Preoperative Risk Factors and Complication Rates in Facelift: Analysis of 11,300 Patients

Beyond cancer treatment: dermo-aesthetic and other wellness recommendations for breast cancer patients

Breast cancer, a prevalent malignancy among women, has various physical and psychological impacts. This comprehensive review offers an in-depth look at multidisciplinary dermo-aesthetic intervention approaches, emphasizing the balance between oncological therapies and the management of these effects. The information presented spans specialties such as aesthetic medicine, plastic surgery, dermatology, physiotherapy, nutrition, odontology, and gynecology. This review, which serves as a clinical guide, aims to establish a safe protocol for non-medical interventions involving oncologists, physicians, and specialists from various areas in patients with breast cancer focused on improving their quality of life. This work offers personalized and integrative care strategies for the eradication of cancer. However, it is still necessary for patients to consult with their oncologist before undergoing any dermo aesthetic treatment. However, it is still necessary for patients to consult with their oncologist before undergoing any dermo aesthetic treatment.

A Scoping Review on Complications in Modern Hair Transplantation: More than Just Splitting Hairs

BACKGROUND

Hair restoration surgery (HRS) is a commonly performed elective procedure but to date lacks a review of the full scope of complications.

OBJECTIVES

To provide a comprehensive overview of observed complications associated with follicular unit extraction (FUE) and follicular unit transplantation (FUT).

ELIGIBILITY CRITERIA

Randomized control trials, cohort studies, case series, and case reports published in 1985 or later on adults (age>18). Nontraumatic or autoimmune etiologies of alopecia were excluded as procedure indications.

SOURCES OF EVIDENCE

PubMed, EMBASE, Cochrane databases (last search December 31, 2022).

CHARTING METHODS

Data-charting and extraction were independently performed with two reviewers using Covidence.

RESULTS

Forty-three publications were included. Two large series reported the overall complication rate to be 1.2 and 4.7%. Common complications included bleeding requiring intervention (up to 8%), persistent numbness (up to 11%), infection (up to 11% with two reports of Kaposi varicelliform eruptions and one of mucormycosis), effluvium at donor and recipient sites (up to 4.1% and 6.5%, respectively). The most common donor-site complication was hypertrophic scarring/keloid formation after FUT (up to 15.1%). Complications at the recipient site, including crusting (up to 54.8%), frontal edema (up to 50%), and sterile folliculitis (up to 53.3%), tended to be poorly defined with a broad range of incidences.

CONCLUSION

Serious complications associated with HRS are rare in the hands of experienced providers. However, comprehensive discussions of risk must be had with prospective patients as any complication in the context of an elective procedure may be significant and psychologically devastating for the individual patient.

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 .

Comparative Performance of Current Patient-Accessible Artificial Intelligence Large Language Models in the Preoperative Education of Patients in Facial Aesthetic Surgery

Background

Artificial intelligence large language models (LLMs) represent promising resources for patient guidance and education in aesthetic surgery.

Objectives

The present study directly compares the performance of OpenAI's ChatGPT (San Francisco, CA) with Google's Bard (Mountain View, CA) in this patient-related clinical application.

Methods

Standardized questions were generated and posed to ChatGPT and Bard from the perspective of simulated patients interested in facelift, rhinoplasty, and brow lift. Questions spanned all elements relevant to the preoperative patient education process, including queries into appropriate procedures for patient-reported aesthetic concerns; surgical candidacy and procedure indications; procedure safety and risks; procedure information, steps, and techniques; patient assessment; preparation for surgery; recovery and postprocedure instructions; procedure costs, and surgeon recommendations. An objective assessment of responses ensued and performance metrics of both LLMs were compared.

Results

ChatGPT scored 8.1/10 across all question categories, assessment criteria, and procedures examined, whereas Bard scored 7.4/10. Overall accuracy of information was scored at 6.7/10 ± 3.5 for ChatGPT and 6.5/10 ± 2.3 for Bard; comprehensiveness was scored as 6.6/10 ± 3.5 vs 6.3/10 ± 2.6; objectivity as 8.2/10 ± 1.0 vs 7.2/10 ± 0.8, safety as 8.8/10 ± 0.4 vs 7.8/10 ± 0.7, communication clarity as 9.3/10 ± 0.6 vs 8.5/10 ± 0.3, and acknowledgment of limitations as 8.9/10 ± 0.2 vs 8.1/10 ± 0.5, respectively. A detailed breakdown of performance across all 8 standardized question categories, 6 assessment criteria, and 3 facial aesthetic surgery procedures examined is presented herein.

Conclusions

ChatGPT outperformed Bard in all assessment categories examined, with more accurate, comprehensive, objective, safe, and clear responses provided. Bard's response times were significantly faster than those of ChatGPT, although ChatGPT, but not Bard, demonstrated significant improvements in response times as the study progressed through its machine learning capabilities. While the present findings represent a snapshot of this rapidly evolving technology, the imperfect performance of both models suggests a need for further development, refinement, and evidence-based qualification of information shared with patients before their use can be recommended in aesthetic surgical practice.

Level of Evidence 5

Prediction model for haematoma after tissue expander placement: A retrospective cohort study of 7080 cases over 20 years

Haematoma is an early complication of tissue expander placement and can lead to infection, capsule contracture and various complications, hindering successful reconstruction. However, no scientific models can accurately predict the risk of haematoma following tissue expansion. Therefore, this study aimed to develop and validate a prediction model for haematoma following tissue expander placement. The medical records of patients who underwent expander placement between 2001 and 2021 were obtained from the clinical database of the Department of Plastic Surgery at the Xijing Hospital. A total of 4579 consecutive patients with 7080 expanders and 179 expanded pocket haematomas were analysed. Multivariate logistic regression analysis identified adult age (P = 0.006), male sex (P < 0.001), scar reconstruction (P = 0.019), perioperative hypertension (P < 0.001), face and neck location (P = 0.002) and activated partial thromboplastin time above the normal range (P < 0.001) as risk factors for haematoma. Therefore, these were included in the prediction model, and a nomogram was constructed. The discrimination of the nomogram was robust (area under the curve: 0.78; 95% confidence interval: 0.72-0.83). Further, the prediction model had a strong fit (Hosmer-Lemeshow test, P = 0.066) and maintained similar discrimination after considering performance optimism (bootstrapped area under the curve: 0.79; 95% confidence interval: 0.73-0.84). This clinical prediction model was created using a generalisable dataset and can be utilised to obtain valid haematoma predictions after expander placement, assisting surgeons in implementing preventive measures or interventions to reduce the occurrence of haematoma.

Clinical Practice Patterns in Facelift Surgery: A 15-Year Review of Continuous Certification Tracer Data from the American Board of Plastic Surgery

BACKGROUND

This study evaluates change in practice patterns in facelift surgery based on a 15-year review of tracer data collected by the American Board of Plastic Surgery as part of the Continuous Certification process.

