Scientific Abstract Presentations: Top Residents Abstract Session 1 (Aesthetic) Thursday, September 26 Thu, Sep 26 8:00-9:30 a.m. PDT

Introduction: Body contouring procedures have recently gained popularity and become more prevalent in the United States (1). Dexamethasone, or Decadron, is a steroid often used intraoperatively in many surgical procedures to prevent postoperative nausea and vomiting while also suspectedly improving postoperative analgesia. Yet, there lacks investigations concerning the relationship between intraoperative dexamethasone use and postoperative complications. The purpose of this study was to investigate intraoperative dexamethasone use and the risk of postoperative complications following body contouring procedures.

Methods: A retrospective chart review was conducted from January 2020 to October 2023 at the University of Texas Medical Branch for patients undergoing body contouring procedures using relevant current procedural terminology (CPT) codes. Primary variables of interest include intraoperative dexamethasone use and dosage, post operative complications, body mass index (BMI), and comorbidities including diabetes mellitus (DM), end-stage renal disease (ESRD), hypertension (HTN), and tobacco use. Secondary variables of interest include demographic data (age, gender, race, ethnicity). All statistical analyses were done by the Statistical Analysis System, SAS version 9.4 (SAS, Inc., Cary, NC).

Results: A total of 568 patients were identified, with 35 being excluded due to incomplete patient information. Of the 533 included patients, 490 (91.9%) patients received intraoperative dexamethasone while 43 (8.1%) patients did not. In the entire study sample, 252 (47.3%) patients experienced postoperative complications. 238 (48.6%) patients receiving intraoperative dexamethasone had postoperative complications, while 14 (32.6%) patients without intraoperative dexamethasone administration experienced complications postoperatively. The most common complications encountered were superficial skin dehiscence--constituting over a third of the recorded complications, followed by seroma, surgical site infection, and partial skin necrosis. In an unadjusted logistic-regression model, intraoperative dexamethasone was shown to significantly increase the risk of complications by 96% with an odds ratio of 1.96 (p<0.047). In an adjusted logistic-regression model controlling for the other investigated variables, the risk of complications with intraoperative dexamethasone use significantly increased further to 122% with an odds ratio of 2.22 (p<0.02). In the adjusted logistic-regression model, BMI was also statistically significant with an odds ratio of 1.03 (p<0.03). No significant interaction was found with dexamethasone use in conjunction with any other covariates investigated, including the comorbidities.

Conclusion: Previous studies have suggested that comorbidities such as DM, ESRD, HTN, and tobacco use significantly increase the risk of complications following body contouring procedures (2). When controlling for these variables, our data proposes that the use of intraoperative dexamethasone use significantly increases the risk of complications following body contouring procedures. As such, physicians should be aware of this relationship when risk-stratifying patients and providing proper perioperative care and have discussions with anesthesia colleagues regarding its use.

1. The Aesthetic Society's Cosmetic Surgery National Data Bank: Statistics 2019. Aesthet Surg J. 2020;40(Suppl 1):1-26. doi:10.1093/asj/sjaa144
2. Garoosi K, Mundra L, Jabbari K, et al. Comorbid Conditions and Complications in Body Contouring Surgery: A Retrospective Review. Aesthet Surg J Open Forum. 2023;5:ojad080. Published 2023 Aug 31. doi:10.1093/asjof/ojad080

