postoperative facial nerve injury was noted.

CONCLUSION

Facelift following superficial parotidectomy was safely performed in all cases. Special consideration should be given to contour deformities, facial nerve location and scar placement. However, if approached properly, these patients can still be considered as suitable candidates for facelift surgery.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Objectifying the Risk of Vascular Complications in Gluteal Augmentation With Fat Grafting: A Latex Casted Cadaveric Study

BACKGROUND

Fat transfer is the most popular means of gluteal augmentation. However, this procedure may be complicated by pulmonary fat embolisms (PFEs). Of 135 PFEs out of 198,857 cases reported by the Aesthetic Surgery Education and Research Foundation task force, 32 were fatal, contributing to the mortality risk of this procedure being as high as 1:2351.

OBJECTIVES

The aim of this study was to generate an anatomic map of the 3-dimensional location and variability in size of the gluteal region vessels.

METHODS

Twenty cadaveric gluteal regions were dissected. The aorta, venae cavae, popliteal, and saphenous veins were cannulated and injected with colored latex. Dissection was performed subcutaneously, in the gluteus maximus (GM), and submuscularly to evaluate the number and vascular distribution of all the vessels. Vessels were mapped on an XYZ axis.

RESULTS

The subcutaneous plane, containing 25 vessels on average, had the smallest vessel diameters (artery, 0.9 [0.3] mm; vein, 1.05 [0.22] mm). The GM vein diameter was 1.3 [0.3] mm. Branches of the inferior gluteal vessels had arterial and venous calibers of 2.2 [0.04] mm and 3.5 [0.99] mm, respectively. Superior gluteal artery and vein branches were 1.8 [0.2] mm and 3.85 [1.9] mm in diameter, respectively. Superior and inferior gluteal vein diameters were 7.61 [2.24] mm and 13.65 [6.55] mm, respectively.

CONCLUSIONS

The deeper and more medial planes of the gluteal region house larger, more prominent vessels. This research objectifies and is consistent with recommendations made by various recent task force reports to limit fat transfer to the subcutaneous plane.

Facelift Part I: History, Anatomy, and Clinical Assessment

In this article, the authors aim to thoroughly describe the critical surgical anatomy of the facial layers, the retaining ligamentous attachments of the face, and the complex three-dimensional course of the pertinent nerves. This is supplemented with clarifying anatomic dissections and artwork figures whenever possible to enable easy, sound, and safe navigation during surgery. The historic milestones that led the evolution of cervicofacial rejuvenation to the art we know today are summarized at the beginning, and the pearls of the relevant facial analysis that permit accurate clinical judgment and hence individualized treatment strategies are highlighted at the end. The facelift operation remains the cornerstone of face and neck rejuvenation. Despite the emergence of numerous less invasive modalities, surgery continues to be the most powerful and more durable technique to modify facial appearance. All other procedures designed to ameliorate facial aging are either built around or serve as adjuncts to this formidable craft.

Neck Rejuvenation: Anatomy and Technique

An aesthetically pleasing neck contour remains the cornerstone for facial rejuvenation. In this article a detailed description of the anatomy pertaining to the necklift surgery is provided, with supplemental cadaver video dissections going over the most common and novel necklift techniques.

Retrobulbar Injection for Hyaluronic Acid Gel Filler-Induced Blindness: A Review of Efficacy and Technique

While blindness after hyaluronic acid gel filler injection occurs only very rarely, it represents a devastating complication for the patient and the surgeon. Retrobulbar injection with hyaluronidase is the only known potential means of reversing this adverse event. However, positive outcomes remain anecdotal. We have attempted to review the current literature regarding possible efficacy and detail the indications and technique to be utilized, if hyaluronidase retrobulbar injection is to be attempted. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Pathophysiology Study of Filler-Induced Blindness

Background

A number of authors have proposed retrograde arterial embolism as the responsible mechanism for filler-induced blindness. However, no previous human study has substantiated this proposed mechanism.

Objectives

The aim of this study was to investigate the pathophysiology of filler-induced blindness using a fresh cadaver perfusion technique.