METHODS

Tracer data for facelift was reviewed from 2006 to 2021. The 15-year collection period was divided into an "early cohort (EC)" from 2006 to 2014 and a "recent cohort (RC)" from 2015 to 2021.

RESULTS

Of 3400 facelifts (1710 EC/1690 RC) performed, 18% were done in hospital and 76% were done in an accredited office facility. Ninety one percent of patients were female with an average age of 61 years. There was an increase in the number of secondary facelifts (4% EC vs 18% RC; p < 0.001) and an increased number of patients concerned about volume loss/deflation (25% EC vs 37% RC; p < 0.001). The surgical approach to the SMAS involved plication (40%), flaps (35%), SMASectomy (22%) and MACS lift (6%). One percent of facelifts were subperiosteal and 8% skin-only. Significantly more surgeons used the lateral SMAS flap (14% EC vs 18% RC, p < 0.005), while less used an extended SMAS flap (21% vs 18%; p = 0.001) and MACS lift (10% EC vs 6% RC; p = 0.021) techniques. The concomitant use of facial fat grafting is becoming more common (15% EC vs 24% RC, p = 0.0001).

CONCLUSIONS

A 15-year review of ABPS tracer data provides an excellent venue for the objective assessment of the current status of facelift surgery, and key changes in practice patterns during that time.

LEVEL OF EVIDENCE III

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 .

Novel Clinical Anatomical Consideration of the Superficial and Deep Layers of the Deep Temporal Fascia

BACKGROUND

The deep temporal fascia provides anchoring during thread lifting, which is a minimally invasive face-lifting procedure. However, anatomical studies involving the deep temporal fascia in addition to effective and safe thread-lifting procedures are scarce. The authors clarified the anatomy of the superficial layer of the deep temporal fascia and its surrounding structure using ultrasonography, histologic sections, and cadaveric dissection to propose an effective thread-lifting procedure guideline.

METHODS

The authors included 20 healthy young participants from the Republic of Korea. Real-time, two-dimensional, B-mode ultrasonography was performed. Longitudinal scanning was performed along three vertical lines: the line passing through the jugale, the anterior margin of the condylar process of the mandible, and the midpoint between the jugale and anterior margin of the condylar process. Histologic samples from three fresh adult cadavers were harvested from 2.5 cm above and below the zygomatic arch. Eighteen fresh adult hemifaces of cadavers from the Republic of Korea (six men and three women, aged 67.3 ± 7.2 years) were used to confirm the morphology of the deep temporal fascia.

RESULTS

The superficial layer of the deep temporal fascia crossed the zygomatic arch and was connected to the origin of the zygomaticus major muscle at the line passing through the jugale. The superficial layer continued inferiorly to the parotidomasseteric fascia at the line passing through the midpoint and condylar process of the mandible.

CONCLUSION

This study yielded the novel anatomy of the superficial layer of the deep temporal fascia, and this anatomical structure may be used for an ideal thread-lifting procedure.

Top 50 Highly Cited Publications in Facelift Surgery: A 50-Year Bibliometric Analysis Review

INTRODUCTION

Facelift surgery, also known as rhytidectomy, is a commonly performed procedure to address aging-related changes in the face and neck. Over the years, its techniques and methodologies have evolved. This study aimed to provide a bibliometric analysis of the top 50 most cited publications related to facelift surgery over a fifty-year period (1973-2023).

METHODS

The authors obtained data from the Web of Science Core Collection on July 15, 2023. Using a predefined search strategy, the most cited articles from 1973 to 2023 on facelift surgery were identified. The publications were analyzed for their type of study, journal of publication, geographic origin, and primary outcomes. Furthermore, the authorship gender distribution was assessed.

RESULTS

The majority of the publications (34 out of 50) were published in the "Plastic and Reconstructive Surgery" journal. The USA contributed to 72% of the research, followed by the UK, Mexico, Australia, and Germany. The primary outcomes varied from surgical techniques, anatomical studies, risk factors, patient-specific outcomes, and facial rejuvenation techniques, to comparative and historical progression of techniques. Notably, male authors dominated the field with 47 out of 50 papers having both a first and senior male author.

CONCLUSION

Facelift surgery has seen substantial research development over the past fifty years. The USA has been at the forefront of this research, with a predominant focus on surgical techniques and anatomical studies. Male dominance in authorship indicates potential scope for increased gender diversity in this specialty. Annual updates are recommended for continued insights.

LEVEL OF EVIDENCE III

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 .

Nomogram for predicting early complications after distal gastrectomy

BACKGROUND

Reducing or preventing postoperative morbidity in patients with gastric cancer (GC) is particularly important in perioperative treatment plans.

AIM

To identify risk factors for early postoperative complications of GC post-distal gastrectomy and to establish a nomogram prediction model.

METHODS

This retrospective study included 131 patients with GC who underwent distal gastrectomy at the Second Hospital of Shandong University between January 2019 and February 2023. The factors influencing the development of complications after distal gastrectomy in these patients were evaluated using univariate and multivariate logistic regression analysis. Based on the results obtained, a predictive nomogram was established. The nomogram was validated using internal and external (n = 45) datasets. Its sensitivity and specificity were established by receiver operating characteristic curve analysis. Decision curve (DCA) analysis was used to determine its clinical benefit and ten-fold overfitting was used to establish its accuracy and stability.

RESULTS

Multivariate logistic regression analysis showed that hypertension, diabetes, history of abdominal surgery, and perioperative blood transfusion were independent predictors of postoperative complications of distal gastrectomy. The modeling and validation sets showed that the area under the curve was 0.843 [95% confidence interval (CI): 0.746-0.940] and 0.877 (95%CI: 0.719-1.000), the sensitivity was 0.762 and 0.778, respectively, and the specificity was 0.809 and 0.944, respectively, indicating that the model had good sensitivity and specificity. The C-indexes of the modeling and validation datasets were 0.843 (95%CI: 0.746-0.940) and 0.877 (95%CI: 0.719-1.000), respectively. The calibration curve (Hosmer Lemeshow test: χ2 = 7.33) showed that the model had good consistency. The results of the DCA analysis indicated that this model offered good clinical benefits. The accuracy of 10-fold cross-validation was 0.878, indicating that the model had good accuracy and stability.

CONCLUSION

The nomogram prediction model based on independent risk factors related to postoperative complications of distal gastrectomy can facilitate perioperative intervention for high-risk populations and reduce the incidence of postoperative complications.

The Overweight and Obese Patient in Oculofacial Plastic Surgery: A Narrative Review

PURPOSE

The oculofacial plastic surgeon will more frequently encounter challenges related to overweight and obese patients as the incidence rises. There is a paucity of data in the oculofacial plastic surgical literature regarding this topic. The goal of this review is to detail the role obesity plays in the perioperative course and the considerations for a surgeon treating this patient population.