Introduction: The demand for gluteal augmentation worldwide has increased exponentially since 2013, where there was a record of approximately 11,505 procedures per year in the United States; in 2022, 42,528 procedures were reported according to the ISAPS report. Due to its popularity, different techniques have been developed to achieve the best results in this procedure. However, concern has been raised by recent reports of increased mortality mainly due to fat embolism, which may result from two mechanisms: injection of fat directly into the gluteal veins or migration of fat deposited near injured veins, both mechanisms being related. Methodology: A systematic review and evaluation of the information on complications associated with gluteal lipoinjection for aesthetic objectives was carried out. A search was generated by an independent author in the period of 2023 on the platforms of PubMed, MEDLINE, Cochrane, Wiley Online and Science Direct, using the following terms: "buttocks", "lipoinjection", "Lipotransfer", "body contour". , "fat transplant", "gluteoplasty", "buttock augmentation". The inclusion criteria were the use of fat grafting for gluteal augmentation for aesthetic purposes. The variables of age, sex, body mass index, procedure performed, fat harvesting technique, antibiotic use, gluteal anatomical plane of the fat graft, grafted volume and associated complications were analyzed. The statistical analysis was carried out with the IBM SPSS system version 26. The information was analyzed through independent samples and t-student, as well as variance correction through the Bonferroni method. The limit for statistical significance was α= 0.05. Results: The first search returned 1263 articles of which 674 were eliminated after duplicates, subsequently 190 remained after elimination by title, leaving 81 after elimination by abstract, leaving 21 articles that met the inclusion criteria. Data from 4868 patients are reported, where the average age was 32 + 5 years (range 18-72 years), the body mass index on average was 24 + 3 kg/m2. 98% of the patients were women. Of the 21 articles captured, only 12 report the detailed surgical technique. In relation to gluteal lipoinjection and the anatomical plane, most articles reported infiltration in the subcutaneous and muscular plane (54%), only subcutaneous (36%) and only muscular (10%). The average volume injected was 320 ml + 170 ml of fat in each buttock. The use of ultrasound for gluteal injection was reported in 4 articles. Of the 21 articles, 20 report their complications, with a total of 4271 patients, these are described in table No. 2. In relation to the gluteal injection planes, 15 articles mention the injection site, where 8 of them report injection in the muscular and subcutaneous plane, 5 only in the subcutaneous plane and 2 in the muscular plane. There were fewer complications in the subcutaneous plane group (5.3%) compared to those who injected in the muscular and subcutaneous plane (23.8%), this result was not statistically significant (p = 0.063). Regarding fat embolism, only two articles reported the presence of this complication, where it was injected in the subcutaneous and muscular plane, which is why it was not possible to associate this complication with the injection plane. Discussion: Injection of fat in the subcutaneous plane and above the fascia improves projection and improves contour, however the increase in volume is better achieved with injection at the muscular level, which is why combining the two planes is usually done to improve results. Although fatty tissue survives longer when injected into muscle, this leads to a greater risk of fatal complications if it is not performed with the appropriate technique, and may generate fat embolism or fat embolism syndrome as a result of damage to the gluteal veins. The high degree of vascularity of the gluteal muscle, with the gluteal vein in the piriformis and suprapiriformis canal, represents a considerable risk in the injection, therefore, intramuscular gluteal lipoinjection should be performed in the superficial plane of the latter to avoid deep vessels. . Measures to achieve the above include the use of ultrasound, keeping the cannula parallel to the gluteal surface, as well as a slow, low-volume injection in the muscular plane. The aforementioned is widely studied, evidencing the high risk of fat embolism by damaging the deep vessels; however, in this review, no association was found with the superficial plane of the gluteal muscle. Bibliography: 1.Pereira LH, Radwanski HN. Fat grafting of the buttocks and lower limbs. Aesthetic Plastic Surgery. 1996;20(5). 2.Morales R, Mentz J, Hallman TG, Castillo C. Subfascial/Intramuscular Dual-Plane Gluteal Implantation and Supplemental Fat Grafting: A Novel Technique for Buttock Augmentation. Aesthetic Surgery Journal. 2023 Dec 1;43(12):1499–507

Introduction: Body contouring surgery is becoming increasing popular. Many patients desire aesthetic improvement, but many also desire functional improvement after significant weight loss. One study by Paul et al. showed that body contouring surgery resulted in statistically significant improvement in body appearance and overall body image.1 There is little doubt that these surgeries improve the lives of many patients. However, there are few studies which analyze whether these patients should be admitted post operatively.

Purpose: To evaluate whether inpatient admission postoperatively for body contouring surgery has any impact on outcomes and readmission rates in an Appalachian population.

Methods/cases: The authors performed a retrospective chart review of 370 patients from January 2010 to December 2023 age 18 years and older who underwent body contouring surgery at an Appalachian tertiary academic center. It was first noted what surgery the patient underwent and whether the patient was admitted post operatively. Then, outcomes and complications within 90 days were noted. These included unexpected admission/readmission, infection, seroma/hematoma formation, wound dehiscence, venous thromboembolism (VTE), and mortality. We also examined rates of unexpected reoperation one year post operatively. Statistical analysis was then performed.

Results: Of the 370 people who underwent body contouring surgery, 16 patients underwent surgery that did not have a corresponding procedure in the opposite group (outpatient surgery with no corresponding inpatient surgery or vice versa). As such, these patients were removed. There were 264 remaining patients that underwent outpatient surgery and 90 patients that underwent inpatient surgery. In regards to infection, seroma/hematoma formation, wound dehiscence, and mortality, there was no statistical difference between these complications whether performed inpatient or outpatient. There was a statistically significant decreased risk in readmission for breast reduction when performed outpatient (OR = 0.0519, P= 0.004). There was also no statistically significant difference in unexpected surgery one year post operatively between the inpatient or outpatient surgeries. Neither group had any VTE events 90 days post operatively.

