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Intense pulsed light (IPL) is a noninvasive therapeutic option to treat benign pigmented lesions by targeting melanin.The purpose of this study was to assess IPL as a treatment for benign pigmented dorsal hand lesions.A total of fifteen subjects, 40 to 73 years old, received 3 monthly IPL treatments over the dorsal hands. Subjects followed up 1 and 3 months after treatment. At every visit, photographs were taken using the VISIA Complexion Analysis System (Canfield Scientific, Fairfield, NJ) and analyzed using the RBX Brown Spots Analysis algorithm. The Clinician Global Aesthetic Improvement Scale and Subject Global Aesthetic Improvement Scale were completed at both follow-up visits.A total of fifteen subjects completed all six visits. The number of brown spots decreased 9.26% ( p = .0004) and 7.52% ( p = .0132) at each follow-up visit. The mean brown intensity decreased 6.15% ( p = .0183) and 7.67% ( p = .0178), whereas the mean contrast intensity decreased 8.88% ( p.0001) and 6.60% ( p = .0007) 1 and 3 months after treatment, respectively. The mean Clinician Global Aesthetic Improvement Scale was 2.03 and 2.23, whereas the mean Subject Global Aesthetic Improvement Scale 1 and 3 months after treatment was 1.6 and 1.8, respectively.Objective analysis, along with clinician and subject assessments, showed an improvement in the appearance of benign pigmented lesions in the treated area after 3 IPL treatments.

Background Noninvasive treatments for skin tightening are gaining popularity. However, no studies have assessed bipolar fractional radiofrequency treatment on suprapatellar skin. Objectives The purpose of this study was to evaluate the efficacy of bipolar fractional radiofrequency treatment on suprapatellar skin. Methods Twenty patients received 1 bilateral suprapatellar bipolar fractional radiofrequency treatment. They returned 7 days, 3 weeks, 3 months, and 6 months posttreatment. Noninvasive measurements were obtained at each visit, including high-resolution ultrasonography, optical coherence tomography, transepidermal water loss and skin elasticity. Microbiopsies were collected in the treatment area for histologic and gene expression analyses. Three clinicians completed photographic evaluations comparing texture and laxity at baseline vs 6 months posttreatment. Results Fifteen subjects completed all 6 visits. Both transepidermal water loss and dermal-epidermal junction roughness were increased at 3 weeks and 3 months posttreatment. Both attenuation coefficient and stiffness were increased significantly at 3 and 6 months posttreatment. Blood flow 0.5 mm below the surface and expression of epidermal hyaluronic acid and inflammatory genes IL-1b and IL-6 were significantly higher at 7 days posttreatment compared with pretreatment and 3 months posttreatment. There were no statistically significant changes in collagen- or elastin-related genes and proteins at 7 days or 3 months posttreatment. An improvement in texture and laxity was observed at 6 months posttreatment in 17.7% and 24.4% of photographs, respectively. Conclusions Radiofrequency treatment by microneedling of suprapatellar skin shows limited effects in decreasing skin laxity and improving skin appearance. At a molecular level, the treatment resulted in lower elastin and hyaluronic acid levels and increased dermal-epidermal junction roughness based on histology and optical coherence tomography imaging. Level of Evidence: 4

Background Although ablative techniques are the standard of care for the treatment of fine lines and wrinkles, microneedling offers a minimally invasive alternative. Objectives The purpose of this study was to assess the efficacy of microneedling on facial and neck fine lines and wrinkles. Methods Thirty-five subjects between 44 and 65 years old with Fitzpatrick skin types I to IV received 4 monthly microneedling treatments over the face and neck. Subjects returned 1 and 3 months posttreatment. At every visit, high-resolution ultrasonography and optical coherence tomography were performed, and transepidermal water loss and skin elasticity were measured. Microbiopsies (0.33 mm) were collected pretreatment, before the fourth treatment and 3 months posttreatment. Results Thirty-two subjects (30 females, 2 males) completed all 7 visits. Facial dermal and epidermal density increased 101.86% and 19.28%, respectively, from baseline at 3 months posttreatment. Facial elasticity increased 28.2% from baseline at 3 months posttreatment. Facial attenuation coefficient increased 15.65% and 17.33% at 1 and 3 months posttreatment, respectively. At study completion, blood flow at a depth of 300 µm decreased 25.8% in the face and 42.3% in the neck. Relative collagen type III and elastin gene expression was statistically higher 3 months posttreatment. However, total elastin protein levels were unchanged from baseline values. Dermal muscle formation was observed in 58% of biopsies extracted 3 months posttreatment compared with 15.3% at baseline. Conclusions The results illustrate the effects of microneedling treatments. Noninvasive measurements and biopsy data showed changes in skin architecture and collagen/elastin gene expression, suggesting skin rejuvenation, with new extracellular matrix production and muscle formation. Level of Evidence: 3

Recent advancements in laser technology have led to its expanded utilization in smaller clinical settings and medical spas, particularly for facial rejuvenation and the treatment of other aesthetic concerns. Despite the increasing popularity of this technology, discussion of laser safety programs has remained limited, mostly to operating rooms at larger clinical institutions. Although smaller facilities do not operate at the same capacity as a large hospital or medical center, the requirements for utilizing a laser are no less stringent. Employers must comply with local and federal regulations, the Occupational Safety and Health Administration (OSHA) General Duty Clause, American National Standards Institute (ANSI) standards, and professional recommended practices applicable to their business. Although the laser safety officer (LSO) is often a full-time position within larger facilities, smaller clinical settings and medical spas may be limited in staff number. It is important, therefore, that clinical practices establish laser policies and procedures with consideration of their individual needs and capabilities. In this paper, we will define a laser safety program, highlight basic requirements needed to establish this program, and outline the specific responsibilities of the LSO. To ensure that safe laser practices are being conducted at the healthcare facility, it is imperative that small business owners are aware of these regulations and standards in place for the operation of laser systems.

Background Despite the proven efficacy of liposuction, there is a population of patients who prefer non-surgical alternatives. Laser hyperthermia-induced lipolysis has emerged as one non-invasive alternative to liposuction. Objectives The authors sought to evaluate the safety and efficacy of a 1060-nm (±10 nm) diode laser for non-invasive fat reduction of the abdomen. Methods This single-arm, 2-center study enrolled 30 patients. Patients received a 25-minute 1060-nm diode laser treatment on their abdomen. Ultrasound adipose measurements, body weight, and circumference were taken at baseline and at 6- and 12-week follow-up visits. Blinded evaluators identified “before” and “after” photos of each patient. A patient satisfaction questionnaire was completed by each patient at study exit. Results A total 29 patients completed all treatment and follow-up visits. Ultrasound images showed an adipose reduction of 8.55% at 12 weeks post-treatment (P Conclusions These results indicate that a single treatment with a 1060-nm (±10 nm) diode laser, per the treatment protocol, is safe and effective in reducing unwanted fat in the abdomen as objectively measured employing ultrasound. The treatment was well-tolerated among all patients, with minimal discomfort reported and high patient satisfaction. Level of Evidence: 4