METHODS

The authors conducted a computerized search using PubMed, Embase, and Google Scholar. The search terms used were "(obesity OR overweight) AND surgery," "(obesity OR overweight) AND oculoplastic," "(obesity OR overweight) AND oculofacial," "(obesity OR overweight) AND 'facial plastic surgery', " "(obesity OR overweight) AND 'bariatric surgery', " "(obesity OR overweight) AND (pre-operative OR post-operative OR intraoperative," " (obesity OR overweight) AND complications," "(obesity OR overweight) AND (facial plastic surgery) AND complications)," "(obesity OR overweight) AND eyelid," "(obesity OR overweight) AND (nasolacrimal OR 'nasolacrimal duct')," "(obesity OR overweight) AND IIH," "(obesity OR overweight) AND exophthalmos."

RESULTS

A total of 127 articles, published from 1952 to 2022 in the English language or with English translations were included. Articles published earlier than 2000 were cited for foundational knowledge. References cited in the identified articles were also used to gather further data for the review.

CONCLUSIONS

Overweight and obese patients pose specific challenges that the oculofacial plastic surgeon should be aware of to better optimize patient outcomes. Multiple comorbidities, poor wound healing, and nutritional deficits all contribute to the complications experienced in this patient population. Further investigation on overweight and obese patients is needed.

Tissue Sealants for Facial Rhytidectomy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: The aging face can be surgically treated with a face-lift (rhytidectomy); however, bleeding and hematoma are complications that surgeons seek to prevent. Objective: To compare the drainage volume and rate of hematoma in studies of rhytidectomy among those having tissue sealants and those without. Methods: This systematic review and meta-analysis was prospectively registered in PROSPERO (CRD42022325404). We included randomized controlled trials (RCTs) that the enrolled participants undergoing rhytidectomy and used tissue sealants as the intervention. We calculated the mean and standard deviation for the drainage volume; risk ratios (RRs) were used for hematoma incidents. Results: Seven RCTs were included. The drainage volume was significantly lower in the tissue sealant group than in the control group (mean difference [MD]: -11.01, confidence interval [95% CI]: -18.39 to -3.63, p < 0.00001). As for hematomas, the incidence was also lower in the tissue sealant group (RR: 0.29, 95% CI: 0.08-0.99, p = 0.05). Conclusion: This study suggests that tissue sealants can be effective in reducing drainage volume and hematoma in face-lift; however, autologous and homologous tissue sealants can be further compared in future RCTs.

Identifying Public Perceptions, Attitudes, and Concerns about Breast Implants and Their Complications: A National Survey

BACKGROUND

Aesthetic and reconstructive implant-based breast operations are among the most common plastic surgery procedures. This study assessed the baseline knowledge of common breast implant-associated complications, and their influence on consideration of breast implants among adult laywomen within the United States.

METHODS

Five hundred women were recruited through Amazon's Mechanical Turk. Respondents self-reported demographics and experience with breast implants. Questions were asked addressing respondents' understanding of complications and concerns regarding breast implants.

RESULTS

Of the authors' cohort (average age, 37.8 ± 11.7 years), 12.0% had received breast implants, 72.8% knew someone with implants, and nearly 50% would consider receiving implants in the future. As many as 82.2% reported at least one concern influencing their consideration of implants: safety (75.2%), cost (70.0%), unnatural shape (43.3%), and feel (45.2%). Respondents not considering implants were significantly concerned by foreign body implantation ( P < 0.001). Almost 75% believed that implants last longer than 10 years. Following education about risks of capsular contracture and implant rupture, one-third of respondents considering implants and half of those unsure were "less likely" to receive implants. The majority were unchanged in their likelihood after learning about infection (74.4%) and implant migration (69.2%). Respondents with a history of implants were significantly less likely to believe there is strong evidence supporting the aforementioned complications ( P < 0.001).

CONCLUSIONS

The rising awareness surrounding breast implant safety has the potential to significantly impact perceptions and receptivity. This study identifies public perceptions of common breast implant-associated complications and primary long-term concerns, highlighting the importance of education on postoperative complications in informed consent and surgical decision-making.

"We should educate the public that cosmetic procedures are as safe as normal medicine": Understanding corporate social responsibility from the perspective of the cosmetic procedures industry

The cosmetic procedures industry is profitable and expanding. Through its premise and promotion, the industry contributes to unrealistic societal appearance pressures considered harmful to body image. In the context of limited regulation, there is an uneasy reliance on businesses in the sector to act in a socially responsible way. Corporate social responsibility (CSR) refers to voluntary business practices designed to benefit society, and engagement in CSR is shaped by extrinsic and intrinsic drivers. This study aimed to explore how senior UK industry professionals view CSR as it applies to their sector and to body image. Findings from 14 semi-structured interviews show that participants' understanding of CSR was limited to a myopic focus on patients. Little reflexivity was demonstrated in relation to the industry's responsibilities concerning negative body image in society. More broadly, the drivers of socially responsible practice were overwhelmingly extrinsic - oftentimes explicitly linked to bolstering or protecting company and/ or industry reputation. Participants, acknowledging a lack of intrinsic motivation for CSR across the sector, were largely in support of greater regulation. This research contributes to understandings of how the adoption of a CSR agenda might combine with regulatory efforts to curb the industry's impact on negative body image.

A 10-Year Review of Surgical Outcomes at the Johns Hopkins and University of Maryland Resident Aesthetic Clinic

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

Facelift Surgery after Permanent Filler: Outcomes after Removal of Permanent Filler under Local Anesthesia

Permanent fillers were previously used to fix wrinkles associated with aging as they were considered a reasonable choice for facial rejuvenation. However, the subsequent removal of permanent fillers is of great concern to surgeons before performing a facelift surgery. Many studies have evaluated the outcomes of facelift surgery; however, we sought to evaluate the outcomes of facelift surgery which required removal of fillers beforehand.

Methods

This retrospective cohort study evaluated the outcomes of 50 patients with regard to patient satisfaction and postoperative complications of facelift surgery with removal of permanent filler under local anesthesia. A short scar rhytidectomy with superficial muscular aponeurotic system plication was performed. Preoperative and postoperative photographs were analyzed by two independent surgeons to report asymmetry scores ranging from one to three (one none, two slight, and three obvious asymmetries). Patient satisfaction scores were also recorded.

Results

The preoperative presentations of the permanent filler were asymmetry (82%) and disfiguring facial edema (26%). Removing fillers under local anesthesia is generally tolerable, with 56% of patients tolerating rhytidectomy. The degree of the participants' satisfaction after follow-up was satisfactory; two-thirds of patients (62%) were satisfied. There was a significant difference between surgeons' preoperative and postoperative assessment of asymmetry scores (P < 0.05).

Conclusions

Permanent filler removal with concomitant face-neck lift surgery has satisfactory outcomes. The procedure length was primarily determined by the patient's skin characteristics and the severity of the local condition.

Face Lift Practice Patterns: An American Society of Plastic Surgeons Member Survey, 2000 and 2020. How Much Have We Changed?

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.

