Light-Guided Percutaneous Neck Rejuvenation With Division of Platysma Bands and Suture Suspension: A Multicenter Retrospective Study

BACKGROUND

Traditional invasive suture suspension techniques have proven efficacy and durability. A previously described percutaneous placement of a neck suspension suture with light guidance has transformed this into a minimally invasive technique. This novel technique provides a major advance for minimally invasive neck rejuvenation.

OBJECTIVES

The authors sought to describe their experience with light-guided percutaneous neck rejuvenation over the past 4.5 years, including technique, patient selection, safety profile, and expected outcomes.

METHODS

Data were retrospectively reviewed for all patients who underwent the procedure with 5 surgeons across 4 aesthetic plastic surgery practices from January 2018 through May 2022. Inclusion criteria were mild to moderate neck laxity, prominent anterior platysma bands, and desire to improve neck contour. Patients undergoing concurrent skin incision >5 mm (ie, open rhytidectomy or platysmaplasty) were excluded.

RESULTS

A total of 391 patients meeting criteria were identified during the study period. No hematomas were documented. Four patients (1%) developed infection at the suture site, 1 resolving on antibiotics and 3 requiring suture removal. Eighteen (4.6%) developed recurrent platysmal bands, and 7 (1.8%) had residual loose skin. Four (1%) experienced transient marginal mandibular neuropraxia. Mean length of follow-up time was 240 days.

CONCLUSIONS

Light-guided percutaneous suture suspension is a safe and viable option for improving neck contours. Although it does not address extensive skin laxity or excess submental fat, it can be combined with energy-based tissue tightening, submental liposuction, or skin excision. In selected patients, this minimally invasive procedure provides predictable results with a low risk of complications.

LEVEL OF EVIDENCE: 3

Comparison of a Novel Silicone Gel Wound Dressing vs Bacitracin After Follicular Unit Extraction Hair Transplantation

BACKGROUND

Follicular unit extraction (FUE) hair transplantation subjects are excellent candidates to assess wound dressings. The wound surface area is large and adequately delineated to allow randomization, while in-patient split scalp designs allow patients to serve as their own controls.

OBJECTIVES

This randomized, single-blinded, split-scalp comparison trial compares a novel, film-forming silicone gel-Stratamed (SM; Stratpharma AG, Basel, Switzerland)-to Bacitracin (Bac; McKesson Medical-Surgical Inc., Richmond, VA) in subjects undergoing FUE.

METHODS

Twenty subjects were randomized to receive SM and Bac on alternating sides of the scalp. Primary outcome measures included blinded clinician assessments of edema, erythema, crusting, healing response and outcome preference. Secondary measures included subject-reported assessments of pain and pruritis as well as FaceQ scores taken at post-FUE days two through six.

RESULTS

Twenty subjects were enrolled. Nineteen completed the trial. All subjects were non-smokers, and none had medical comorbidities expected to impact wound healing. An average of 1778 follicles per subject were harvested. No adverse events were reported, and all subjects healed by day 7. Healing response and outcome preference were significantly higher at day 1 in the SM group and by day 7, both groups were similar. There were no significant differences between groups for edema, erythema, or crusting. There were no significant differences between groups for subject-reported outcomes of pain, pruritis, or FACE-Q scores. When asked which product they preferred using, 44% of subjects preferred using SM versus 22% who preferred Bac.

CONCLUSIONS

The SM wound dressing was well-tolerated in patients undergoing FUE. SM may speed the healing response in the early phase of wound healing.

LEVEL OF EVIDENCE 2

Temperature-Controlled Monopolar Radiofrequency in the Treatment of Submental Skin Laxity: A Prospective Study

BACKGROUND

Laxity of the submental area is a common cosmetic complaint of the aging population.

OBJECTIVES

The aim of this study was to determine the safety and effectiveness of a temperature-controlled, minimally invasive percutaneous monopolar radiofrequency device to improve dermal laxity and achieve lift.

METHODS

A total of 72 subjects (35-65 years old) with mild to moderate skin laxity in the submental area were included in this single-center prospective study. All subjects received 1 treatment at baseline with an average subdermal temperature of 63°C. The primary endpoint was the proportion of subjects with at least a 20-mm2 decrease in surface area at Day 90 based on 3-dimensional photography. Secondary endpoints included skin elasticity measured by Cutometer, assessment by a blinded physician panel from 2-dimensional photographs, and physician- and subject-reported outcomes.