Background Skin scarring can occur after punch biopsies, prohibiting their routine utilization, especially in the central face. Objectives This paper describes a scarless, 0.33-mm-diameter skin microbiopsy for molecular analysis of skin. Methods This is was single-center, randomized, prospective study with 15 patients receiving no biopsy or biopsy on the left or right nasolabial fold. Six blinded raters assessed participant photos at baseline, 1 month, and 3 months post biopsy to evaluate for a visualized scar. Patient and Observer Scar Assessment Scale was completed. Additionally, biopsies from various skin regions of body along with arm skin after treatment with a single Erbium-YAG laser were processed for molecular analysis. Results No patients exhibited scar formation based on evaluation of photographs and patient feedback. There was no mark at the biopsy site 7 days post-procedure. Optical coherence tomography showed a complete closing of the biopsy-punch wound 48 hours post-biopsy. One month post-biopsy, photography reviewers were unable to identify a scar, on average, 90% of the time at 3-month follow-up. Microbiopsies from various anatomical regions were successfully extracted for histology, electron microscopy, and gene expression analysis. Selected skin rejuvenation markers in the biopsies from Erbium-YAG–treated forearm skin resulted in significant gene upregulation in extracellular matrix molecules at 1 month posttreatment compared with untreated skin. Conclusions A core microbiopsy of 0.33 mm can be extracted reproducibly for histological, ultrastructural, and gene expression analysis without scarring. This allows repeated sampling for assessment of skin treatments and diseases, including aesthetics and wound-healing progress.

Background It is dangerous, although not uncommon, in some clinical settings for laser operators to place gauze underneath external patient protective eyewear when performing laser procedures. Objectives The purpose of this study was to evaluate 4 lasers, commonly used for aesthetic facial procedures, on 3 materials commonly found in the clinical setting. Methods We performed tests with 4 lasers: the 2940-nm erbium-doped yttrium aluminum garnet (Er:YAG) laser, the 532-nm potassium titanyl phosphate (KTP) laser, the 1064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser, and a Lumenis UltraPulse 10,600-nm carbon dioxide (CO2) laser. Their effects were evaluated on dry gauze pads, wet gauze pads, and adhesive external eye shields. Results When exposed to the 2940-nm Er:YAG and 10,600-nm CO2 lasers, dry gauze smoked on the first pulse and ignited on the second pulse, whereas no damage occurred to the wet gauze or adhesive eye shields after 8 and 4 pulses, respectively. No damage to any material or the underlying surface was seen after 30 pulses of the 532-nm KTP laser. After 2 pulses of the 1064-nm Nd:YAG laser, the adhesive eye shields sparked; dry gauze smoked after 1 pulse, but no damage to the underlying surface occurred after 30 pulses. Conclusions The results of our study highlight the inherent flammability of gauze when exposed to lasers commonly used to address aesthetic facial concerns. Although moistened gauze conveyed more protection than dry gauze, these results do not guarantee patient ocular safety. Therefore, we do not recommend the use of any gauze under protective eyewear.

Background During their work on the cerebrospinal fluid (CSF) circulatory system of human nerves and brain, the authors applied imaging and tissue techniques that complemented basic anatomical dissection. Objectives The authors sought to show how integrating fluorescent imaging and basic immunohistochemistry (IHC) with facial anatomy can address current problems in aesthetic surgery. Methods The authors developed an algorithm and a set of principles from their work on the CSF circulatory system and applied these to 3 problems in aesthetic surgery: the functional anatomy of the vermilion-cutaneous junction; chemosis; and the functional anatomy of periosteal fixation. Results Integrating fluorescent imaging and IHC with anatomical dissection characterizes structural and functional anatomy. Fluorescent imaging helps to identify and locate easily missed structures. IHC defines cell type and function. The vermilion-cutaneous junction is defined by a major lymphatic vessel. Lymphatic flow from the medial limbus to the lateral canthus suggests the etiology of chemosis. Periosteal sites of fixation prevent shear where dural CSF vessels drain directly to subcutaneous lymphatics. Conclusions Integrating anatomical dissection with fluorescent imaging and basic IHC characterizes structural and functional anatomy and helps to better understand many problems encountered in aesthetic surgery.

Background Historically, standard evaluations for photoaging have involved subjective analysis; recently, however, investigators have turned to noninvasive systems for more objective evaluation of facial aging. Objectives The aim of this study was to establish a clinical correlation between the Glogau Photoaging Scale and the VISIA-CR Complexion Analysis System (Canfield Imaging Systems, Fairfield, NJ), and thereby reduce intra- and interobserver variability when assessing photodamage. Methods In total, 117 subjects aged between 18 and 89 years were included. Two-dimensional facial photographs were analyzed by 3 independent reviewers and assigned Glogau scores. Images were also captured and analyzed with VISIA software. Data were grouped by median Glogau score and compared between groups. Results All groups were statistically different (P Conclusions The results illustrate that an imaging system can be used to reliably determine objective scores correlating to Glogau photoaging evaluations, and indicate that aging appears to be an exponential process. Collectively, these findings will assist future investigations of facial aging and the therapeutic options available for facial skin rejuvenation, and enable objective assessment of treatment outcomes.

On January 31, 2018, The Multi-Society Task Force for Safety in Gluteal Fat Grafting released a practice advisory regarding gluteal fat grafting. The task force was assembled in the wake of several highly publicized patient deaths involving Brazilian Butt Lift (BBL) and produced a second practice advisory in August 2019. In 2021, The Aesthetic Surgery President commissioned a Working Group on BBL Patient Safety, charging the group to address new guidelines affecting safety and welfare of BBL patients. The “Practice Advisory on Gluteal Fat Grafting” is the first advisory developed since the working group was formed. In addition to surgical technique as a major cause of fatal complications of BBL, the working group focused on micro-economic trends of operative time and regional BBL pricing and considered fatigue and distraction in formulating the current guidelines. In Florida, the majority of BBL deaths occur at the end of the week. Such a non-normalized distribution most likely represents the result of fatigue and/or distraction, which has been linked to surgical mortality in multiple published communications. In addition, mortality is likely due to uncertainty or lack of documentation as to the correct plane of fat injection. Therefore, the newest and most compelling recommendations from these guidelines include the utilization of ultrasound-guided documentation of cannula placement prior to and during fat injection, and the limitation of 3 BBL cases as a maximum amount of total operative cases per day. The authors thank members of the task force for the insights they brought to this process. Level of Evidence: 4

Background A microneedling pen has been cleared by the US FDA and is indicated for improving the appearance of facial acne scars in adults. Objectives The aim of this study was to assess the effectiveness of this microneedling pen for treating wrinkles. This paper focuses on the results on the neck, an area of recent importance with video meetings placing physical stress on the neck area, leading to wrinkles. Methods Healthy adult men and women were enrolled (N = 35). Subjects received 4 monthly microneedling procedures at depths of up to 2.5 mm. Wrinkle assessments were performed by 2 trained blinded raters by comparing images of each subject at baseline and at 90 days postprocedure. The 2 raters were unblinded for the Clinician’s Global Aesthetic Improvement Scale assessment. Subjects completed the Subject’s Global Aesthetic Improvement Scale and a questionnaire regarding satisfaction with the treated areas of the face and neck at 30 and 90 days posttreatment. Results The study was completed by 32 subjects. Wrinkle assessments demonstrated significant improvement in the neck areas (P Conclusions Microneedling is a viable, minimally invasive option for treating wrin kles of the neck. Level of Evidence: 4

Assessments of non-surgical office-based aesthetic treatments' efficacy including lasers are mostly based on subjective evaluation of clinical photography. Accumulating evidence suggest that non-invasive skin imaging such as optical coherence tomography (OCT) can be effectively used to assess not only the skin surface but also the underlying epidermis and dermis, providing objective and clinically relevant data. In this review, we highlight the potential of OCT imaging for the aesthetic medicine field along with OCT measurement parameters and their clinical relevance to healthy and pathological skin conditions. Lasers Surg. Med. © 2020 Wiley Periodicals, Inc.