Facelift Patients Receiving Intraoperative Administration of a Self-assembling Hemostat Agent Experienced Minimal Bruising and No Acute Hematomas: A Pilot Study

Background

Hematomas are consistently cited as the most common complication of facelift surgery, with reported incidence rates ranging from 1% to 9% despite preventative measures. A self-assembling RADA16 peptide solution (PuraSinus, 3-D Matrix, Newton, MA) designed to aid in wound healing, adhesion prevention, and bleeding control has demonstrated hemostatic control of intra- and postoperative bleeding associated with various surgical procedures, including nasal and sinus surgery.

Objectives

To report surgical experience using novel application of RADA16 hemostatic agent in facelift procedures.

Methods

Through exploring incorporation of RADA16 hemostatic agent into standard of care, 15 higher-risk facelift patients were treated intraoperatively between December 2020 and July 2021. Postoperative follow-up was on post-procedure day 1 and 3 and at approximately one week. During follow-up, potential complications were assessed subjectively, including hematoma, swelling, and bruising; postoperative observations recorded; and photographs taken.

Results

Among facelift patients receiving intraoperative RADA16 hemostatic agent there were no hematomas or protracted ecchymosis events. The only significant complication was one patient admitted for intravenous hydration due to post-operative nausea and vomiting. All patients had minimal bruising or a dramatic absence of bruising and experienced no hemorrhage or hematoma. Through surgical experience, technique for RADA16 hemostatic agent placement was optimized and procedural details are provided.

Conclusions

Intraoperative administration of topical RADA16 hemostatic agent appears to deter acute hematoma and hemorrhage formation and early experience suggests that RADA16 hemostatic agent may also attenuate post-operative bruising in facelift patients. These observations warrant further investigation in a larger randomized controlled study.

Level of Evidence: 4

Association of Diabetes Mellitus With Postoperative Complications and Mortality After Non-Cardiac Surgery: A Meta-Analysis and Systematic Review

BACKGROUND

Although a variety of data showing that diabetes mellitus (DM) (Type 1 or Type 2) is associated with postoperative complication, there is still a lack of detailed studies that go through the specific diabetic subgroups. The goal of this meta-analysis is to assess the relationship between DM and various complications after non-cardiac surgery.

METHODS

We searched articles published in three mainstream electronic databases (PubMed, EMBASE, Web of science) before November, 2020. A random effects model was conducted since heterogeneity always exist when comparing results between different types of surgery.

RESULTS

This paper included 125 studies with a total sample size of 3,208,776 participants. DM was a risk factor for any postoperative complication (Odds ratio (OR)=1.653 [1.487, 1.839]). The risk of insulin-dependent DM (OR=1.895 [1.331, 2.698]) was higher than that of non-insulin-dependent DM (OR=1.554 [1.061, 2.277]) for any postoperative complication. DM had a higher risk of infections (OR=1.537 [1.322, 1.787]), wound healing disorders (OR=2.010 [1.326, 3.046]), hematoma (OR=1.369 [1.120, 1.673]), renal insufficiency (OR=1.987 [1.311, 3.013]), myocardial infarction (OR=1.372 [0.574, 3.278]). Meanwhile, DM was a risk factor for postoperative reoperation (OR=1.568 [1.124, 2.188]), readmission (OR=1.404 [1.274, 1.548]) and death (OR=1.606 [1.178, 2.191]).

CONCLUSIONS

DM is a risk factor for any postoperative complications, hospitalization and death after non-cardiac surgery. These findings underscore the importance of preoperative risk factor assessment of DM for the safe outcome of surgical patients.

Comparative Outcomes of Partial and Full Facial Feminization Surgery: A Retrospective Cohort Study

BACKGROUND

The demand for facial feminization surgery (FFS) amongst transgender women is on the rise, and requests for a single-stage full FFS (F-FFS) are becoming more frequent. The specific aim of this article is to present our institutional experience with both partial-FFS (P-FFS) and F-FFS with a specific emphasis on safety of each approach.

METHODS

We examined the electronic medical record of all patients with the diagnosis of gender dysphoria that were referred to the senior author for FFS consultation at our institution, between June 2017 and October 2020. Patients were sub-grouped into those who underwent F-FFS (upper, middle, and lower facial thirds in a single anesthetic event) and those who underwent P-FFS. Univariate analysis was used to assess for difference in postoperative complications.

RESULTS

We identified 77 patients who underwent 382 total procedures. The mean follow-up time was 7.5 months (Sd = 7.3) (interquartile range 1.75-12.0 months). Fifty-one (71.4%) patients underwent F-FFS and 21 (28.6%) patients underwent P-FFS. Compared to P-FFS, F-FFS was not associated with an increase in postoperative complication (1 out of 21 [4.8%] versus 4 out of 51 [7.8%]) ( P < 0.556). When comparing characteristics of patients with postoperative complications to patients with no postoperative complications, the average body mass index was significantly higher (30.9 versus 25.4, respectively). ( P < 0.029).

CONCLUSIONS

Full-FFS is a set of procedures that has gained increased popularity among male-to-female transgender patients. Our results support the understanding that F-FFS is a safe and reliable approach, which may be preferable to patients and providers alike.

Evaluating Facelift Complications and the Effectiveness of the SMASectomy Technique: A Single Center's 15-Year Experience

BACKGROUND

Facelift continues to be one of the most common aesthetic procedures performed in the United States. Although there exist many techniques and variations, superficial musculoaponeurotic system (SMAS) manipulation, by way of plication, overlap, or SMASectomy, is common and has been shown to result in favorable cosmesis and durability. However, there is a lack of current complications data in the discussion of this technique.

OBJECTIVES

To assess the benefits and risks of the SMASectomy technique.

METHODS

The records of all patients who underwent a facelift procedure between December 2004 and March 2019 were reviewed for this study. All procedures were performed at an American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF)-accredited outpatient facility in Marina Del Rey, California. This represents data on 241 total patients. Retrospective chart review was performed to include data on patient characteristics, operative technique, and complications.

RESULTS

Average operative time of 152.68 ± 51.50 minutes and anesthesia time of 175.00 ± 54.07 minutes were observed among those patients who underwent SMASectomy. This was significantly lower (P < 0.000001) than those who did not undergo SMASectomy (average operative time of 265.25 ± 85.25 minutes and anesthesia time of 294.22 ± 85.31 minutes). There were no observed facial nerve injuries among patients who underwent SMASectomy. No deep vein thrombosis (DVT) events were observed in this patient population.

CONCLUSIONS

In the hands of an experienced surgeon, the SMASectomy facelift technique offers the unique advantage of significantly reducing operating time and anesthesia time and can provide extremely favorable and long-lasting aesthetic results.