Methods

A fresh cadaver head perfusion model that simulates both physiologic blood pressure and flow rate of the carotid artery, ophthalmic artery, and supratrochlear artery was used. The common carotid artery was cannulated and the internal jugular vein exposed for open venous drainage. A plasma-based perfusate was circulated through the cadaver head, which was connected to a perfusion system consisting of a roller pump, preload reservoir, and pressure monitor. The hyaluronic acid filler mixed with methylene blue was injected into the cannulated superficial branch of the supratrochlear artery. Cadaver dissection, angiographic study, and histology were used to investigate filler-induced blindness.

Results

Cannulation of the superficial branch of the supratrochlear artery was successful in all six cadavers. Emboli to the ophthalmic artery was successfully demonstrated in the three out of 6 fresh cadaver heads. The C-arm angiogram documented a cut-off sign in the ophthalmic artery due to hyaluronic acid filler emboli. An average intravascular volume of the intraorbital part of the supratrochlear artery was 50.0 µL. The average depth of location of the superficial branch of the supratrochlear artery from the epidermal surface was 1.5 mm.

Conclusions

Our cadaveric study demonstrated that retrograde hyaluronic acid filler emboli to the ophthalmic artery could be produced by the cannulation of the supratrochlear artery. The superficial location of the supratrochlear artery, the rich vasculature surrounding it, and the variability in the anatomy make this possible.

Face and Neck Lifting After Weight Loss

After massive weight loss, deflation of the tissues and loss of skin elasticity in the face and neck can result in the appearance of accelerated facial aging. Surgical facial rejuvenation can be successfully performed with several modifications. Proper preoperative counseling and expectation management regarding staged or ancillary procedures is recommended. Wide undermining of the face and neck, and extended postauricular incisions are required to allow for mobilization of excess skin and access to the mobile superficial musculoaponeurotic system (SMAS). Fat transfer into the deep malar compartment for midface volumizing is helpful. Treatment of the SMAS and platysma are universally necessary.

Apparent Age is a Reliable Assessment Tool in 20 Facelift Patients

BACKGROUND

Although the literature is replete with favorable facelift results, there are few validated facial rejuvenation outcome measures. Apparent age (AA), a visual estimate of age by objective observers, has been utilized in several studies; although attractive, AA lacks validation.

OBJECTIVE

The aim of this study is to examine the reliability of AA, highlighting the importance of the exclusive use of validated outcome measures in future studies.

METHODS

Ten blinded reviewers assessed pre- and postoperative photographs of 32 patients who underwent facelift. Each reviewer completed 3 surveys at 3-month intervals composed of 40 randomly ordered photos; totaling 1200 photographs assigned an AA. The intra-class correlation coefficient was classified as "excellent," "good," "fair," or "poor." The accuracy of assigned AA, agreement within 5 years, and reduction in AA were also evaluated.

RESULTS

The mean difference of preoperative true age from assigned AA was 2.74 ± 4.36 years. Forty-three percent of raters were within 5-years (±2.5) of the mean. Intra-rater reliability preoperatively and postoperatively were 0.77 (95% CI, 0.82-0.72) and 0.75 (95% CI, 0.79-0.71), respectively. Inter-rater reliability preoperatively was 0.98 (95% CI, 0.99-0.96), while postoperatively was 0.95 (95% CI, 0.99-0.95). Mean AA reduction was 5.23 ± 2.81, with an intra-rater reliability 0.15 (95% CI, 0.03-0.34) and inter-rater reliability 0.65 (95% CI, 0.84-0.38).

CONCLUSION

Using current statistical measures and analysis, AA is an acceptable tool for pre- and postoperative facial evaluation when assessed by a group of 10 reviewers. Therefore, apparent age represents a reliable and valid objective observer assigned measure for evaluation of facelift outcomes.

Patient Satisfaction With an Early Smartphone-Based Cosmetic Surgery Postoperative Follow-Up

BACKGROUND

While prevalent in everyday life, smartphones are also finding increasing use as a medical care adjunct. The use of smartphone technology as a postoperative cosmetic surgery adjunct for care has received little attention in the literature.