Their group previously demonstrated high-patient satisfaction for the treatment of hypertrophic burn scar (HBS) with the erbium: yttrium aluminum garnet (Er:YAG) laser, but this and other literature supporting the practice suffer from a common weakness of a reliance on subjective assessments by patients or providers. Herein, they sought to prospectively study the effects of Er:YAG fractional ablation on HBS using noninvasive, objective technologies to measure outcomes. Patients with HBS had identical regions of scar designated for treatment by the Er:YAG laser (TREAT) or to be left untreated (CONTROL). They prospectively collected scar measurements of TREAT and CONTROL regions preoperatively, 3 weeks, and 3 months after Er:YAG treatment. Scar measurements included viscoelastometry, transepidermal water loss, optical coherent tomography, and high-frequency ultrasound. Outcomes were measured for the aggregate difference between the TREAT group vs the CONTROL group, as well as within each group in isolation. Seventeen patients were seen preoperatively, followed by n = 15 at 3 weeks and n = 11 at 3 months. A mixed-model repeated measures analysis showed no significant effect of fractional ablation when comparing the overall TREAT group measurements with those of the CONTROL group. However, when considered as within-group measurements, TREAT scars showed significant improvement in viscoelastic deformity (P = .03), elastic deformity (P = .004), skin roughness (P = .05), and wrinkle depth (P = .04) after fractional ablation, whereas CONTROL scars showed no such within-group changes. HBS treated by the Er:YAG laser showed objective improvements, whereas no such changes were seen within the untreated scars over the same time frame.

The advancement of laser technology has seen its use gain popularity across a wide range of specialties to treat diseases, as well as address aesthetic concerns. In order to protect both the patient and the healthcare personnel providing treatment, instruction and knowledge of laser safety remain of utmost importance. In this paper, we discuss the classification of laser systems, review ocular injuries that may be caused by inappropriate laser exposure, and provide background on laser protective eyewear. In addition, we highlight the current recommendations for proper eyewear during laser use outlined in the American National Standards Institute standard Z136.3, Safe Use of Lasers in Health Care. Finally, although it is common in some healthcare facilities to place gauze under external eye shields or use gauze alone over eyes during laser procedures, this practice poses an extreme risk to both patients and healthcare personnel. Therefore, we discuss why the use of gauze under eyewear for any laser procedures is not recommended, and instead, offer suggestions to consider when acquiring safe and comfortable patient eyewear.

The COVID-19 pandemic has necessitated a reorganization of healthcare delivery, shedding light on the many unrealized advantages telehealth has to offer. In addition to facilitating social distancing, minimizing the risk of pathogen exposure, and preserving healthcare resources, there are many benefits of utilizing this platform that can extend beyond the current pandemic, which will change the way healthcare is delivered for generations to come. With the rapid expansion of telehealth, we present data from our high-volume academic institution’s telehealth efforts, with a more focused analysis of plastic surgery. Although state legislation regarding telehealth varies greatly, we discuss challenges such as legal issues, logistical constraints, privacy concerns, and billing. We also discuss various advantages and the future direction of telehealth not only for plastic surgery but also its general utilization for the future of medicine in the United States.

Breast implants have evolved for decades. In 2011, the U.S. Food and Drug Administration identified an association between textured breast implants and breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). The purpose of this study was to identify the trends of textured implant use since that time.Maintenance of Certification tracer data were queried between 2011 and 2015 for cosmetic breast augmentation cases submitted by American Board of Plastic Surgery diplomates. A nested random effects logistic regression analysis was used to identify associations between variables.Eleven thousand seven hundred sixteen breast augmentations were performed by 880 unique surgeons. The overall proportion of cases using textured implants increased steadily from 2.3 percent in 2011 to 13.0 percent in 2015 (p0.001). The proportion of surgeons whose cases included both textured and smooth implants increased (from 6.2 percent to 24.3 percent), as did those using only textured implants (from 0.4 percent to 4.4 percent) (p0.001). Significance remained after controlling for form-stable implants, suggesting an alternative motivation for use of textured implants. Subglandular cases (20.5 percent) were more likely to use a textured implant than submuscular (8.4 percent) or dual-plane (7.8 percent) (p0.001) cases.Maintenance of Certification tracer data represent a random sampling of American Board of Plastic Surgery-certified plastic surgeons spanning the gamut of practice settings. Despite ongoing education regarding the association of BIA-ALCL with textured implants, American Board of Plastic Surgery diplomates have trended toward increased use of textured implants for cosmetic breast augmentation since 2011. This finding does not appear to be driven by the introduction of anatomical implants during the study period.

Demand for noninvasive aesthetic medicine options is increasing because of the popularity of nonsurgical procedures and industry's focus on direct-to-consumer marketing. Such techniques as nonablative and ablative lasers, intense pulsed light, radiofrequency, high-intensity focused ultrasound, and skin care with peeling agents may also be used in conjunction with surgery to optimize overall aesthetic results. To maximize benefits, the provider must have a detailed understanding of the science behind each device. Combined therapy is safe and well tolerated by many patients in an office-based setting. Although surgery remains the gold standard, nonsurgical therapy should be a portion of surgical practices.

Background Breast augmentation is the most common aesthetic surgery performed in the United States. Despite its popularity, there is no consensus on many aspects of the procedure. Objectives The authors assessed current trends and changes in breast augmentation from January 1, 2011 to December 31, 2015. Methods A retrospective cross-sectional study of 11,756 women who underwent breast augmentation based on the American Board of Plastic Surgery (ABPS) Maintenance of Certification Tracer Database was performed. Results There were clearly dominant trends in how ABPS-certified plastic surgeons performed breast augmentations. Most surgeries were performed in freestanding outpatient (47.3%) or office operating room (33.7%). The inframammary fold incision was most popular (75.1%), followed by periareolar (17.8%) and transaxillary approaches (4.1%). Implants were more commonly placed in a submuscular pocket (30.6%) compared with dual plane (26.7%) or subglandular (6.7%). Silicone implants (66.8%) were favored over saline (25.1%), with a statistically significant increase in silicone prostheses from 2011 to 2015. Data were “not applicable” or “other” in the remainder of cases. Administration of both preoperative antibiotics (3.8% in 2011, 98.7% in 2015, P < 0.05) and deep venous thromboembolism (DVT) prophylaxis (3.8% in 2011, 90.6% in 2015, P < 0.05) dramatically increased during the study period. Overall adverse events (7.4%) and reoperation rates (2.2%) were low. Conclusions Changes in standard of care for breast augmentation are reflected by the evolving practice patterns of plastic surgeons. This is best evidenced by the dramatic increase in use of antibiotic and DVT prophylaxis from 2011 to 2015. Level of Evidence: 4

Since its advent in the early 1980s, liposuction has made tremendous advancements, making it the most popular aesthetic surgery performed today. The goal of this Continuing Medical Education (CME) article is to provide a foundation of knowledge of the relevant anatomy, preoperative evaluation, intraoperative technique, and postoperative management for surgeons performing liposuction. Finally, the prevention and management of potential complications will be reviewed along with measures to optimize patient safety and outcomes.

