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Liposuction is the most common procedure in plastic surgery and becoming increasingly common in male patients. Recently, liposuction has evolved from a procedure whose goal was primarily fat extraction, to one that sculpts tissue with the goal of enhancing muscular definition. The popularity of high-definition liposuction has increased rapidly due to visibility on social media and has broadened the patient population presenting for liposuction, particularly among men. Herein, the authors review patient selection, surgical technique, and postoperative outcomes following high-definition liposuction in male patients.

Over the past decades, the understanding of the nuances of forehead anatomy and facial aging has grown immensely. Safe and reliable options for forehead rejuvenation followed. Although noninvasive techniques are an important adjunct in forehead rejuvenation, the mainstay of treatment of the eyebrow is operative intervention. The senior author's technique has developed over many years, first focusing on the open coronal and anterior hairline approach to the forehead lift, then the endoscopic brow lift, and most recently, the lateral subcutaneous temporal lift. This technique allows for reliable and safe elevation of the lateral brow with minimal complications.

OBJECTIVE The aim of the present systematic review and meta-analysis was to assess the clinical efficacy of regenerative periodontal surgery of intrabony defects using a combination of enamel matrix derivative (EMD) and bone graft compared with that of EMD alone. MATERIALS AND METHODS The Cochrane Oral Health Group specialist trials, MEDLINE, and EMBASE databases were searched for entries up to February 2014. The primary outcome was gain of clinical attachment (CAL). Weighted means and forest plots were calculated for CAL gain, probing depth (PD), and gingival recession (REC). RESULTS Twelve studies reporting on 434 patients and 548 intrabony defects were selected for the analysis. Mean CAL gain amounted to 3.76 ± 1.07 mm (median 3.63 95 % CI 3.51-3.75) following treatment with a combination of EMD and bone graft and to 3.32 ± 1.04 mm (median 3.40; 95 % CI 3.28-3.52) following treatment with EMD alone. Mean PD reduction measured 4.22 ± 1.20 mm (median 4.10; 95 % CI 3.96-4.24) at sites treated with EMD and bone graft and yielded 4.12 ± 1.07 mm (median 4.00; 95 % CI 3.88-4.12) at sites treated with EMD alone. Mean REC increase amounted to 0.76 ± 0.42 mm (median 0.63; 95 % CI 0.58-0.68) at sites treated with EMD and bone graft and to 0.91 ± 0.26 mm (median 0.90; 95 % CI 0.87-0.93) at sites treated with EMD alone. CONCLUSIONS Within their limits, the present results indicate that the combination of EMD and bone grafts may result in additional clinical improvements in terms of CAL gain and PD reduction compared with those obtained with EMD alone. The potential influence of the chosen graft material or of the surgical procedure (i.e., flap design) on the clinical outcomes is unclear. CLINICAL RELEVANCE The present findings support the use of EMD and bone grafts for the treatment of intrabony periodontal defects.

SUMMARY The American Society of Plastic Surgeons, the American Academy of Otolaryngology-Head and Neck Surgery, and the American Academy of Facial Plastic and Reconstructive Surgery commissioned the multidisciplinary Rhinoplasty Performance Measure Development Work Group to identify and draft quality measures for the care of patients undergoing both functional and aesthetic rhinoplasty. One outcome measure and three process measures were identified. The outcome looked at patient satisfaction with rhinoplasty procedures. The process measures look at motivations and expectations of the procedure, airway assessment, and nonnarcotic shared decision-making strategies for pain management. All measures in this report were approved by the American Society of Plastic Surgeons Quality and Performance Measures Work Group and Executive Committee, and the American Academy of Otolaryngology-Head and Neck Surgery Foundation, the American Academy of Facial Plastic and Reconstructive Surgery, The Rhinoplasty Society, and the American Association of Oral and Maxillofacial Surgeons. The Work Group recommends the use of these measures for quality initiatives, Continuing Medical Education, Maintenance of Certification, Qualified Clinical Data Registry reporting, and national quality reporting programs.