OBJECTIVES

The purpose of this effort was to assess the potential efficacy of a smartphone-based cosmetic surgery early postoperative follow-up program. Specifically, could smartphone photography provided by the patient to the plastic surgeon in the first few days after surgery allay patient's concerns, improve the postoperative experience and, possibly, detect early complications?

METHODS

From August 2015 to March 2016 a smartphone-based postoperative protocol was established for patients undergoing cosmetic procedures. At the time of discharge, the plastic surgeon sent a text to the patient with instructions for the patient to forward a postoperative photograph of the operated area within 48 to 72 hours. The plastic surgeon then made a return call/text that same day to review the patient's progress. A postoperative questionnaire evaluated the patients' postoperative experience and satisfaction with the program.

RESULTS

A total of 57 patients were included in the study. Fifty-two patients responded to the survey. A total of 50 (96.2%) patients reported that the process improved the quality of their postoperative experience. The protocol allowed to detect early complications in 3 cases. The physician was able to address and treat the complications the following day prior to the scheduled clinic follow up.

CONCLUSIONS

The smartphone can be effectively utilized by the surgeon to both enhance the patient's postoperative experience and alert the surgeon to early postoperative problems.

LEVEL OF EVIDENCE

4.

The Role of Injectables in Aesthetic Surgery: Financial Implications

Background

The plastic surgeon competes with both core and noncore physicians and surgeons for traditional cosmetic procedures. In 2007, the American Society for Aesthetic Plastic Surgery (ASAPS) and the American Society of Plastic Surgeons (ASPS) joined efforts to form a Cosmetic Medicine Task Force to further analyze this trend.

Objectives

Our objective is to document and quantify the patient capture and total collections generated in a single surgeon's practice exclusive from Botulinum Toxin A and filler injections over a 10-year period. We subsequently identified the effect and importance that fillers and Botulinum Toxin A have on an active cosmetic practice.

Methods

A retrospective chart review of all male and female patients who received Botulinum Toxin A or soft tissue filler injections (noninvasive aesthetic treatment) in a single surgeons practice from January 2004 to December 2013 was undertaken. Only those patients new to the practice and who were exclusively seeking out Botulinum Toxin A or fillers were included in the study. Chart review then identified which of these selected patients ultimately underwent invasive aesthetic surgery during this 10-year period. Noninvasive and invasive aesthetic surgery total collections were calculated using billing records.

Results

From January 2004 to December 2013, 375 patients entered the senior surgeon's practice specifically requesting and receiving noninvasive aesthetic treatments. Of these 375 patients, 59 patients (15.7%) subsequently underwent an aesthetic surgery procedure at an average of 19 months following initial noninvasive aesthetic treatment. Of these 375 patients, 369 were female and 6 were male. The most common initial invasive aesthetic procedure performed after injectable treatment included 22 facelifts (18.5%), 21 upper eyelid blepharoplasties (17.6%), and 15 endoscopic brow lifts (12.6%). Total collections from noninvasive aesthetic sessions and invasive surgery combined represented US$762,470 over this 10-year span. This represented US$524,771 and US$396,166 in total collections for injectables and surgery respectively.

Conclusions

Noninvasive aesthetic surgery is a critical part of a plastic surgery practice. A measurable and significant number of patients who sought out a single plastic surgeon exclusively for noninvasive treatment ultimately underwent traditional invasive cosmetic surgical procedures.

Resident and Program Director Perceptions of Aesthetic Training in Plastic Surgery Residency: An Update

Background

This is the third survey exploring the quality of cosmetic training in plastic surgery residency. We focused on determining: (1) the applied modalities and extent of resident exposure; and (2) resident confidence in performing variable cosmetic procedures.

Objectives

To analyze trends in resident exposure and confidence in aesthetic plastic surgery procedures from the standpoint of program directors (PDs) and residents.

Methods

The survey was developed and e-mailed to 424 residents enrolled in the ASAPS Residents Program and 95 PDs. Both independent and integrated programs were included. The questions were posed in a five-point ranking format. Univariate statistical analysis was used to examine all aspects. The results were analyzed in relation to our previous surveys in 2008 and 2011.