Background Lockwood described the importance of Colles' fascia anchoring in medial thighplasty to reduce morbidity associated with the procedure. However, this maneuver may still have complications including traumatic dissection, prolonged edema, and potential wound healing ramifications form increased tension. Alternatively, we suggest orienting tension in medial thighplasty for massive weight loss (MWL) patients in the horizontal vector rather than a vertical direction, negating the need for Colles' fascia anchoring. Objectives To compare the morbidities, complications, and outcomes between Colles' fascia suture fixation (CFSF) and horizontal vector fixation (HVF) in medial thighplasties in MWL patients. Methods A retrospective chart review was conducted on an Institutional Review Board approved database of MWL patients who had medial thighplasty between October 2004 and March 2014. Patient demographics and surgical outcomes were reviewed between those MWL patients with CFSF and HVF. Results Of 65 post-MWL patients, 26 (40.0%) patients were in the CFSF group, and 39 (60.0%) patients were in the HVF group. The 2 groups had statistically equivocal preoperative characteristics and comorbidities. Intraoperatively, the HVF group had increased use of barbed suture (92.3% vs 30.6%, P < 0.0001) and liposuction (71.8% vs 26.9%, P < 0.0001). Postoperatively, the HVF group had decreased incidence of infection (5.1% vs 23.0%, P = 0.051) and lymphocele/seroma (10.3% vs 34.6%, P = 0.0257). No statistical differences were observed for dehiscence, necrosis, or hematoma. Conclusions HVF for medial thighplasty in MWL patients is a safe and effective procedure, with a lower complication profile than CFSF. Furthermore, the incorporation of barbed sutures and/or liposuction may help to achieve optimal results. Level of Evidence 3.

Background Low satisfaction rates and severe complications are two major limitations for temporal hollowing augmentation using autologous fat grafting. Despite fat compartments in temporal region have been reported, its clinical applied anatomy for fat grafting have not been the subject of studies that show its benefits objectively and statistically. Objectives To investigate temporal fat compartments and relative neurovascular structures in cadavers, developing a safe and effective fat grafting technique for temporal hollowing augmentation. Methods The study was conducted on 8 cadavers (16 temples). The tissue layers, fat compartments, ligaments, and neurovascular structures in the temporal region were analysed. The variables were the number and location of sentinel veins, perforator vessels of the middle temporal vein. Measurements were taken with a digital calliper. Results Two separate fat compartments, the lateral temporal-cheek fat compartment and lateral orbital fat compartment, were found in the subcutaneous layer, and two separate septum compartments, the upper and lower temporal compartment, were found in the loose areolar tissue layer. One sentinel vein and 1 to 6 perforator vessels were found to travel through the subcutaneous tissue layer, traverse the overlapping tissue layers in the lower temporal septum region, and finally join in the middle temporal vein. Conclusions The four fat compartments in the temporal region are ideal receipt sites for fat grafting. The medial border of the junction of the hairline and temporal line is a safe and effective cannula entry site for temporal fat grafting. The anterior half of the lower temporal compartment is a “zone of caution” for temporal fat grafting.

In 2015, ATX-101 (deoxycholic acid injection; Kybella in the United States and Belkyra in Canada; Kythera Biopharmaceuticals, Inc., Westlake Village, CA [an affiliate of Allergan plc, Dublin, Ireland]) was approved as a first-in-class injectable drug for reduction of submental fat. Use of a pharmacologic/injectable therapy within the submental region requires a thorough understanding of cervicomental anatomy to ensure proper injection technique and safe administration. To this end, an anatomy laboratory was conducted to review key external landmarks and important internal anatomic structures that characterize the lower face and anterior neck. External landmarks that define the boundaries of the cervicomental and submental regions were identified including the inferior mandibular border, the anterior border of the sternocleidomastoid muscle, the antegonial notch, the submental crease, the thyroid notch, and the hyoid bone. Relevant internal anatomic structures, including preplatysmal submental fat (the target tissue for ATX-101) and the platysma muscle as well as critical neurovascular and glandular tissues were revealed by dissection. Of particular interest was the marginal mandibular branch of the facial nerve because it typically courses along the inferior mandibular border near the proposed treatment area for ATX-101.

Our group began performing erbium-YAG 2940 wavelength fractional resurfacing of burn scar in our burn center's dedicated burn operating room (OR) in January 2016. The impact of these procedures on the performance of a mature, dedicated burn OR is unknown. All burn OR cases performed between January 1, 2015 and December 31, 2015 served as a pre-laser (PRE-LSR) historical control. A postintervention cohort of laser-only cases (LSR) performed between January 1, 2016 and August 17, 2016 was then identified. PRE-LSR and LSR cases were retrospectively reviewed for OR component times, and work relative value units (wRVU) billed. A total of 628 burn OR cases were done in 2015 (PRE-LSR), while 488 burn OR cases were done between January 1 and August 17, 2016. Of these 488, 59 cases were LSR (12.1%). Calculated on a monthly basis, significantly more cases were done per day in the LSR era (2.2 ± 0.4 cases/d) than PRE-LSR (1.6 ± 2.0 cases/d; P < .0001). The LSR group was significantly shorter than the PRE-LSR group for all OR component times (induction, prep, and procedure all P < .0001; transport out, P = .01; room turnover, P = .004). Aggregate OR component time was 79.2 ± 33.4 minutes for LSR and 157.5 ± 65.0 minutes for PRE-LSR (P < .0001). LSR yielded 6.9 ± 3.2 wRVU/h, while PRE-LSR generated 12.2 ± 8.9 wRVU/h (P < .0001). Despite significantly shorter OR component times and more cases being done per day, laser treatment of burn scar using a single 17108 Current Procedural Terminology code cuts wRVUs generated per hour in a mature burn OR roughly in half.