Discussion: There are no studies comparing complications in regards to inpatient vs outpatient body contouring surgery. Physicians consider admission for many reasons, include pain control, lengthy surgery, monitoring for severe fluid shifts, and monitoring to follow outpatient activity/positioning instructions. Physicians consider outpatient surgery to reduce cost and to allow for other patients to be admitted in proper allocation of hospital resources, both of which are critical factors to keep in mind when treating patients in rural Appalachia. In our retrospective study, there was no statistically significant difference in complication rates, mortality, or unexpected surgery. The only statistically significant finding was decreased odds of readmission when breast reduction is performed outpatient.

Conclusion: There is no significant difference in outcomes/complication rates between inpatient and outpatient body contouring surgery in our Appalachian population. In order to reduce cost to the patient and to allow for proper utilization of hospital resources, surgeons should aim to perform as many contouring surgeries as possible on an outpatient basis.

REFERENCES 1. Paul MA, Opyrchał J, Knakiewicz M, Jaremków P, Duda-Barcik Ł, Ibrahim AMS, Lin SJ. The long-term effect of body contouring procedures on the quality of life in morbidly obese patients after bariatric surgery. PLoS One. 2020 Feb 21;15(2):e0229138. doi: 10.1371/journal.pone.0229138

Purpose: Surgeons were historically taught that maximum vasoconstriction occurred 7-10min after epinephrine injection. Mckee and Lalonde et al. reported maximal effect 25.9min following injection for hand surgery.1 However, there are no human studies to date analyzing time to maximal hemostatic effect in facial aesthetic surgery, specifically for facelifts. We hypothesized that the timing for the maximal vasoconstrictive effect of epinephrine in local anesthetic for facelift is <20 minutes.

Methods: A retrospective chart review was conducted on all patients who underwent facelift surgery by a single surgeon (JZ, Primary Investigator) at the Cleveland Clinic between July 2023 and March 2024. Intraoperative skin surface temperatures were recorded using an infrared camera at various time points after the injection of local anesthetic (0.5% lidocaine with 1:200,000 epinephrine) to the cheek and compared to controls (nasal temperature). A pilot study was performed first to evaluate ideal study parameters and timing, helping to guide our final project design. Results: Sixteen patients were enrolled in the pilot study; it was determined that the maximal decrease in skin temperature occurred well before 20min: mean time to coldest recorded temperature was 4.8min (mean decrease 3.91C, p<0.001). Ten additional patients were included in the formal study period following the pilot. All patients underwent primary facelift/necklift surgery and had not previously had any surgical procedures on their face. Mean baseline temperature was 30.21C. The average time from injection to minimum recorded skin temperature was 7.8min. Ninety percent of patients (9/10) reached the minimum temperature by 9min. Temperature was 3.81C (p<0.001) lower on average compared to controls.

Conclusions: Skin surface temperature decreases after injection of local anesthetic with epinephrine. Ninety percent of patients reach minimum skin surface temperature by 9min; thus, we believe that to be the optimal facelift incision time to allow for epinephrine to elicit its full vasoconstrictive effect.

References: 1. Mckee DE, Lalonde DH, Thoma A, Dickson L. Achieving the optimal epinephrine effect in wide awake hand surgery using local anesthesia without a tourniquet. Hand (N Y). 2015;10(4):613-615. doi:10.1007/s11552-015-9759-6

Liposuction is a common cosmetic body contouring procedure. According to several studies, the incidence of postliposuction iatrogenic liver perforation is considered very low, ranging from 0.02% to 0.09%.(1) This case report provides an overview of this complication focusing on the incidence, risk factors, and management of postliposuction iatrogenic liver perforation.