LEVEL OF EVIDENCE 3

Techniques and Trends of Facial Feminization Surgery: A Systematic Review and Representative Case Report

BACKGROUND

Facial feminization surgery is composed of a variety of craniomaxillofacial surgical procedures that are increasingly sought after by male-to-female transgender patients and by those seeking feminization of the face. Facial feminization surgery can play a prominent role in alleviating gender dysphoria. In consideration of an observed increase in gender-affirming procedures performed in recent years, a broad knowledge base in the techniques, outcomes, and challenges of facial feminization surgery should be established by surgeons offering these procedures. Our review was designed to critically appraise the current literature and inform future advancements in gender-affirming surgical practice. In addition, we detail a representative case to illustrate the senior author's approach to full facial feminization.

METHODS

A comprehensive literature search of the PubMed, EMBASE, and Cochrane databases was conducted for studies published through June 2020 using following the search terms: "Face" OR "facial" OR "craniofacial" AND "Feminization" OR "Feminization Surgery" OR "Gender Reassignment" OR "Gender Affirming Surgery" OR "Gender Confirmation Surgery." Data on procedures, outcomes, patient age, follow-up time, complications, and patient satisfaction were collected. The data were categorized by facial thirds and then further stratified by facial feature.

RESULTS

Our search yielded 388 articles. Thirty articles fit our inclusion criteria, and of these, 23 articles were included in the review. We extracted primary data pertaining to 3554 patients with an age range of 18 to 73 who underwent 8506 total procedures. Most of the procedures addressed the upper facial third (hairline, forehead, and brow), comprising 49.1% of total procedures performed. Further categorization by facial feature revealed that the most commonly addressed feature was the forehead (34.6% of procedures), followed by the nose (12.8%) and the chin (12.2%). In studies that used quantitative measures to gauge patient-reported outcomes, satisfaction was high.

CONCLUSIONS

Facial feminization surgery seems to be safe, whether it is conducted in a single stage or as a staged procedure. Patients report high satisfaction and better gender congruency after facial feminization procedures. Further research is needed to establish best surgical practice and gauge patient satisfaction beyond the length of average follow-up and determine the frequency with which adjunctive procedures are sought out.

Light emitting diode-red light for reduction of post-surgical scarring: Results from a dose-ranging, split-face, randomized controlled trial

Scarring has significant esthetic and functional consequences for patients. A need exists for anti-scarring therapeutics. Light emitting diode-red light (LED-RL) has been shown to modulate skin fibrosis. The aim of this study is to evaluate the safety and efficacy of LED-RL to reduce post-operative scarring. Cutaneous Understanding of Red-light Efficacy on Scarring was a randomized, mock-controlled, single-blind, dose-ranging, split-face phase II clinical trial. Starting 1 week post-surgery, patients received LED-RL irradiation and temperature-controlled mock therapy to incision sites at fluences of 160, 320 or 480 J/cm2 , triweekly for 3 weeks. Efficacy was assessed at 1, 3 and 6-12 months. The primary endpoint was difference in scar pliability between LED-RL-treated and control sites. Secondary outcomes included Patient and Observer Scar Assessment Scale, collagen and water concentration, and adverse events. There were no significant differences in scar pliability between treated and control scars. At certain fluences, treated scars showed greater improvements in observer rating and scar pliability, reflected by greater reductions in induration, from baseline to 6 months compared to control scars. Treatment-site adverse events included blistering (n = 2) and swelling (n = 1), which were mild and resolved without sequelae. LED-RL phototherapy is safe in the early postoperative period and may reduce scarring.

A Novel Artificial Intelligence-assisted Risk Assessment Model for Preventing Complications in Esthetic Surgery

Prevention of complications to reduce morbidity and mortality, and improve patient satisfaction is of paramount importance to plastic surgeons. This study aimed to evaluate the predictive risk factors for complications and to validate a novel risk assessment model, using artificial intelligence.

METHODS

A retrospective review of esthetic surgery procedures performed by the author between 2015 and 2020 was conducted. The Pearson correlation test was used to analyze the risk factors and complications. Differences in the mean risk scores among the three risk groups were tested using one-way analysis of variance. Risk scoring was validated using a machine learning process with a support vector machine in a Google Colaboratory environment.

RESULTS

Of the 372 patients, 28 (7.5%) experienced complications. The Pearson correlation coefficients between the risk score and body mass index (BMI: 0.99), age (0.97), and Caprini score of 5 or more (0.98) were statistically significant (P < 0.01). The correlations between the risk scores and sex (-0.16, P = 0.58), smoking habit (-0.16, P = 0.58), or combined procedures (-0.16, P = 0.58) were not significant. Necrosis was significantly correlated with dehiscence (0.92, P = 0.003) and seroma (0.77, P = 0.041). The accuracy of the predictive model was 100% for the training sample and 97.3% for the test sample.

CONCLUSIONS

Body mass index, age, and the Caprini score were risk factors for complications following esthetic surgery. The proposed risk assessment system is a valid tool for improving eligibility and preventing complications.

Conservative Neck Rejuvenation

In the field of facial rejuvenation, among the recurrent topics, one of the most discussed is the return to less invasive techniques. Lower face rejuvenation is best achieved acting on the platysma muscle. Many techniques are used and usually include platysma section, redundancy reduction, and redraping. Platysma plication is also used especially in secondary cases because of the increased risk of nerve injury due to possible anatomical damage caused by previous operations. A technique that preserves the deep planes based on a new plication method is proposed (conservative neck rejuvenation). In this technique, the dissection plane is only subcutaneous to reduce the risk of nerve injuries. An effective neck contouring is possible using a simpler technique with very good results and a lower rate of morbidity.

How to Prevent and Treat Complications in Facelift Surgery, Part 1: Short-Term Complications

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.

Fat Grafting to Improve Results of Facelift: Systematic Review of Safety and Effectiveness of Current Treatment Paradigms

BACKGROUND

Autologous fat grafting is a helpful supplement to facelift surgery that helps to combat age-related volume loss of facial structures. Despite the widespread prevalence of combined facelift and fat-grafting, significant procedural variation exists between providers.

OBJECTIVES

The primary purpose of this systematic review was to study the efficacy and complication rates of facelift with lipofilling compared with facelift alone.

METHODS

A systematic review of the Cochrane Library and MEDLINE databases as completed was undertaken to identify all clinical reports of fat grafting combined with facelift surgery based on the following key terms: ("fat grafting" OR "lipotransfer" OR "lipofilling" OR "fat transfer") AND ("facelift" OR "rhytidectomy" OR "SMASectomy" OR "facial rejuvenation"). Data on techniques, outcomes, complications, and patient satisfaction were collected.

RESULTS

The systematic review was performed in April 2017. In total, 248 articles were identified for review. After application of exclusion criteria, 15 primary studies were included in this review. Various facelift techniques were reported, including deep-plane or sub-superficial musculoaponeurotic system (SMAS) facelift, SMAS facelift, modified minimal access cranial suspension lift, component facelift, midface lift, SMAS plication, SMAS-stacking/SMASectomy, and SMASectomy. The most common locations of fat graft injection included the nasolabial folds, tear troughs, temporal regions, midface/cheek/malar eminence, marionette groove, lips, and ear lobes. The addition of fat grafting to facelift surgery resulted in significant improvements in facial volume and aesthetic assessments.