Circumferential bodylift is a powerful procedure for achieving dramatic and natural body contouring changes in the massive weight loss patient. The care of these patients has raised our awareness of several important issues including safety, nutritional status, skin quality, recurrent laxity, surgical steps, and postoperative scars. Integration of this knowledge with various technical modifications over the last 15 years has improved our care for this cohort. We have not only seen a rise in the number of surgeries performed, but also the development of principles, techniques, and details that the authors feel necessary to share to achieve improved contour and more predictable outcomes. Level of Evidence 4![Graphic][1] Therapeutic [1]: /embed/inline-graphic-1.gif

Juvéderm Voluma XC (VYC-20L) is approved in the United States for correction of age-related volume loss in the midface region in adults.To characterize the effects of VYC-20L in 3 midface subregions based on injection volumes.In this single-blind controlled trial, subjects with midface volume deficit received VYC-20L in ≥1 of 3 facial subregions (zygomaticomalar, anteromedial cheek, and submalar), with touch-up treatment available 30 days later. Responders achieved ≥1-point improvement on the Mid-Face Volume Deficit Scale (MFVDS), analyzed by facial subregion and stratified by injection volume quartiles. Subject satisfaction and safety were assessed.The treatment arm comprised 235 subjects aged 35 to 65 years. Month 6 MFVDS responder rates were 75.5% for zygomaticomalar, 83.2% for anteromedial cheek, and 76.9% for submalar subregions. Higher responder rates were observed with increasing injection volume quartiles for each subregion. Similar median injection volumes (≈2.0 mL total) of VYC-20L provided correction durations of 15 to 24 months: 24 months for anteromedial cheek, 19 months for zygomaticomalar, and 15 months for submalar subregions. Subject satisfaction was high across injection volume quartiles. No unanticipated treatment-site adverse reactions occurred.VYC-20L is effective at restoring midface volume, with high subject satisfaction and an acceptable safety profile.

Background Fat grafting is a common procedure in plastic surgery but associated with unpredictable graft retention. Adipose tissue (AT) "product" quality is affected by the methods used for harvest, processing and transfer, which vary widely amongst surgeons. Currently, there is no method available to accurately assess the quality of AT. Objectives In this study, we present a novel method for the assessment of AT product quality through direct measurements of oxygen consumption rate (OCR). OCR has exhibited potential in predicting outcomes following pancreatic islet transplant. Our study aim was to reapportion existing technology for its use with AT preparations and to confirm that these measurements are feasible. Methods OCR was successfully measured for en bloc and postprocessed AT using a stirred microchamber system. OCR was then normalized to DNA content (OCR/DNA), which represents the AT product quality. Results Mean (±SE) OCR/DNA values for fresh en bloc and post-processed AT were 149.8 (± 9.1) and 61.1 (± 6.1) nmol/min/mg DNA, respectively. These preliminary data suggest that: (1) OCR and OCR/DNA measurements of AT harvested using conventional protocol are feasible; and (2) standard AT processing results in a decrease in overall AT product quality. Conclusions OCR measurements of AT using existing technology can be done and enables accurate, real-time, quantitative assessment of the quality of AT product prior to transfer. The availability and further validation of this type of assay could enable optimization of fat grafting protocol by providing a tool for the more detailed study of procedural variables that affect AT product quality.

Objective Fractional laser therapy is a new treatment with potential benefit in the treatment of burn scars. We sought to determine patient satisfaction after burn scar treatment with the Erbium-Yag laser. Methods We performed a telephone survey of all patients who underwent fractional resurfacing of burn scars with the Erbium-Yag 2940 wavelength laser at Parkland Hospital from 01/01/2016 to 05/01/2017. Subjects were asked to rate their satisfaction with their scars’ after treatment characteristics on a scale from 1 (completely unsatisfied) to 10 (completely satisfied). Subjects were also asked to assess their treatment response using the UNC 4P Scar Scale before and after treatment. Results Sixty-four patients underwent 156 treatments. A survey response rate of 77% (49/64) was seen (age: 36.8 + 21 years; surface area treated = 435 + 326 cm2; 35% of burn scars were >2 years old; mean scar age of 1.02 + 0.4 years). Overall, 46/49 (94%) of patients reported some degree of scar improvement after treatment. Patient satisfaction scores were 8.3 + 2.3. Number of laser treatments included: 1 (31%), 2 (33%), 3 (18%), 4(10%), >5 (8%). Treatment depth, scar age, and number of laser procedures were not significant predictors of satisfaction or UNC 4P Scar scores. The paired t-test showed a significant reduction on each of the UNC 4P Scar scale items (pain, pruritus, pliability, paresthesia). One subject reported that she felt that the laser treatment made her scar worse (2%). Conclusion Burn patients treated with the Erbium-Yag laser are highly satisfied with changes in their burn scars.

Background This is the third survey exploring the quality of cosmetic training in plastic surgery residency. We focused on determining: (1) the applied modalities and extent of resident exposure; and (2) resident confidence in performing variable cosmetic procedures. Objectives To analyze trends in resident exposure and confidence in aesthetic plastic surgery procedures from the standpoint of program directors (PDs) and residents. Methods The survey was developed and e-mailed to 424 residents enrolled in the ASAPS Residents Program and 95 PDs. Both independent and integrated programs were included. The questions were posed in a five-point ranking format. Univariate statistical analysis was used to examine all aspects. The results were analyzed in relation to our previous surveys in 2008 and 2011. Results Thirty-three PDs (34.7%) and 224 (52.8%) residents responded. Residents felt most confident with abdominoplasty, breast reduction, and augmentation-mammaplasty. Facial aesthetic procedures, especially rhinoplasty and facelift, were perceived as "challenging." The three most preferred modalities of aesthetic education were, in descending order, residents' clinic, staff cosmetic patients, and cadaver dissections. Both residents and PDs felt a need for more training especially in facial procedures. Only 31.5% of residents who planned to focus on cosmetic surgery felt ideally prepared integrating cosmetic surgery into their practice (compared to 50% in previous surveys). Conclusions Despite improvements observed from 2008 to 2011 published surveys, there are still challenges to be met especially in facial cosmetic procedures. It is suggested that resident clinics and cadaver courses be universally adopted by all training programs.

After studying this article, the participant should be able to: 1. Discuss the key components in the aesthetic, functional, and emotional evaluation of a patient presenting for rhinoplasty. 2. Describe the various surgical options to achieve the goals identified during consultation. 3. Recognize appropriate nonsurgical options and their limitations for treating nasal deformities. 4. Assess the benefits and risks of using perioperative antibiotics in rhinoplasty. 5. Identify common postoperative sequelae of rhinoplasty and formulate a plan of care based on best evidence data.This article was prepared to accompany practice-based assessment with ongoing surgical education for the Maintenance of Certification for the American Board of Plastic Surgery. It outlines the evaluation of the rhinoplasty patient and highlights both surgical and nonsurgical options to address nasal defects. In addition, data from the current literature are included to supplement physician knowledge for enhanced perioperative care and improved outcomes.

Background: Patients recovering from outpatient surgery are responsible for managing their pain, managing ambulation, and even implementing thromboembolism prophylaxis after discharge. Because of the importance of postoperative care to prevent complications, a model of care that helps a patient transition to independent self-care could provide optimal results. Objectives: The authors investigated the safety and morbidity rate for patients who underwent body contouring procedures and overnight care at an attached, nurse-staffed guest suite facility. Methods: A retrospective review was conducted of 246 patients who underwent major body contouring and who stayed at least 1 night in the guest suite facility. Major complications included a return to the operating room within 48 hours, major wound infection, and unplanned hospitalization within 48 hours. Minor complications included any postsurgical effect necessitating unplanned physician intervention within the first 30 days. Univariate analyses correlating patient characteristics and complication rates were conducted, as well as comparison of complication rates among same procedures reported in the literature. Results: The complication rate (major and minor complications) was 25.20%. Surgical site infection occurred in 8.13% of patients. The most common wound complication was erythema around the incision site (12.20%). Death, deep vein thrombosis, or pulmonary embolism did not occur. Comparison with relevant results reported in the literature indicated a significant reduction in the occurrence of postoperative venous thromboembolism. Conclusions: Patient education after surgery is essential to healing and adequate care. The guest suite model provides improved care and education for the patient and family postsurgery by addressing some of the known risk factors of plastic surgery. Level of Evidence: 4 ![Graphic][1] [1]: /embed/inline-graphic-1.gif