A 42-year-old female presented to our emergency department with abdominal pain and generalized body weakness 3 days after undergoing revision suction-assisted abdomino-dermolipectomy (SADL) with buttock lipo-filling and back dermolipectomy in a private hospital. The patient had no known comorbidities. Her past surgical history included sleeve gastrectomy, laparoscopic cholecystectomy, and abdominoplasty, brachioplasty, and thigh lift. Upon presentation, her vital signs were stable. Abdominal examination revealed abdominal tenderness, mostly in the left and right flanks, with associated rigidity. Laboratory results showed slightly elevated liver enzymes, and elevated C-reactive protein of 200. The hemoglobin level was 10.2, and white blood cell count was normal. MRI and CT studies showed active bile leak. She underwent exploratory laparotomy and multiple sessions of re-exploration and peritoneal lavage. Abdominal drains were kept until no further bile leakage was noted. Intraoperatively, a penetrating injury was noted on the lateral surface of the right lobe of the liver, with an active bile leak detected from the site of the penetrated area. Laparotomy wound was kept open in between re-explorations, fascia had retracted, hence, abdominal wall reconstruction was done to achieve total wound closure. The patient remained in the hospital for a total of 3 months, including her stay in the ICU. Upon discharge, she had a complete recovery.

A significant factor that increases the risk of iatrogenic liver perforation is the wrong trajectory when performing back-and-forth strokes during the procedure.(2) The trajectory should be tangential, and the cannula should not be oriented deeply or in the direction of the viscera.(3)

A high index of suspicion and patient monitoring postoperatively is crucial. Early signs include severe abdominal pain, fever, and low blood pressure.(4) Signs of organ injury in the first 72 h include: abdominal pain and distention, nausea, vomiting, tachycardia, and hypotension. Patients should be educated to seek immediate medical attention if similar symptoms occur. If a patient presents with peritonitis or sepsis, blood workup such as complete blood count, metabolic panel, and inflammatory markers is recommended. In cases of suspected perforation, CT scans are adequate to establish an initial diagnosis.

(1) Harnett P, Koak Y, Baker D. Splenic trauma during abdominal wall liposuction: a case report. J R Soc Med.2008;101(4):201-203. doi: 10.1258/jrsm.2008.081010

(2)Pohlan J, Miller H, Lerchbaumer MH, et al. Multiple liver perforations: complication of an outpatient liposuction procedure. Radiol Case Rep. 2021;16(4):906-910. doi: 10. 1016/j.radcr.2021.01.049

(3)Zakine G, Baruch J, Dardour JC, Flageul G. Perforation of viscera, a dramatic complication of liposuction: a review of 19 cases evaluated by experts in France between 2000 and 2012. Plast Reconstr Surg. 2015;135(3):743-750. doi:10.1097/PRS.0000000000001030

(4) Lu J, Jiang X, Huang H, et al. Infectious shock after liposuction. BMC Infect Dis. 2022;22(1):617. doi: 10.1186/s12879-022-07574-1

Goals/Purpose: In the quest for precision within aesthetic surgery, there is a critical need for an objective method to evaluate the impact of facial cosmetic procedures on perceived age. Our research introduces an innovative artificial intelligence (AI) model designed to assess age reduction following specific surgeries such as facelifts, blepharoplasty, and laser treatments, aiming to personalize surgical planning and enhance patient outcomes.

Methods/Technique: Our approach utilizes a deep convolutional neural network (DCNN) enhanced by a multi-dimensional analysis algorithm, allowing for the nuanced evaluation of the age-reducing effects of various facial cosmetic procedures. This model has been enriched with over 250,000 additional facial images, broadening the scope of post-procedure outcomes analysis. Employing the Xception architecture for its advanced feature extraction capabilities, the model combines regression analysis with a novel multi-layer softmax probability function for precise age estimation. The study analyzes a comprehensive dataset, incorporating a wide array of patient faces from the Mayo Clinic, annotated with detailed procedural information.

Results/Complications: The AI model exhibited an accuracy rate of 93.7% in predicting age, with a standard deviation of 3.8 years. The analysis revealed significant differences in age reduction effectiveness across procedures, with facelifts leading to an average perceived age reduction of 6.5 years, followed by laser treatments at 4.5 years, and blepharoplasty at 3.5 years. These results highlight the distinct impacts of each procedure type on facial rejuvenation.

Conclusion: Our advanced AI model provides a groundbreaking tool for quantifying the effectiveness of various facial cosmetic surgeries in reducing perceived age. By offering detailed, procedure-specific insights into age reduction, the model empowers surgeons to tailor their interventions more closely to individual aging patterns and patient expectations. This study represents a significant leap forward in personalized aesthetic surgery, leveraging AI to optimize treatment decisions and improve patient satisfaction with age-defying outcomes.

Introduction Hypertrophic scars and keloids are a significant challenge in clinical practice, causing aesthetic and functional impairments for patients (1). These types of scars result from abnormal wound healing processes, characterized by excessive collagen deposition and fibroblast proliferation (2). Current treatment options, such as surgical excision, corticosteroid injections, and silicone gel sheeting, have limitations and variable success rates (2). As a result, alternative approaches are being explored, with botulinum toxin type A (BTX-A) showing promise in modulating scar formation and improving outcomes. This article aims to provide a systematic review of the available literature on the use of BTX-A in the prevention and treatment of hypertrophic scars and keloids.