Results

Thirty-three PDs (34.7%) and 224 (52.8%) residents responded. Residents felt most confident with abdominoplasty, breast reduction, and augmentation-mammaplasty. Facial aesthetic procedures, especially rhinoplasty and facelift, were perceived as "challenging." The three most preferred modalities of aesthetic education were, in descending order, residents' clinic, staff cosmetic patients, and cadaver dissections. Both residents and PDs felt a need for more training especially in facial procedures. Only 31.5% of residents who planned to focus on cosmetic surgery felt ideally prepared integrating cosmetic surgery into their practice (compared to 50% in previous surveys).

Conclusions

Despite improvements observed from 2008 to 2011 published surveys, there are still challenges to be met especially in facial cosmetic procedures. It is suggested that resident clinics and cadaver courses be universally adopted by all training programs.

Age as a Risk Factor in Abdominoplasty

Background

Recent studies reviewing large patient databases suggested that age may be an independent risk factor for abdominoplasty. However, these investigations by design considered only short-term major complications.

Objectives

The purpose of this investigation was: (1) to compare the safety of abdominoplasty in an elderly and younger patient population; (2) to determine the complication rates across all spectrums: major, minor, local, and systemic; and (3) to evaluate complications occurring both short and long term.

Methods

Abdominoplasty procedures performed from 2010 to 2015 were retrospectively reviewed. Subjects were divided into two groups: ≤59 years old and ≥60 years old. Major, minor, local, and systemic complications were analyzed. Patient demographics, comorbidities, perioperative details, adjunctive procedures were also assessed.

Results

A total of 129 patients were included in the study: 43 in the older and 86 in the younger age group. The median age of The elderly and young groups was 65.0 and 41.5 years, respectively (P < .001). No statistically significant differences in major, minor, local, or systemic complications were found when both age groups were compared. Major local, major systemic, minor local, and minor systemic in the elderly were 6.9%, 2.3%, 18.6%, and 2.3%, while in the younger patients were 9.3%, 4.7%, 10.5%, and 0.0%, respectively (P > .05). Median follow-up time of the elderly (4.0 months) was no different than the younger (5.0 months) patients (P > .07). Median procedure time in the elderly (4.5 hours) was no different than the younger group (5.0 hours) (P = .4). The elderly exhibited a greater American Society of Anesthesiologist score, median body mass index (28.7 vs 25.1 kg/m2), and number of comorbidities (2.7 vs 0.9) (P < .001).

Conclusions

There was no significant difference in either major or minor complications between the two groups. This suggests that with proper patient selection, abdominoplasty can be safely performed in the older age patient population.

Level of Evidence

2.

Current Evidence for Clinical Efficacy of Platelet Rich Plasma in Aesthetic Surgery: A Systematic Review

Background

Platelet rich plasma (PRP) has attracted attention in a number of surgical fields due to a wide variety of potential clinical benefits. Yet PRP has not gained wide popularity in aesthetic surgery as a result of uncertainty surrounding objective clinical evidence.

Objectives

We aim to describe the current applications, define preparation and activation, explore effectiveness, and propose a classification system to facilitate comparisons across studies.

Methods

A comprehensive review of the literature regarding the use of platelet rich plasma in aesthetic surgery was performed. Data gathered included: PRP application, study type, subject number, centrifugation, anticoagulation, activation, PRP composition, and outcomes.

Results

Thirty-eight reports were identified. Applications included injection into aging skin (29%), scalp alopecia (26%), lipofilling (21%), fractional laser (13%), and facial surgery (11%). The majority of studies (53%) were case series without controls. Leucocytes were sparsely defined (32%). The concentration of injected and/or baseline platelets was rarely clarified (18%). The mechanism of activation was described in 27 studies (71%), while anticoagulation was uncommonly elucidated (47%). While most studies (95%) claim effectiveness, objective measures were only utilized in 17 studies (47%).

Conclusions

Current studies produce context-dependent results with a lack of consistent reporting of PRP preparation, composition, and activation in aesthetic applications, making meaningful meta-analysis unrealistic. Thus the method of PRP preparation warrants increased attention. We recommend a set of descriptors, FIT PAAW (described below), to produce scientifically grounded conclusions, facilitating a clearer understanding of the situations in which PRP is effective.

Level of Evidence

4