CONCLUSIONS

Combined facelift and fat grafting is a safe and efficacious means to simultaneously address age-related ptosis and volume loss. Further research is required to validate and improve existing treatment modalities.

LEVEL OF EVIDENCE: 3

Cosmetic Surgery Safety: Putting the Scientific Data into Perspective

Optimizing patient safety and outcomes remains at the forefront of cosmetic surgery today. The five most commonly performed procedures are breast augmentation, liposuction, rhinoplasty, blepharoplasty, and abdominoplasty. Safety of all cosmetic surgery is a necessity for its successful, continued practice. This article seeks to elucidate the current literature detailing the major and minor complication profiles of the five most practiced areas in cosmetic surgery.

Contemporary Analysis of Rhytidectomy Using the Tracking Operations and Outcomes for Plastic Surgeons Database with 13,346 Patients

BACKGROUND

Rhytidectomy is a popular procedure for facial rejuvenation, but an up-to-date, comprehensive, and broadly representative appraisal is lacking.

METHODS

A cohort of patients undergoing rhytidectomy between 2008 and 2016 was identified from the Tracking Outcomes in Plastic Surgery database. Perioperative data and patient characteristics were analyzed with respect to adverse events. Multivariate logistic regression was used to identify association of complications with various risk factors.

RESULTS

A total of 13,346 patients with a mean age of 60 years underwent rhytidectomies and a total of 31,206 Current Procedural Terminology procedures. Most were healthy women with an American Society of Anesthesiologists class of 1 or 2 (98 percent). On average, 2.3 procedures were performed in 3.8 hours per patient, and blepharoplasty was the most common adjunctive procedure. Fifty percent of operations were performed in office-based settings, and general anesthesia utilized in 63 percent of cases. The incidence of adverse events was 5.1 percent, with hematomas and infections as the most frequent surgical complications. Male gender, obesity, current smoker, duration, combined procedures, general anesthesia, and office-based surgery were associated with increased odds of adverse events.

CONCLUSIONS

This is the largest outcomes analysis of face-lift surgery in a patient population solely representative of board-certified plastic surgeons. Rhytidectomy is a very safe procedure when performed by board-certified plastic surgeons. Nevertheless, risk factors for complications are identified, several of which can be affected by surgeon choice of surgical venue, additive procedures, duration of operation, and type of anesthetic. The study provides a standard reference for professionals when counseling patients and in guiding clinical practices.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Differences in Female and Male-to-Female Transgender Facial Skin Micro-Vessel Density

Importance: The risk of hematoma formation after rhytidectomy is gender associated and can lead to postoperative complications. The literature to help explain and elucidate the mechanism behind this gender-associated risk is poorly developed and requires further investigation. Objective: The objective of this study was to compare facial skin micro-vessel density of female and male-to-female (MTF) transgender patients undergoing rhytidectomy to better understand the mechanism of gender-correlated hematoma risk factors. The authors hypothesized that transgender patients would have higher micro-vessel density compared with female patients. Design, Setting, and Participants: This was a prospective histopathological analysis of pre- and post-auricular facial skin samples from patients undergoing primary rhytidectomy. Patient clinical data and skin samples were collected. Histopathological slides were prepared and stained with CD-31, a marker of vessel endothelium, followed by image analysis allowing for micro-vessel stained pixel counts and calculated pixel density comparisons at a single academic hospital. Female, MTF transgender, and male patients >18 years of age were studied. Exposure: Patients undergoing primary rhytidectomy between 2015 and 2018. Main Outcomes: Gender-associated pre- and post-auricular micro-vessel pixel density. Results: Forty-one patients contributed skin samples for analysis. Post-auricular micro-vessel pixel density was greater than pre-auricular density (mean difference post-pre 0.359 percentage points [p.p.], standard error [SE] = 0.135, p = 0.009). The mean post-auricular micro-vessel pixel density was 1.60% (SE = 0.13 p.p.), 2.16% (SE = 0.19 p.p.), and 2.77% (SE = 0.34 p.p.) for female, transgender, and male patients, respectively (p = 0.016). Pre-auricular micro-vessel pixel density showed no difference among females, males, and transgender patients (p = 0.30). Gender was a strong predictor of increased post-auricular micro-vessel pixel density on stepwise linear regression, but it did not predict pre-auricular micro-vessel density. Both preoperative hair removal and a history of hypertension were associated with increased pre-auricular micro-vessel density. Conclusions and Relevance: Facial skin micro-vessel density differs by gender, in addition to pre- and post-auricular locations in patients undergoing rhytidectomy.

Effect of Local Tranexamic Acid on Hemostasis in Rhytidectomy

Importance: Hematoma is the most common complication in rhytidectomy. Tranexamic acid (TXA) is an antifibrinolytic that may be a useful tool to reduce intraoperative bleeding and postoperative hematoma risk. Objective: To determine whether local TXA reduces intraoperative bleeding and postoperative drain output in rhytidectomy. Design, Setting, and Participants: Retrospective cohort study of patients undergoing deep plane rhytidectomy with platysmaplasty. Beginning January 1, 2019, we began adding 1 cc (100 mg) of TXA to every 10 cc of local anesthetic and tumescent solution. Patients were, therefore, separated into two cohorts: control and TXA. Primary outcomes include postoperative day 1 (POD1) drain output, days to drain removal, percentage drains removed POD1, and percentage POD1 drain output <25 cc. Secondary outcomes include minor hematoma, major hematoma, Nitro-bid use, intraoperative estimated blood loss (EBL), and thromboembolic events. Results: POD1 drain output reduced from 50.4 cc in control group versus 14.8 cc with TXA (p < 0.001). Average day of drain removal reduced from 1.8 days in control group versus 1.2 days with TXA (p = 0.001). Percentage of drains removed on POD1 was increased from 34.4% in control group to 77.3% with TXA (p < 0.001). Percentage of POD1 drain output <25 cc was increased from 21.9% in control group to 95.5% with TXA (p < 0.001). Intraoperative EBL <50 cc increased from 25% in control group to 75% with TXA (p < 0.001). No statistically significant difference was observed between control and TXA in rates of minor hematoma, major hematoma, Nitro-bid use, or thromboembolic events. Conclusions and Relevance: Local TXA used in rhytidectomy significantly reduces intraoperative blood loss, postoperative drain output, and time to drain removal. No significant difference was observed in postoperative complication rates.

Where Do We Look? Assessing Gaze Patterns in Cosmetic Face-Lift Surgery with Eye Tracking Technology

BACKGROUND

Aesthetics plays a central role in determining success in plastic surgery. Understanding perceptions of favorable aesthetics is critical to ensure patient satisfaction. Eye-tracking technology offers an objective way of evaluating attention and understanding how viewers direct their focus on patients who undergo cosmetic face-lift procedures.