Methods A systematic review was conducted following the guidelines set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The review encompassed literature from the inception of relevant databases until September 2023. Electronic databases, including CENTRAL, MEDLINE, Google Scholar, and EMBASE, were searched using a combination of keywords and MeSH terms related to hypertrophic scars, keloids, and botulinum toxin type A. The inclusion criteria for the review were randomized controlled trials (RCTs) that compared the use of BTX-A with placebo or other treatments for hypertrophic scars and keloids. The primary outcomes of interest were the Visual Analog Scale (VAS) and Vancouver Scar Scale (VSS) scores, which assess the cosmetic appearance and quality of the scars.

Results The initial search yielded 1,001 articles, of which 12 RCTs met the inclusion criteria and were included in the systematic review. The pooled analysis of VAS scores revealed a significant improvement in the cosmetic outcomes for the BTX-A group compared to the control group (MD 1.03, 95% CI 0.01-2.05, p < 0.0001). Similarly, the pooled analysis of VSS scores indicated superior scar quality in the BTX-A group compared to the control group (MD = -1.18, 95% CI −1.94 to -0.42, p = 0.001). Adverse events associated with BTX-A treatment were minimal and included mild eyelid drooping and the development of an abscess requiring surgical intervention in one study.

Conclusion This systematic review and meta-analysis provide evidence supporting the use of botulinum toxin type A in the prevention and treatment of hypertrophic scars and keloids. BTX-A treatment resulted in significant improvements in scar appearance and quality, as demonstrated by better VAS and VSS scores compared to control groups. Adverse events associated with BTX-A were minimal, suggesting a favorable safety profile. However, further large-scale, well-designed RCTs with longer follow-up periods are needed to validate these findings and establish the long-term efficacy and safety of BTX-A in scar management.

Reference: 1. Arno, A.I., Gauglitz, G.G., Barret, J.P., & Jeschke, M.G. (2014). Up-to-date approach to manage keloids and hypertrophic scars: A useful guide. Burns, 40(7), 1255-1266. https://doi.org/10.1016/j.burns.2014.02.011 2. Gauglitz, G.G. (2013). Management of keloids and hypertrophic scars: Current and emerging options. Clinical, Cosmetic and Investigational Dermatology, 6, 103-114. https://doi.org/10.2147/CCID.S35252 3. Nast, A., Eming, S., Fluhr, J., & et al. (2012). German S2k guidelines for the therapy of pathological scars (hypertrophic scars and keloids). Journal der Deutschen Dermatologischen Gesellschaft, 10(10), 747-762. https://doi.org/10.1111/j.1610-0387.2012.08012.x

Background: There is a fast-evolving field promoting potential longevity agents to the general population. Previous plastic surgery literature on longevity has emphasized metabolic and lifestyle factors (1). Metformin is among the most well-supported pharmaceuticals in the field as an evidence-based agent for anti-aging (2). We aim to expand the current longevity literature in plastic surgery through a comprehensive review of three leading anti-aging pharmaceutical agents – metformin, rapamycin, and resveratrol – to show their current and potential future applications to the plastic surgery patient population (3).

Methods and Materials: A literature review was performed using a PubMed search, with the keywords "human longevity and plastic surgery", "metformin and plastic surgery", "rapamycin and plastic surgery", "sirolimus and plastic surgery", and "resveratrol and plastic surgery". Relevant papers written in the English language including one the three anti-aging agents and experimental studies based on humans, animals, and microorganisms were included.

Results: A total of 589 articles were reviewed and 153 articles fit our inclusion criteria. There were 31 studies investigating the anti-aging agents' effects directly in human subjects. Rapamycin was most commonly used in human subject studies and its applications were focused on treating lymphatic and vascular malformations as well as improving survival rates and angiogenesis of adipose-derived stem cells, holding potential to improve fat grafting efficiency (4). There was also prospective evidence for topical rapamycin improving skin appearance by increasing collagen VII production (5). Resveratrol's applications included increased wound healing and protection from photoaging. Metformin's applications ranged broadly for burn injuries, Dupuytren disease, keloid and hypertrophic scars, lymphedema, hidradenitis suppurativa, and diabetic foot ulcers. Both resveratrol and metformin were associated with improved skin flap survival. All three agents also showed potential for preventing age-related diseases, underscoring their therapeutic potential for promoting human longevity.