RESULTS

At Day 90, 72.1% (95% CI: 62.2%-84.0%; P < 0.001) of subjects achieved at least a 20-mm2 lift of the submental area. All Cutometer-measured skin elasticity values (R2, R5, R7) showed significant improvement by 180 days. The independent panel graded 74.2% of subjects as "improved" at 90 days (95% CI: 62.0%-84.2%; P < 0.001). The treatment was well tolerated, and only 1 possibly related serious adverse event was reported (pharyngeal inflammation).

CONCLUSIONS

Treatment with temperature-controlled monopolar radiofrequency alone is a safe and effective treatment to achieve submental lift for at least 6 months.

LEVEL OF EVIDENCE: 4

A Step in the Right Direction: A Prospective Randomized, Controlled Crossover Trial of Autologous Fat Grafting for Rejuvenation of the Heel

BACKGROUND

The shock-absorbing soft tissues of the heel are composed of dermis and specialized fat pads. Heel fat pad atrophy is common and can be painful and debilitating. In our previous work, autologous fat grafting was effective for treating pain from forefoot fat pad atrophy.

OBJECTIVES

The authors hypothesized that autologous fat grafting to the heel would relieve pain and improve function in patients with heel fat pad atrophy.

METHODS

Patients with heel fat pad atrophy and associated pain were recruited and randomized into 2 groups. Group 1 received autologous fat grafting on enrollment and was followed for 2 years. Group 2 received offloading and activity modification for 1 year, then crossed over, underwent autologous fat grafting, and was followed for 1 year afterward. Outcome measures included ultrasound-measured fat pad and dermal thickness; pedobarograph-measured foot pressures and forces; and patient-reported outcomes as measured by the Manchester Foot Pain and Disability Index.

RESULTS

Thirteen patients met the inclusion criteria and completed the study. Seven (12 affected feet) were randomized into Group 1; and 6 (9 affected feet) were randomized into Group 2. The average age was 55 years and BMI was 30.5 kg/m2. Demographics did not significantly differ between groups. Heel fat pad thickness increased after autologous fat grafting but returned to baseline at 6 months. However, autologous fat grafting increased dermal thickness significantly and also increased fat pad thickness under a compressive load compared with controls at 6 and 12 months. Foot pain, function, and appearance were also significantly improved compared with controls at 6 and 12 months.

CONCLUSIONS

Autologous fat grafting improved patient-reported foot pain, function, and appearance and may rejuvenate local soft tissues in patients with heel fat pad atrophy.

LEVEL OF EVIDENCE: 3

Flap Closure of Spinal Defects in High-Risk Patients: A 10-Year Institutional Experience

BACKGROUND

Complication rates after spinal surgery are high, in part because of surgical advancements that have made procedures available to a broader range of medically complicated patients. The high rates of infection, hematoma, and dehiscence resulting in open wounds after spinal surgery often warrant plastic surgery involvement. In this study, we aim to examine the effects of preoperative and operative risk factors on complication rates, reoperation rates, and hospital length of stay after flap reconstruction of spinal defects.

METHODS

A retrospective review was performed of 373 patients who required flap reconstruction for spinal wound closure at our institution between 2003 and 2013. Data regarding demographics, comorbidities, operative variables, and postreconstructive course were collected.

RESULTS

Of the 373 patients, 97.3% had at least 1 comorbid condition associated with poor wound healing, 91.2% had a significant wound condition at the time of reconstruction, and 81.8% had a history of 2 or more spinal surgeries. After reconstruction, average hospital stay was 14 days, with 35% of patients developing complications and 30% requiring reoperation. Risk factors including elevated body mass index, diabetes, tobacco use, steroid use, low prealbumin level, therapeutic anticoagulation, infection, history of spine surgery, multilevel spinal reconstruction, and spinal hardware were associated with complications, reoperations, and prolonged length of stay.

CONCLUSIONS

Local muscle flap coverage is an effective strategy for the reconstruction of spinal defects in medically complex patients. To reduce the inherently high risks associated with paraspinous reconstruction in this challenging population, special consideration should be given to preoperative and operative variables associated with poor outcomes. Early coordination between spine and plastic surgeons should be considered in patients at high-risk of wound complications.