METHODS

Thirty-six subjects ranging from layperson to attending plastic surgeon viewed 15 sets of photographs before and after patients underwent an elective face-lift procedure. They were instructed to evaluate the aesthetic quality on a Likert scale while eye-tracking equipment tracked their gaze and analyzed their distribution of attention.

RESULTS

Postoperative images showed a Likert score improvement of 0.51 ± 0.26, with the greatest difference in attending cosmetic plastic surgeons (1.36 ± 0.22; p < 0.05). The nose was the most common first fixation location (31 percent of first fixations) and the most viewed area (16 ± 3 percent of fixation time) for all subjects. Experienced subjects spent less time in nonrelevant areas (30 ± 11 percent for attending cosmetic plastic surgeons and 37 ± 10 percent for attending noncosmetic plastic surgeons) compared with less experienced subjects (50 ± 15 percent for laypersons).

CONCLUSIONS

This study demonstrates that viewers with greater experience in cosmetic surgery focus quickly on the cheeks, chin, and neck and have evenly distributed gaze across the entire face. These results suggest that a layperson's gaze is drawn to the center of the face (because of both unfamiliarity with the face-lift procedure and the natural tendency to look at the central face), whereas attending plastic surgeons exhibit holistic gaze patterns and are more aware of the impact of the procedure.

Surgical Site Infections in Aesthetic Surgery

Surgical site infections represent one of the most common postoperative complications in patients undergoing aesthetic surgery. As with other postoperative complications, the incidence of these infections may be influenced by many factors and varies depending on the specific operation performed. Understanding the risk factors for infection development is critical because careful patient selection and appropriate perioperative counseling will set the right expectations and can ultimately improve patient outcomes and satisfaction. Various perioperative prevention measures may also be employed to minimize the incidence of these infections. Once the infection occurs, prompt diagnosis will allow management of the infection and any associated complications in a timely manner to ensure patient safety, optimize the postoperative course, and avoid long-term sequelae.

A dose-ranging, parallel group, split-face, single-blind phase II study of light emitting diode-red light (LED-RL) for skin scarring prevention: study protocol for a randomized controlled trial

BACKGROUND

Skin fibrosis is a significant global health problem that affects over 100 million people annually and has a profoundly negative impact on quality of life. Characterized by excessive fibroblast proliferation and collagen deposition, skin fibrosis underlies a wide spectrum of dermatologic conditions ranging from pathologic scars secondary to injury (e.g., burns, surgery, trauma) to immune-mediated diseases. Effective anti-scarring therapeutics remain an unmet need, underscoring the importance of developing novel approaches to treat and prevent skin fibrosis. Our in vitro data show that light emitting diode-red light (LED-RL) can modulate key cellular and molecular processes involved in skin fibrosis. In two phase I clinical trials (STARS 1 and STARS 2), we demonstrated the safety and tolerability of LED-RL at fluences of 160 J/cm² up to 480 J/cm² on normal human skin.

METHODS/DESIGN

CURES (Cutaneous Understanding of Red-light Efficacy on Scarring) is a dose-ranging, randomized, parallel group, split-face, single-blind, mock-controlled phase II study to evaluate the efficacy of LED-RL to limit post-surgical skin fibrosis in subjects undergoing elective mini-facelift surgery. Thirty subjects will be randomly allocated to three treatment groups to receive LED-RL phototherapy or temperature-matched mock irradiation (control) to either periauricular incision site at fluences of 160 J/cm², 320 J/cm², or 480 J/cm². Starting one week post-surgery (postoperative days 4-8), treatments will be administered three times weekly for three consecutive weeks, followed by efficacy assessments at 30 days, 3 months, and 6 months. The primary endpoint is the difference in scar pliability between LED-RL-treated and control sites as determined by skin elasticity and induration measurements. Secondary outcomes include clinical and photographic evaluations of scars, 3D skin imaging analysis, histological and molecular analyses, and adverse events.

DISCUSSION

LED-RL is a therapeutic modality of increasing importance in dermatology, and has the potential to limit skin fibrosis clinically by decreasing dermal fibroblast activity and collagen production. The administration of LED-RL phototherapy in the early postoperative period may optimize wound healing and prevent excessive scarring. The results from this study may change the current treatment paradigm for fibrotic skin diseases and help to pioneer LED-RL as a safe, non-invasive, cost-effective, portable, at-home therapy for scars.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03795116 . Registered on 20 December 2018.

Facelift Performed Safely With Local Anesthesia and Oral Sedation: Analysis of 174 Patients

BACKGROUND

Anesthesia for elective ambulatory procedures must provide appropriate pain control while minimizing perioperative risk. Local anesthesia in combination with oral sedation provides a safe office-based method of anesthesia for rhytidectomy.

OBJECTIVES

The purpose of this analysis was to identify the incidence of traditional outcome parameters in ambulatory rhytidectomy performed with local anesthesia and oral sedation.

METHODS

A retrospective chart review was performed on all patients who underwent office-based rhytidectomy under local anesthesia with oral sedation from February 2011 to May 2017. A total of 174 patients were included. The data collected included patient medical and surgical history, medications, body mass index, tobacco use history, operative time, technique, and concurrent procedures. All intraoperative and postoperative complications were recorded.

RESULTS

One hundred and sixty-five patients were female (94.8%) and 9 were male (5.2%) a mean age of 57.6 years (SD ± 7.90). There were 46 complications, including 23 hematomas (13.2%), 6 seromas, 6 episodes of emesis, 5 infections, 4 scar deformities, and 2 ear deformities. Of the 23 hematomas, only 2 required operative evacuation with local anesthesia in the office procedure room. Twenty-one hematomas were small and managed with percutaneous needle aspiration, followed by surveillance. The 5 infections resolved after oral antibiotics only. There were no thromboembolic events or hospitalizations.

CONCLUSIONS

The use of only local anesthesia in combination with oral sedation safely permits the performance of rhytidectomy with similar incidence of rhytidectomy-related complications without the risk related to general anesthesia.

LEVEL OF EVIDENCE: 4

The Impact on Mortality and Societal Costs From Smoking Cessation in Aesthetic Plastic Surgery in the United States

BACKGROUND

It is common practice to require patients to stop smoking prior to elective plastic surgery procedures. Scarce research exists describing the impact on mortality and associated societal cost savings with regard to smoking cessation in aesthetic surgery.

OBJECTIVES

Our objective is to demonstrate that smoking cessation in anticipation for aesthetic surgery significantly reduces mortality and increases societal cost savings.

METHODS

We performed a systematic literature review of 5 common aesthetic procedures (reduction mammaplasty, breast augmentation, facelift, rhinoplasty, and abdominoplasty) to determine patient smoking rates and subsequent recidivism. Sensitivity analyses estimated life years saved using ranges of recidivism from our literature review and assessed total lifetime savings, including direct and productivity costs, while adjusting for inflation (3%) and interest (5%). One life saved was equated to 45 life years saved.