Conclusion: There are numerous applications of anti-aging agents for human longevity in plastic surgery. The lack of longevity focus in current plastic surgery practices presents the opportunity for valuable future studies, particularly in the field of aesthetic surgery with the holistic goal of bridging the reversal of both the internal and external aging processes.

References: 1. Iacob S, Hersant B, Mezi MS, Meningaud JP. Factors That May Enhance Longevity: A Literature Review and a Comprehensive Update for Aesthetic Surgeons. Aesthetic Plast Surg. 2016;40(4):625-631. doi:10.1007/s00266-016-0648-3 2. Kulkarni AS, Gubbi S, Barzilai N. Benefits of Metformin in Attenuating the Hallmarks of Aging. Cell Metab. 2020;32(1):15-30. doi:10.1016/j.cmet.2020.04.001 3. Sorrenti V, Benedetti F, Buriani A, et al. Immunomodulatory and Antiaging Mechanisms of Resveratrol, Rapamycin, and Metformin: Focus on mTOR and AMPK Signaling Networks. Pharmaceuticals (Basel). 2022;15(8):912. Published 2022 Jul 23. doi:10.3390/ph15080912 4. Yang F, Du L, Song G, et al. Rapamycin and 3-Methyladenine Influence the Apoptosis, Senescence, and Adipogenesis of Human Adipose-Derived Stem Cells by Promoting and Inhibiting Autophagy: An In Vitro and In Vivo Study. Aesthetic Plast Surg. 2021;45(3):1294-1309. doi:10.1007/s00266-020-02101-6 5. Chung CL, Lawrence I, Hoffman M, et al. Topical rapamycin reduces markers of senescence and aging in human skin: an exploratory, prospective, randomized trial. Geroscience. 2019;41(6):861-869. doi:10.1007/s11357-019-00113-y

INTRODUCTION

The concept of Liposuction has evolved in this era as much as the advent of technology to provide a safe and satisfactory result for the patient. The new concept of Deep Liposuction has not only helped us avoid irregularities in liposuction results but it has also helped us obtain a better waist for the patient. (1 )The "ideal waist", in our concept, is the narrow one between the last rib and the iliac crest, which should be proportional to the patient's body, thus obtaining a good body contour. In this study, the waist was made in the shape of an Italic S.

METHOD

A retrospective cross-sectional quantitative research study was carried out on 59 patients in Buenos Aires, Argentina during the period from January to October 2023, age ranges from 18 to 53 years. Smoking patients with diseases such as diabetes, high blood pressure, untreated acute or chronic anemia were excluded. The inclusion criteria were primary or secondary patients with BMI less than or equal to 26 who wanted to obtain a small waist.

In all patients, tumescent solution was used for lipoaspiration, with the exception that we did not use local anesthetic, only adrenaline. An average of 4 liters of this solution was infiltrated. An average of 3,5 liters of fatty tissue was lipoaspirated. We use ultrasound to emulsify the previous fat and achieve less tissue injury. The position of the patient is essential for good liposuction in the lateral, prone and supine positions.

As well as the cannula that was used to liposuction the waist, which were modified curved cannulas. All patients were hospitalized overnight in the clinic for better control. No blood transfusion was required, except in 2 cases. Lymphatic drainage was performed the day after surgery and a low-compression girdle was used for the first few days.

RESULTS

All patients rated the surgery as satisfactory through a survey that was carried out 3 months after surgery. The minor complications were first degree burn in 1 case which was treated with topicals such as plate nitrate with good evolution, seromas in a lesser part. There were no cases of skin necrosis or any other major complication.

CONCLUSION

Deep liposuction in the waist has marked an important milestone in plastic surgery. With the support of adequate technology and surgical material we can achieve the Italic S-shaped waist.

BIBLIOGRAPHY

1. Durán H, Manzaneda R, Flores E: Deep Back Liposuction: Ultrasound-Guided Deep Fat Liposuction of the Subiliac Crest. Aesthet Surg J . 2024 Feb 15;44(3):296-301

Purpose Nasal tip position is a crucial aspect of rhinoplasty. To stabilize and set the nasal tip position, various techniques, including cartilaginous grafts, have been developed and widely utilized in rhinoplasty. The purpose of this systematic review is to critically evaluate and compare two prevalent grafting techniques: septal extension grafts (SEGs) and columellar strut grafts (CSGs). Specifically, it aims to: 1) Review rhinoplasty studies directly comparing CSGs with SEGs, 2) outline variations in graft implementation (i.e. suture fixation, shape modifications), 3) compare the impact of these grafts on nasal tip projection, stabilization, rotation, and patient-reported outcomes, and 4) synthesize findings to offer evidence-based recommendations for the optimal grafting technique selection in open rhinoplasty.