Long-gap peripheral nerve repair through sustained release of a neurotrophic factor in nonhuman primates

Severe injuries to peripheral nerves are challenging to repair. Standard-of-care treatment for nerve gaps >2 to 3 centimeters is autografting; however, autografting can result in neuroma formation, loss of sensory function at the donor site, and increased operative time. To address the need for a synthetic nerve conduit to treat large nerve gaps, we investigated a biodegradable poly(caprolactone) (PCL) conduit with embedded double-walled polymeric microspheres encapsulating glial cell line–derived neurotrophic factor (GDNF) capable of providing a sustained release of GDNF for >50 days in a 5-centimeter nerve defect in a rhesus macaque model. The GDNF-eluting conduit (PCL/GDNF) was compared to a median nerve autograft and a PCL conduit containing empty microspheres (PCL/Empty). Functional testing demonstrated similar functional recovery between the PCL/GDNF-treated group (75.64 ± 10.28%) and the autograft-treated group (77.49 ± 19.28%); both groups were statistically improved compared to PCL/Empty-treated group (44.95 ± 26.94%). Nerve conduction velocity 1 year after surgery was increased in the PCL/GDNF-treated macaques (31.41 ± 15.34 meters/second) compared to autograft (25.45 ± 3.96 meters/second) and PCL/Empty (12.60 ± 3.89 meters/second) treatment. Histological analyses included assessment of Schwann cell presence, myelination of axons, nerve fiber density, and g-ratio. PCL/GDNF group exhibited a statistically greater average area occupied by individual Schwann cells at the distal nerve (11.60 ± 33.01 μm2) compared to autograft (4.62 ± 3.99 μm2) and PCL/Empty (4.52 ± 5.16 μm2) treatment groups. This study demonstrates the efficacious bridging of a long peripheral nerve gap in a nonhuman primate model using an acellular, biodegradable nerve conduit.

Characteristics and Immunomodulating Functions of Adipose-Derived and Bone Marrow-Derived Mesenchymal Stem Cells Across Defined Human Leukocyte Antigen Barriers

Background

Vascularized composite allotransplantation opens new possibilities in reconstructive transplantation such as hand or face transplants. Lifelong immunosuppression and its side-effects are the main drawbacks of this procedure. Mesenchymal stem cells (MSCs) have clinically useful immunomodulatory effects and may be able to reduce the burden of chronic immunosuppression. Herein, we assess and compare characteristics and immunomodulatory capacities of bone marrow- and adipose tissue-derived MSCs isolated from the same human individual across defined human leukocyte antigen (HLA) barriers.

Materials and methods

Samples of omental (o.) adipose tissue, subcutaneous (s.c.) adipose tissue, and bone marrow aspirate from 10 human organ donors were retrieved and MSCs isolated. Cells were characterized by flow cytometry and differentiated in three lineages: adipogenic, osteogenic, and chondrogenic. In mixed lymphocyte reactions, the ability of adipose-derived mesenchymal stem cells (ASCs) and bone marrow-derived mesenchymal stem cells (BMSCs) to suppress the immune response was assessed and compared within individual donors. HLA mismatched or mitogen stimulations were analyzed in co-culture with different MSC concentrations. Supernatants were analyzed for cytokine contents.

Results

All cell types, s.c.ASC, o.ASC, and BMSC demonstrated individual differentiation potential and cell surface markers. Immunomodulating effects were dependent on dose and cell passage. Proliferation of responder cells was most effectively suppressed by s.c.ASCs and combination with BMSC resulted in highly efficient immunomodulation. Immunomodulation was not cell contact-dependent and cells demonstrated a specific cytokine secretion.

Conclusion

When human ASCs and BMSCs are isolated from the same individual, both show effective immunomodulation across defined HLA barriers in vitro. We demonstrate a synergistic effect when cells from the same biologic system were combined. This cell contact-independent function underlines the potential of clinical systemic application of MSCs.

The Effects of Platelet-Rich Plasma on Cell Proliferation and Adipogenic Potential of Adipose-Derived Stem Cells

BACKGROUND

Platelet-rich plasma (PRP) contains multiple growth factors and has been shown to enhance fat graft survival after lipotransfer. However, the molecular mechanisms mediating this effect remain unknown. Adipose-derived stem cells (ASCs) play an important role in fat graft survival and are a likely target for PRP-mediated effects. This study seeks to investigate the impact of PRP on ASC proliferation and adipogenic differentiation.

METHODS

Human ASCs were isolated using our laboratory protocol. The experiments were divided into four arms: (1) ASCs cultured in general culture medium alone; (2) ASCs in general culture medium + 5%, 10%, 15%, or 20% PRP; (3) ASCs cultured in adipogenic differentiation medium alone; (4) ASCs cultured in adipogenic medium + 5%, 10%, 15%, or 20% PRP. Cell proliferation was analyzed and comparative m-RNA expression of adipogenic genes was assessed by quantitative PCR. Protein expression was determined by western blot.