Background: The impact of massive weight loss (MWL) on body contouring procedures and outcomes has not been firmly established in the literature. Objective: The authors investigate the correlations between MWL status, the method of achieving MWL, and the amount of weight lost with wound-healing complications after body contouring procedures. Methods: The charts of 450 patients (124 of whom had undergone MWL) who underwent body contouring procedures including abdominoplasty, brachioplasty, thighplasty, breast mastopexy/reduction, lower bodylift, bodylift, buttock lift, and liposuction were reviewed. MWL patients were classified as having achieved weight loss through diet and exercise, gastric banding or sleeving, or gastric bypass. Postoperative complication data were collected, including cases of infection, delayed wound healing, seroma, hematoma, dehiscence, and overall wound problems. Odds ratios (OR) were estimated using 4 multivariate logistic regression models. Results: MWL status was a significant predictor of wound problems (OR, 2.69; P < .001). Patients with 50 to 100 lbs of weight loss did not have a significantly increased risk of wound problems (OR, 1.93; P = .085), while patients with over 100 lbs of weight loss did (OR, 3.98; P < .001). Gastric bypass (OR, 3.01; P =

Background: The American Society of Anesthesiologists Physical Status (ASA-PS) classification is a ranking system that quantifies patient health before anesthesia and surgery. Some surgical disciplines apply the ASA-PS to gauge a patient's likelihood of developing postoperative complications. Objective: In this study, the authors analyze whether ASA-PS scores can successfully predict risk for postoperative complications in plastic and reconstructive operations. Methods: The authors retrospectively reviewed the charts of 1801 patient procedures and selected for inclusion 1794 complex plastic and reconstructive operations that took place at 1 of several academic medical institutions between January 2008 and January 2012. ASA-PS scores, patient comorbidities, and postoperative complications were analyzed. Percentile data were treated with tests for proportions. Nonpercentile data were analyzed through comparison of means ( t test). Low-risk (ASA 1-2) and high-risk (ASA 3+) groups were compared with simple odds ratios. Results: For the 1430 women and 364 men in the patient cohort (average age, 49.5 years), the overall complication rate was 27.7%. When patients with complications were compared to those without, body mass index, operation time, recent major surgery, diabetes, hypertension, renal disease, cancer, and oral contraceptive use were statistically significant. After high-risk (n = 398) and low-risk (n = 1396) groups were identified, infection, delayed wound healing, deep vein thrombosis, and overall complications had significantly increased incidence in the high risk group. Notably, deep vein thrombosis displayed the highest odds ratio (4.17) and a complication rate increase from 0.93% to 3.77%. Conclusions: ASA-PS scores can be used either as substitutes for or as adjuncts to questionnaire-based risk assessment methods in plastic surgery. In addition to deducing significant findings for deep vein thrombosis incidence, ASA-PS scores hold important predictive associations for multiple non–venous thromboembolism complications, providing a broader measurement for postoperative complication risks. Level of Evidence: 4 ![Graphic][1] [1]: /embed/inline-graphic-1.gif

Background: The use of autologous fat for augmentation has become common practice among plastic surgeons for both cosmetic and reconstructive procedures. Previously reported data suggest that the method of fat extraction can have profound effects on adipocyte viability and subsequent fat graft survival. Objective: The authors describe a pilot study comparing a new tissue liquefaction liposuction device (TLL; HydraSolve Lipoplasty System; Andrew Technologies, Irvine, California) with a standard syringe aspiration method with respect to adipocyte viability, fat graft survivability, and fat graft quality. Methods: Lipoaspirate from 5 patients was harvested using either TLL or the standard method. Samples were centrifuged and assayed for cell viability. All lipoaspirate samples were grafted into nude rats and harvested 42 and 84 days later. Graft survival and quality were assessed. Results: There was no difference in adipocyte viability between the lipoaspirate conditions. At 42 days, there was no significant difference in fat graft weight and the TLL grafts were more fibrotic than the standard control grafts, but this was improved with the increased centrifuge rate. At 84 days, fat grafts were equivalent with respect to graft weight and histology. Conclusions: Lipoaspirate harvested with the TLL device and centrifuged at 3000 rpm resulted in fat grafts that were equivalent in weight and histology to those from lipoaspirate harvested with the standard syringe aspiration technique.

In this summary article, the authors discuss the characteristics of abobotulinumtoxinA, incobotulinumtoxinA, and onabotulinumtoxinA. With 3 neuromodulators available in the US market, comparisons between and among products will invariably be made, so arguments for the most effective facial aesthetic uses of each neuromodulator are presented. Topics addressed in this article include patient expectations, toxin reconstitution and preparation, patient positioning, differences among products, the role of complexing proteins, and dosing and injection strategies. Recommendations are also provided by treatment area.

OnabotulinumtoxinA was introduced to the US market in 2002 as the first botulinum toxin type A (BoNTA) approved for facial aesthetics. This article provides an overview of onabotulinumtoxinA's uses and indications as well as safety and efficacy data. As with other BoNTA products, onabotulinumtoxinA is generally well tolerated. Consideration is also given to clinical applications of the product. Information on handling, storage, and dosing is provided.

IncobotulinumtoxinA is the third neurotoxin type A to be approved for aesthetic use in the United States. Because incobotulinumtoxinA has been in use in Europe for some time, the clinical literature is fairly replete with references to its properties and characteristics, as well as its safety and efficacy. In North America, 2 pivotal trials, referred to as GL-1 and GL-2, investigated the safety and efficacy of incobotulinumtoxinA in the glabellar region; both are currently in press with another journal. Other published studies of incobotulinumtoxinA are also described in depth in this article, including reports on aesthetic indications, diffusion, therapeutic indications, and studies pertaining to the preclinical and clinical pharmacology of incobotulinumtoxinA. Topics addressed include potency variability, mean concentration, stability and dissociation, and endopeptide immunoassay.

Background Demand for nonsurgical esthetic body procedures has led to the development of noninvasive techniques for reducing localized subcutaneous adipose tissue. Objective This study assessed multiple treatments with nonthermal focused ultrasound for noninvasive abdominal treatment of excess fat deposits. Materials and methods Subjects were randomly assigned to Group 1 for a 4-week control phase before undergoing 3 abdominal fat reduction treatments, at 2-week intervals, or to Group 2 for immediate treatment. Weight, abdominal circumference, tolerability to treatment, subject satisfaction, and adverse events were recorded. Results Weight remained stable in the 126 participants. Mean reduction in midline circumference was 2.5 ± 2.1 cm in the Group 1 and 3.5 ± 2.7 cm in the Group 2 at Week 22. The effect of multiple treatments was cumulative with a steady decrease in abdominal circumferences during the study. Erythema was observed in 28% of treatments but was mild and transient in nature. Subjects tolerated the treatments well and were satisfied with treatment outcome. Conclusion The study demonstrated the efficacy and safety of multiple nonthermal focused ultrasound treatments of excess abdominal fat deposits. Although the remodeling effect is minor compared with traditional surgical procedures, successive focused ultrasound treatments significantly reduced treatment area circumference, while avoiding invasive techniques and their associated disadvantages.