Methods and materials A systematic review adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and the Cochrane Handbook for Systematic Reviews of Interventions was conducted. Searches encompassed MEDLINE (Pubmed), EMBASE, and the Cochrane Central Register of Trials utilizing predefined keywords. Screening and full-text review were independently performed by two evaluators. Data collection included demographics, operative techniques, patient-reported outcomes, and measures of projection, rotation, and stability.

Results Ninety-three articles were identified and screened based on predetermined criteria, with 24 undergoing full-text review. Eight studies, involving 571 patients, were included in the final analysis. Of these, 54% (n=310) underwent SEGs, while 46% (n=261) underwent CSGs. Although patient-reported outcomes were limited to one study, most patients underwent anthropometric measurements of tip projection and rotation at both short- and long-term follow up periods, with one study providing additional data on nasal tip stiffness.

Conclusions This systematic review provides a comprehensive examination of SEGs and CSGs in open rhinoplasty. While SEGs are recognized for providing improved long-term tip stability, some authors contend that CSGs hold value for specific patients. We propose an algorithmic approach for selecting between CSGs versus SEGs based on data from existing comparative studies.

Background Alloplastic chin augmentation is the most common aesthetic surgical treatment to reshape the chin. However, factory-made chin implants are typically standardized rather than custom-made and have potential to cause complications. Although the fabrication of custom-made implants by using computer-assisted planning and 3D printing technology has become widespread, the process has several disadvantages, including long preoperative prosthesis preparation times, high costs, and unsuitability for patients with asymmetric chins or those who undergo combined mandibuloplasty before implant placement. The present study developed an innovative chin augmentation technique involving stacked expanded polytetrafluoroethylene (e-PTFE) sheets that is suitable for most patients and has minimal side effects.

Materials and Methods A retrospective review of a single surgeon's experience was performed over a 2-year period for patients who underwent a procedure involving piled up e-PTFE sheets for alloplastic chin augmentation. This study analyzed the outcomes, complications (temporary nerve numbness, wound infection, hematoma formation, and implant displacement), and patient satisfaction during follow-up.

Results Between January 2018 and December 2020, 38 patients underwent the procedure involving piled up e-PTFE sheets for alloplastic chin augmentation. Six patients (15.8%) experienced nerve-related temporary numbness, and one (2.6%) experienced wound infection. None had developed major complications such as implant displacement or wound infection at follow-up. Moreover, the patients demonstrated a high level of satisfaction with the surgical results.

Conclusion Piled up e-PTFE sheets can be used to produce custom fit porous polyethylene chin implants that result in minimal complications and a very high satisfaction rate.

Introduction: Bariatric surgery allows to obtain an improvement in quality of life from both a clinical (1) and psychological perspective, as well as a sexual one (2). Nevertheless, the substantial weight loss brought on by bariatric surgery results in an inconvenient skin excess, which may negate the benefits and cause serious issues in social interactions and intimacy. The most common plastic surgery performed in post bariatric patients, is abdominoplasty, which has a significant anatomical and psychological effect on sexual activity (3) especially when combined with a lifting of the pubic region. The aim of this study is quantifying this relationship in this group of patients. Methods: In this study were enrolled 65 female patients who had undergone abdominoplasty with lifting of mons pubis, who previously had bariatric surgery, between January 2019 and December 2022 at the Unit of Plastic, Reconstructive and Aesthetic surgery of Azienda Ospedaliera Senese Le Scotte. Having a stable weight for at least six months and being sexually active were prerequisites for inclusion in the study. Patients were given questionnaires (the Female Sexual Function Index score (4) and the BODY-Q score (5)), in the pre- and post-operative stages, to assess eventual relationships with changes in the sexual domain and the psychological impact resulting from the procedure. Furthermore, we evaluated the physical changes by measuring the variation in distance between the xiphoid process and vulvar commissure [xipho-vc]. Results: Six months after surgery, the distance between xiphoid and vulvar commissure was appreciably decreased (mean t0 = 39.57cm; mean t1 = 37.02cm), corresponding to an elevation of mons pubis. Compared to baseline, sexual satisfaction was higher six months after abdominoplasty and the patients' concerns regarding their body shape improved, according to their FSFI (mean FSFI t0 = 24.03; mean FSFI t1 = 31,11) and Body-Q (mean Body-Q t0 = 7.51; mean Body-Q t1 = 22,58) scores. Conclusions: Our findings suggest that the anatomical modifications and consequent psychological effects of abdominoplasty with mons pubis lift have shown a strong influence on sexual satisfaction, sexual activity and the overall aesthetic result in post-bariatric patients. Increasing the number of cases will help to more accurately assess the impact of this combined procedure on the sexual well-being of these patients.