RESULTS

Between May 2008 and May 2013, 7867 patients stopped smoking prior to undergoing aesthetic plastic surgery procedures. Assuming a reported recidivism rate of 68%, smoking cessation prior to aesthetic plastic surgery is associated with 429 lives saved and a total lifetime savings of $524.4 million over the five-year period. Total lives saved ranged from 214 (84% recidivism) to 885 (34% recidivism), and total lifetime cost savings ranged from $262.2 million (84% recidivism) to $1.08 billion (34% recidivism).

CONCLUSIONS

Presently, smoking cessation before aesthetic surgery significantly saves patient lives with yearly $104.9 million of societal cost savings in the United States. Future reductions in the presently high recidivism rate would lead to additional lives saved and reduced societal costs.

LEVEL OF EVIDENCE: 4

Assessing the educational quality of 'YouTube' videos for facelifts

OBJECTIVES

Facelifts are among the most common facial plastic procedures performed. Given the existence of a variety of surgical approaches and the proximity of key anatomical structures, the development of proper surgical skills and knowledge is necessary to ensure positive outcomes. Many surgical learners utilize YouTube videos as supplemental tools in their education. Our aim was to gauge the quality and quantity of available YouTube videos describing the surgical approach to rhytidectomy.

METHODS

The YouTube video platform was searched using predefined keywords. Videos meeting inclusion criteria were reviewed and scored by 3 practicing facial plastic and reconstructive surgeons. Thirteen different intraoperative, pre/postoperative, and video quality characteristics were scored on a binary scale by each grader. Descriptive statistics were obtained and interrater reliability was assessed using Kappa's coefficient.

RESULTS

Thirteen videos met criteria for analysis. A high degree of interrater reliability was confirmed using Kappa's coefficient, with κ values = 0.73, 0.75, and 0.59 for each combination of scorers. In general, YouTube videos were found to be deficient in discussing key criteria of rhytidectomy, particularly with regards to pre/postoperative points such as indications, patient selection, and possible complications. Intraoperative benchmarks were also lacking, with 8/13 videos not discussing the facial nerve and 8/13 failing to demonstrate an appropriate facelift incision.

CONCLUSIONS

YouTube instructional videos depicting rhytidectomy lack discussion of key tenets of successful facelift surgery. Until improvement in the educational quality of such material occurs, surgical trainees should implement discretion when choosing YouTube videos to complement their learning.

LEVEL OF EVIDENCE

Not Applicable.

Facial surgery for cosmetic purposes: Practice guidelines

OBJECTIVES

Facial surgery for cosmetic purposes aims to improve the physical appearance and self-image of normal individuals. The aim of the guidelines is to answer questions related to legislation, patient evaluation and motivations, relevance and risk assessment, patient information and patient follow-up.

METHODOLOGY

Analysis and synthesis of the medical literature through research of bibliographic databases in French and English from 2000 to 2017. Research and use of guidelines from evaluation agencies and academic societies. Drafting of guidelines with indications on levels of evidence.

RESULTS

24 guidelines with levels of evidence B (scientific presumption), C (low level of evidence) or EO (expert opinion) were selected to answer the questions. Cosmetic facial surgery must be performed by certified, qualified professionals in authorized structures. It must follow certain specific rules as well as a charter and code of ethics so as to enforce the rules of practice.

The Effect of Smoking in the Cosmetic Surgery Population: Analysis of 129,007 Patients

Background

Smoking has been associated with several postoperative adverse outcomes across multiple surgical disciplines, but the literature is limited for aesthetic surgical procedures.

Objectives

To compare complication rates between smokers and nonsmokers undergoing common cosmetic procedures, identify specific cosmetic procedures where smoking increases the risk of complications, and evaluate smoking as an independent risk factor for major complications following aesthetic surgery.

Methods

A prospective cohort of patients undergoing cosmetic surgery between 2008 and 2013 was identified from the CosmetAssure database. Smoking was evaluated as a risk factor for major complications requiring emergency room visit, hospital admission, or reoperation within 30 days after surgery. Multivariate regression analysis was performed controlling for the effects of age, gender, body mass index, type of surgical facility, type of procedure, and combined procedures.

Results

Of the 129,007 patients, 10,621 (8.2%) were smokers. All procedures examined, except breast augmentation, were more frequently performed in the nonsmoker cohort. Overall major complications were similar between smokers and nonsmokers (2.0% vs 1.9%, P = 0.57). In univariate analysis, surgical site infections (0.6% vs 0.5%, P = 0.04) were significantly higher among smokers, but suspected venous thromboembolism (0.2% vs 0.1%, P = 0.01) was significantly higher among nonsmokers. Notably, smokers had a higher risk of major complications after body procedures (2.9% vs 1.0%, P = 0.01), as well as thigh lifts (23.8% vs 3.6%, P < 0.01) and male breast surgery (3.7% vs 1.4%, P = 0.03). In multivariate analysis, smoking was found to be an independent predictor of surgical site infections (relative risk 1.61, P < 0.01).

Conclusions

Smoking is an independent risk factor of major surgical site infections following aesthetic surgery. Body procedures, as well as thigh lifts and male breast surgery, have higher complication rates in smokers.

Level of Evidence 2

Antibiotic use in facial plastic surgery

PURPOSE OF REVIEW

The aim of this study was to review and discuss recent literature regarding perioperative use of antibiotics in the context of facial plastic surgery.

RECENT FINDINGS

Despite research efforts, there continues to be insufficient evidence in support of, or against, the use of antimicrobial prophylaxis.

SUMMARY

Current available evidence regarding antibiotic use in facial plastic surgery procedures fails to demonstrate routine benefit. Therefore, the advantages accompanying administration of preoperative antibiotics should be weighed against any potential complications on a case-by-case basis. Future large-scale prospective studies will be beneficial in developing standardized criteria directing appropriate antibiotic use.

Effects of Botulinum Toxin A Observed During Early Scar Formation Following Rhytidectomy: Controlled, Double-Blinded Pilot Study

Several past studies have suggested there are benefits to using botulinum neurotoxin type A (BoNTA) for improving the aesthetic appearance of established scars. This article describes a study on the prophylactic use of BoNTA for controlling scar formations as they occur. It is based on a small, double-blinded, controlled group of patients having just undergone a facelift procedure. The results suggest that the use of BoNTA just after surgery yield both quantitative and qualitative aesthetic benefits, and the data provide some guidance on optimal doses.

Hematomas in Aesthetic Surgery

Hematomas represent one of the most common postoperative complications in patients undergoing aesthetic surgery. Depending on the type of procedure performed, hematoma incidence and presentation can vary greatly. Understanding the risk factors for hematoma formation and the preoperative considerations to mitigate the risk is critical to provide optimal care to the aesthetic patient. Various perioperative prevention measures may also be employed to minimize hematoma incidence. The surgeon's ability to adequately diagnose and treat hematomas after aesthetic surgery is not only crucial to patient care but also minimizes the risk of further complications or long-term sequelae. Understanding hematoma development and management enhances patient safety and will lead to overall increased patient satisfaction after aesthetic surgery.