BACKGROUND ATX-101 (deoxycholic acid injection; Kythera Biopharmaceuticals, Inc., Westlake Village, CA [an affiliate of Allergan plc, Dublin, Ireland]) was recently approved for submental fat (SMF) reduction in the United States (Kybella) and Canada (Belkyra). The pivotal trials supporting these approvals revealed that ATX-101 is associated with common injection-site treatment reactions consistent with its mechanism of action and administration procedure. OBJECTIVE The purpose of this study was to evaluate 4 patient experience management paradigms targeting the common injection-site adverse events of pain, swelling/edema, and bruising after a single treatment session with ATX-101. METHODS In this double-blind, parallel-group, exploratory Phase 3b study (ClinicalTrials.gov identifier: NCT02007434), subjects with moderate to severe SMF were randomized 4:1 within each paradigm to receive ATX-101 2 mg/cm or placebo. In Paradigm 1, subjects received a cold pack application to the treatment area. In Paradigm 2, in addition to cold pack application, subjects were treated with topical lidocaine and injectable lidocaine containing epinephrine. In Paradigm 3, in addition to the interventions of Paradigm 2, subjects received loratadine and ibuprofen. Subjects in Paradigm 4 received the same interventions in Paradigm 3, plus application of a chin strap. RESULTS Eighty-three subjects were treated. In ATX-101-treated subjects, peak pain occurred within 1 to 5 minutes of treatment, with median values at these time points ranging from 21.4 to 35.7 mm on a 100-mm pain visual analog scale ("mild"). Pain ratings reduced substantially by 15 minutes; at 4 hours after injection, pain was characterized as mild tenderness or mild achiness. Compared with cold alone, treatment with topical and injectable lidocaine reduced median peak pain by 17%. Addition of ibuprofen and loratadine resulted in a total reduction in pain by 40%. Peak swelling/edema in ATX-101-treated subjects was "modest," with mean values ≤1.7 (on a 0-5 scale) across all paradigms. Swelling/edema was not substantially mitigated by the interventions, including ibuprofen, loratidine, and the use of a chin strap. Bruising associated with ATX-101 treatment was confined to the treatment area, with mean values between 1.0 and 1.4 on a 0-to-5 scale. Bruising was modestly reduced by injectable lidocaine with epinephrine. CONCLUSION Results from this study support the safety of ATX-101 for SMF reduction, and demonstrate that pain and bruising associated with ATX-101 treatment can be mitigated by a series of simple measures.

ATX-101 (deoxycholic acid injection; Kybella in the United States and Belkyra in Canada; Kythera Biopharmaceuticals, Inc., Westlake Village, CA [an affiliate of Allergan plc, Dublin, Ireland]) is the first aesthetic injectable approved for reduction of submental fat. In February 2014, an injection practicum was conducted in the anatomy laboratory at the University of Texas Southwestern Medical Center to explore the proper injection technique for ATX-101 and the importance of its appropriate, safe anatomical placement within the submental area. Subsequent to the injection practicum, a structured roundtable discussion was conducted in which potential implications of the various injection protocols evaluated during the practicum were reviewed. Furthermore, the faculty had the opportunity to provide additional perspectives based on their clinical experience with facial injectables and ATX-101 specifically. In this article, the findings from the injection practicum and roundtable discussion are reported.

Background: American Society for Aesthetic Plastic Surgery (ASAPS) survey data showed a 16.7% decrease in the total number of aesthetic surgical procedures from 2008 to 2009, whereas plastic surgeons have seen an increase of 0.6% in their nonsurgical cosmetic procedures. Objective: The authors describe the results of two surveys—one administered to potential patients, one to physicians—assessing the impact of the economy on patient choices in aesthetic facial surgery. Methods: Two surveys were conducted for this study—one from the American Academy of Facial Plastic and Reconstructive Surgeons (AAFPRS) and one from the Aesthetic Surgery Education and Research Foundation (ASERF). Both surveys utilized the unique maximum difference (MaxDiff) scaling format, which assesses respondent opinions through attribute/question grouping and multiple exposures to the same parameter, rather than traditional one-time questioning. In this way, MaxDiff analysis helped identify the varied drivers of patients’ medical antiaging treatment (MAT) selection. The AAFPRS survey was conducted online through Synovate’s Global Opinion Panel to identify an appropriate audience of potential patients. The ASERF survey contained both MaxDiff and traditional questions and was e-mailed to 2267 ASAPS members. Results: Data from the AAFPRS patient survey showed that 53% of respondents had been affected by the economy in their decisions regarding MAT procedures, with many seeking out less-costly options such as microdermabrasion. An overwhelming majority (95%) also reported that they would prefer a longer-lasting treatment over an immediate effect with shorter duration; furthermore, 60% felt that duration of treatment was more important than cost in selecting a facial aesthetic procedure. In the ASERF surgeon-based portion of the study, 61% of plastic surgeons felt that patients preferred long-lasting results over immediate ones, but 63% also reported that cost was a more important factor for their patients than duration. Conclusions: Extrapolating from the patient-reported survey preferences, the authors conclude that nonsurgical facial aesthetic treatment plans should currently be focused more on longevity rather than on immediate impact. There is currently a disconnect between patient preferences and surgeon perception of those preferences, which may be remedied with increased education for both groups. It is worth noting that many patients would be willing to accept a higher cost if it was correlated with a longer-lasting result.

Background In 2006, a survey performed by Morrison et al analyzed the experience of aesthetic surgery training from the perspective of residents and their program directors in plastic surgery programs across the United States. Objectives The authors conducted a survey to follow-up on the Morrison results three years after publication, to assess the changes in plastic surgery residency programs. Methods In December 2009, a 17-question survey was sent to program directors, and a 19-question survey was sent to senior residents in all Accreditation Council for Graduate Medical Education-approved plastic surgery residency programs in the United States. The questions were posed in a five-point ranking format. The two additional questions included in the senior resident survey related to career aspirations and desirable areas of additional training. Ninety-two program directors and 397 senior residents received the survey. Results Forty-four program director surveys (47.8%) and 117 (29.5%) senior resident surveys were returned. Two-thirds of programs offered a residents' clinic, which was considered the preferred method of cosmetic surgery education by residents. Residents reported increased exposure to nonsurgical procedures such as lasers and injectables. Abdominoplasty, breast augmentation, and breast reduction remained the procedures most frequently performed by residents with confidence, as in the 2006 survey. Facial aesthetic procedures, including rhinoplasty and facelift, remained challenging to residents. Many residents (55.7%) felt confident integrating cosmetic surgery into their practice. One-third of residents reported that they would apply for a cosmetic fellowship. Conclusions This survey shows an improvement in cosmetic surgery training for plastic surgery residents in the United States, particularly in that noninvasive cosmetic treatments are being increasingly taught. Since 2006, steps have been taken to provide more comprehensive cosmetic surgery education to residents, encouraging the delivery of the safe, high-quality care expected of a board-certified plastic surgeon.