(1) Wolfe BM, Kvach E, Eckel RH. Treatment of Obesity: Weight Loss and Bariatric Surgery. Circ Res. 2016;118(11):1844-1855. doi:10.1161/CIRCRESAHA.116.307591 (2) Sarwer DB, Wadden TA, Fabricatore AN. Psychosocial and behavioral aspects of bariatric surgery. Obes Res. 2005;13(4):639-648. doi:10.1038/oby.2005.71 (3) de Brito MJ, Nahas FX, Bussolaro RA, Shinmyo LM, Barbosa MV, Ferreira LM. Effects of abdominoplasty on female sexuality: a pilot study. J Sex Med. 2012;9(3):918-926. doi:10.1111/j.1743-6109.2011.02583.x (4) Rosen R, Brown C, Heiman J, et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther. 2000;26(2):191-208. doi:10.1080/009262300278597 (5) Klassen AF, Cano SJ, Alderman A, et al. The BODY-Q: A Patient-Reported Outcome Instrument for Weight Loss and Body Contouring Treatments. Plast Reconstr Surg Glob Open. 2016;4(4):e679. Published 2016 Apr 13. doi:10.1097/GOX.0000000000000665

BACKGROUND: Top surgery for transgender males and nonbinary individuals commonly involves double-incision mastectomy with free nipple grafts to create a masculine-appearing chest. Two important considerations for the procedure include placement of the nipple-areola complex (NAC) and incision pattern. Although this procedure is being performed in high volume across the US, there is a paucity of literature indicating the preferred NAC position or incision pattern among transmasculine patients.

METHODS: An electronic survey instrument was created to determine the aesthetic preferences of transmasculine patients cared for at a large-scale medical system. A line drawing image of a male torso was digitally-altered to represent various nipple positions and incision patterns. The vertical NAC positions represented included 80%, 85%, and 90% of the distance from the suprasternal notch to the xiphisternal joint. Horizontal NAC positions included 50%, 67%, and 75% of the distance from the midline to the anterior axillary line. Additionally, four separate images were generated to represent different scar patterns along the inframammary fold (IMF): straight, slant, curved, and hockey stick. Patients were asked to rate each image on a 7-point Likert scale from very undesirable to very desirable. Subjects were asked to self-report demographic information and gender identity. Data analyses were performed using the Kruskal-Wallis test, followed by the Dunn test with Bonferroni correction for individual comparisons.

RESULTS: We invited 923 patients via electronic message to participate in the study, with 121 total patients agreeing to participate. The mean age of participants was 27.7 years (range=18-58, SD=8.9), with 52.1% identifying as "transgender man", 34.7% identifying as "man", 7.4% identifying as "non-binary," and 5.8% identifying as "other". Almost all (98%) subjects were assigned female at birth. For NAC position, the four images that placed the NAC at 80% or 85% in the vertical dimension AND 67% or 75% in the horizontal dimension were rated significantly higher than all other options (p<0.01) but were not statistically significant from each other. Conversely, all three images that placed the NAC at 50% in the horizontal dimension were rated significantly lower than the other options (p<0.001) but were not statistically significant from each other. Nonbinary individuals rated the NAC placement at 80% vertically and 67% in the horizontal dimension lower than those identifying as man or transgender man. For chest scar, the hockey stick pattern (median=6) was rated significantly higher (p<0.001) than the straight scar (median=5), which was rated significantly higher (p<0.001) than both the slant (median=3) and curved scars (median=2), which had no difference (p=0.17). Participants who identified as man rated "slant" and "straight" incision patterns lower than nonbinary and transgender man.

CONCLUSIONS: Nonbinary and transmasculine individuals prefer NAC placement between 80%-85% of the distance from the sternal notch to xiphisternal joint and 67%-75% of the distance from the midline to anterior axillary line. Additionally, patients most prefer the hockey stick mastectomy scar pattern regardless of gender identity. These results provide valuable context for surgeons offering masculinizing mastectomy to transgender patients.