RESULTS

PRP significantly enhanced proliferation of ASCs, even in the presence of antiproliferative, proadipogenic media. In contrast, PRP inhibited adipogenic differentiation in adipogenic media, evidenced by decreased intracellular lipid accumulation and reduced adipogenic gene expression (PPAR-γ and FABP4). Inhibition appears to occur through downregulation of bone morphogenetic protein receptor IA (BMPRIA) and fibroblast growth factor receptor 1 (FGFR1). Interestingly, PRP elicited these effects across the entire range of doses studied.

CONCLUSIONS

PRP appears to modulate ASC function primarily by enhancing cell proliferation. The consequences of its impact on adipogenesis are less clear. Enhanced proliferation initially might set the stage for more robust regeneration and adipogenesis at later time points, providing an important target for ongoing research.

Improved Estimation of Ultrasound Thermal Strain Using Pulse Inversion Harmonic Imaging

Thermal (temporal) strain imaging (TSI) is being developed to detect the lipid-rich core of atherosclerotic plaques and presence of fatty liver disease. However, the effects of ultrasonic clutter on TSI have not been considered. In this study, we evaluated whether pulse inversion harmonic imaging (PIHI) could be used to improve estimates of thermal (temporal) strain. Using mixed castor oil-gelatin phantoms of different concentrations and artificially introduced clutter, we found that PIHI improved the signal-to-noise ratio of TSI by an average of 213% or 52.1% relative to 3.3- and 6.6-MHz imaging, respectively. In a phantom constructed using human liposuction fat in the presence of clutter, the contrast-to-noise ratio was degraded by 35.1% for PIHI compared with 62.4% and 43.7% for 3.3- and 6.6-MHz imaging, respectively. These findings were further validated using an ex vivo carotid endarterectomy sample. PIHI can be used to improve estimates of thermal (temporal) strain in the presence of clutter.

Long-term Patency of Primary Arterial Repair and the Modified Cold Intolerance Symptom Severity Questionnaire

BACKGROUND

The goal of this study was to assess the long-term arterial patency of repaired arteries in the upper extremity and any morbidity resulting from the subsequent occlusion of these vessels. Concurrently, a new questionnaire, the modified Cold Intolerance Symptom Severity (mod CISS) questionnaire, was developed to allow for better assessment of cold intolerance.

METHODS

Thirteen patients who had undergone repair of the radial (4 patients), ulnar (6 patients), brachial (1 patient), digital (1), and an undefined lower arm artery (1) were examined using questionnaires, physical examination, and high-resolution ultrasound.

RESULTS

Outcome measures that were statistically significantly worse in the group of patients who presented with nerve injuries included cold intolerance symptoms, Disabilities of the Arm, Shoulder, and Hand score, Michigan Hand Questionnaire, and grip strength (middle setting on dynamometer). The results from the mod CISS correlated with high statistical significance with the results of the CISS score for the injured hand. Of note, wrist extension was significantly better with patent arteries.

CONCLUSIONS

Sixty-seven percent of arterial repairs remained patent at 6 years (mean) follow-up. The presence of nerve injury has a higher impact on the outcome metrics assessed in this study than arterial patency. Our modification of the CISS score enhances its utility as a survey of cold intolerance.

Open reconstruction of complex proximal metadiaphyseal fragility fractures of the humerus

PURPOSE

A proactive surgical and rehabilitation protocol was implemented to manage humeral fractures involving both the proximal end and shaft in an older patient population. Primary treatment goals were early return to function and reliable fracture union with minimal complications.

METHODS

From 2008 to 2012, 21 such operations were performed; 18 were considered "fragility" fractures based on mechanism, patient age, and evidence of osteopenia or osteoporosis. Open reduction and internal fixation (ORIF) was employed using direct reduction and fixation with a long periarticular locking plate. Physiotherapy was commenced 2 weeks postoperatively. The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire was used to assess functional outcome at a time point greater than 1 year postoperative.

RESULTS

The study group consisted primarily of elderly females (83% with a median age of 69 years) whom sustained complex metadiaphyseal proximal humeral fractures after simple mechanical fall (78%). Uneventful union occurred in all cases. Local complications included 1 case of partial radial nerve palsy, which had resolved completely by 1 year. No cases of infection were identified. Long-term return to functionality was evident with a median DASH score of 12 (mean = 21, standard deviation = 20, n = 13). Seventy five percent of patients reported minimal or no pain (question [Q] 24), and 75% achieved return of overhead function (Q6, 12, and 15).

CONCLUSION

Treatment of complex metadiaphyseal fragility fractures with anatomic reduction, fixed angle plating, and early physiotherapy returns the older patient to optimized functionality with minimal risk of complication. The DASH outcomes are equivalent to ORIF of isolated proximal humerus fractures and clinically indistinguishable from the general population.