This is a report of the secondary endpoints, Subject Global Evaluation (overall improvement) and Subject Satisfaction scores, from a study designed to examine the efficacy of injectable poly-L-lactic acid for the correction of nasolabial fold wrinkles over 25 months.A randomized, subject-blinded, parallel-group, multicenter clinical study was conducted to compare the effects of injectable poly-L-lactic acid with those of human collagen for the treatment of nasolabial fold wrinkles at 13 months following the last treatment. Injectable poly-L-lactic acid-treated subjects were followed for 25 months.From month 3 through month 13 following the last treatment, injectable poly-L-lactic acid-treated subjects (n = 116) reported significantly higher Subject Global Evaluation scores compared with human collagen-treated subjects (n = 117; p0.001). Overall Subject Global Evaluation scores for injectable poly-L-lactic acid-treated subjects were 99 percent at week 3, 91 percent at month 13, and 81 percent at month 25 (all times following the last treatment). In contrast, for human collagen-treated subjects, overall Subject Global Evaluation scores declined by 84 percent, from 96 percent at week 3 to 15 percent at month 13. Subject Satisfaction scores were significantly different (p0.01) between treatment groups beginning week 3 and continuing through month 13. Overall Subject Satisfaction scores were maintained for over 80 percent of injectable poly-l-lactic acid-treated subjects (n = 106) at month 25 after the last treatment.Treatment of nasolabial fold wrinkles with injectable poly-l-lactic acid resulted in statistically significantly higher Subject Global Evaluation and Subject Satisfaction scores compared with human collagen at 13 months. Injectable poly-l-lactic acid-treated subjects maintained improvements for up to 25 months after treatment.

Background: The emergence of new technologies necessitates a study of current trends in liposuction and other methods for fat removal. Objective: The American Society for Aesthetic Plastic Surgery (ASAPS) conducted a survey of its members to gain valuable information from Board-certified plastic surgeons about their experience with new technologies for fat removal and managing complications after liposuction. Methods: The ASAPS Current Trends in Liposuction Survey was emailed to 1713 ASAPS members. Data were tabulated and examined to determine current trends in liposuction and other fat removal techniques performed by ASAPS members. Results: The response rate for the survey was 28.7% (n = 492). Most ASAPS respondents reported performing between 50 and 100 liposuction procedures annually. Most plastic surgeons currently employ or have previous experience with suction-assisted lipectomy/liposuction (SAL), ultrasound-assisted liposuction (UAL), and power-assisted liposuction, but fewer reported experience with laser-assisted liposuction (LAL), mesotherapy, or external, noninvasive devices. SAL was the preferred method of fat removal for 51.4%. UAL, LAL, and SAL were most commonly associated with complications. Only 10.5% of ASAPS members employ LAL; 38% have treated a patient with complications secondary to LAL. Conclusions: Valuable information about current trends in liposuction and other fat removal techniques has been gained from this survey. Although many studies have been published that review issues related to safety, morbidity, aesthetics, and recovery after different methods of fat removal, more prospective studies with standardized objective outcome measures comparing these techniques, particularly newer modalities, are needed to continue improving safety-related standards of care.

Background: Topical lidocaine is a common form of anesthesia for a wealth of procedures across a large number of disciplines, including laser treatments. Preparations can be purchased over the counter with no prescription necessary. It is considered a safer and more acceptable form of anesthetic than hypodermic injections; however, there have been reports of fatalities following its application. Above certain serum lidocaine concentrations, patients may experience effects of toxicity such as lightheadedness and paraesthesia; these effects can progress to seizures and cardiorespiratory depression, which can ultimately lead to death. The active metabolite of lidocaine, monoethylglycinexylidide (MEGX), can be almost as potent as lidocaine in terms of toxicity. Objectives: The authors examine the levels of both lidocaine and MEGX in blood serum after application of topical lidocaine. Methods: Twenty-five healthy volunteers were assigned to one of four groups (A, B, C, D). Group A had 2.5 g of 4% lidocaine topical anesthetic cream applied to the face for one hour without occlusion, Group B had 5 g applied to the face for one half-hour without occlusion, Group C had 5 g applied to the face for one hour without occlusion, and Group D had 5 g applied to the face for one hour with occlusion. To evaluate serum concentrations, blood was drawn every 30 minutes for four hours. Results: Group D showed the highest serum levels of lidocaine and MEGX, a three-fold increase compared with group C, which received the same dose (5g topical 4% lidocaine) but without occlusion. In group D, peak serum levels occurred at 90 minutes for serum lidocaine, which was also the fastest of the four groups. Serum MEGX levels peaked much later than serum lidocaine levels, at 210 minutes. Individual serum levels did not exceed 0.6 µg/mL. Across the groups, there was significant interindividual variation in both lidocaine and MEGX serum levels ( P = .061). Applications of 5 g of 4% lidocaine resulted in higher serum concentration of both lidocaine and MEGX. When comparing group A to group C, doubling the dose of 4% lidocaine from 2.5 g to 5 g resulted in double the serum levels of MEGX and a 50% increase in the serum lidocaine levels ( P = .021). When comparing groups C and D, the addition of an occlusive dressing resulted in a tripling of the serum lidocaine levels and a doubling of the serum MEGX levels, both of which were statistically significant ( P < .001). When comparing all four groups, there were significant differences between the combined serum concentrations of lidocaine and MEGX ( P < .001). Conclusions: Topical lidocaine preparations are increasingly being employed to provide a patient-friendly form of noninvasive analgesia for a multitude of procedures. Some preparations are available over the counter for unsupervised patient application. Our study has demonstrated significant interindividual variability for a given dose, especially when occlusion is applied. There have been fatalities resulting from topical lidocaine application, and our study suggests that this is the result of the unpredictability of lidocaine metabolism between individuals. Therefore, we recommend that caution be exercised with topical lidocaine preparations, in particular when applied in conjunction with occlusive dressings.

Injectable shaping agents include neurotoxins (botulinum toxin type A products), replacement fillers (hyaluronic acid [HA] agents), and biostimulatory fillers (calcium hydroxylapatite [CaHA], polymethylmethacrylate [PMMA], and poly-L-lactic acid [PLLA]). This article presents an overview of the agents currently available for use in facial rejuvenation in the United States.

Background: This is a report of the histopathological evaluation of the acute damage profile in human skin following treatment with two novel short-pulsed fractional carbon dioxide resurfacing devices used independently and in combination in vivo. Methods: The panni of eight abdominoplasty patients were treated with either the Active FX, the Deep FX (Lumenis Ltd., Yokneum, Israel), or a combination of the two (Total FX) prior to the start of the excisional surgical procedure. Multiple combinations of energies, pulse widths, and densities were evaluated for each device. After surgical removal (two to five hours), each pannus was immediately biopsied and samples were processed for histopathological evaluation. Results: The Active FX system resulted in extensive epidermal injury with wide shallow ablation craters that, at higher fluences, extended through the basement membrane of the epidermis into the papillary dermis. The Deep FX fractional treatment caused deep microcolumns of ablation penetrating up to 3 to 4 mm from the epidermal surface into the deep reticular dermis with a variable rim of coagulated collagen surrounding each ablation column. Conclusions: The in vivo histopathological evaluation of these devices furthers our understanding of the fundamental laser/tissue interaction following treatment with each device independently and in combination.