In 2000, Matarasso et al. performed a survey of American Society of Plastic Surgeons members' face lift practice patterns. Since that publication, the aesthetic marketplace has changed dramatically, as have ancillary face lift techniques. In an attempt to detail these changes, we repeated that original survey, adding questions to address more recent technical issues and advances. The goal of this report was to define current face lift practice patterns, compare current patterns to the previous ones, and define recent advances.A 38-question survey assessing face lift techniques, perioperative management, complications, and concomitant procedures was electronically distributed to a random cohort of American Society of Plastic Surgeons members. Data were recorded and statistically analyzed utilizing the Pearson chi-square test.A total of 251 forms were returned and analyzed. Details of demographics, face lift techniques, ancillary procedures, perioperative care, and complications are presented. Current results were compared to the previously published society member practice patterns delineated in the 2000 Plastic and Reconstructive Surgery publication.The basic approach of American Society of Plastic Surgeons members to the face lift operation has not changed dramatically over the past 20 years. The development of operative adjuncts, however, has been positive, including fat grafting techniques, concomitant use of skin resurfacing, and means of minimizing blood loss with tranexamic acid. In certain instances, respondents do not follow evidence-based guidelines for perioperative care. Finally, common complications of practicing members appear to coincide with published retrospective reviews.

Although body contouring has long been considered a female-dominated market, growing popularity among men has led to shifting market focus. The increase in male body contouring surgery has been fueled by increased recognition of its safety and efficacy, decreased stigma via social media awareness, and increasing desire among men who seek to remain competitive in the workforce. The growth of bariatric surgery has only compounded such trends, with a growing population of men seeking excisional procedures following massive weight loss. The authors review key features of the modern male abdominoplasty, with respect to anatomy, patient selection, surgical technique, and postoperative outcomes.

Growing evidence shows the contribution of physical activity interventions to the gut microbiome. However, specific physical activity characteristics that can modify the gut microbiome are unknown. This review’s aim was to explore the contribution of physical activity intervention characteristics on human gut microbiome composition, in terms of diversity, specific bacterial groups, and associated gut microbiome metabolites. A literature search in PubMed; Cochrane Library; CINAHL-EBSCO; SCOPUS; Web of Science; ClinicalTrials.gov; PROSPERO; and ProQuest. Five studies met the inclusion criteria of a physical activity intervention duration of at least five weeks, with any description of the type or dose used. All included studies reported an endurance training; two studies used endurance and an additional muscle-strengthening training regimen. All studies reported using a dietary intervention control. Reported gut microbiome α-diversity changes were non-significant, β-diversity changes were mixed (three studies reported an increase, two reported non-significant changes). All studies reported significant changes in the abundances of specific bacterial/archaea groups and bacteria-related metabolites following interventions. In conclusion, physical activity (regardless of specific characteristics) has significant contribution to gut microbiome composition and associated metabolites. There are no current recommendations for physical activity to promote gut microbiome composition. Future studies should focus on the contribution of current recommended physical activity dose to gut microbiome composition.

BACKGROUND/AIM: We present the case of a 19-year-old male patient diagnosed concomitantly with extensive thromboses (including two intra-cardiac masses and Budd-Chiari syndrome), as well as acute myeloid leukemia. This necessitated prompt deployment of a monitoring and treatment strategy which included twice-daily blood count assessment, multiple platelet transfusions and anti-coagulation therapy with dose-adjustment per blood count during both induction and consolidation chemotherapy. Multiple factors are believed to contribute to the development of thrombosis in acute leukemia such as diffuse intravascular coagulation, cytokine release and chemotherapy. CASE REPORT: Our patient presented early on in the COVID-19 pandemic, delaying his seeking out medical treatment and we suspect this to have contributed to his 'catastrophic' thrombotic presentation. Well-structured guidelines to help clinicians manage these patients are lacking, and most data are from retrospective analyses or case reports. Our patient continued full-dose anticoagulant therapy until successfully undergoing allogeneic stem cell transplant. The thrombi eventually diminished in size, and the patient was not diagnosed with any further thrombotic events. CONCLUSION: Our case highlights the feasibility of intensive monitoring and provision of platelet transfusion as necessary in order to safely administer low molecular weight heparin from the outset of chemotherapy.

Background Asymmetry of the hips and its implication in body contouring procedures has not yet been reported. Hip asymmetry is common in the general population and may account for uneven abdominoplasty scar and the apparent discrepancies in volume following liposuction of the hips and flanks. The goal of this study was to determine the presence of hip asymmetry in women presenting for abdominal contouring surgery. Methods Analysis of preoperative photographs of 100 female patients was performed by three independent plastic surgeons. They were asked to evaluate for hip asymmetry and, when present, determine which side was higher. Adobe Photoshop was also used to objectively measure hip asymmetry. Patients were women with no known history of hip abnormalities; age ranged from 17 to 64 years and the body mass index ranged from 16 to 47 kg/m(2). Results All three plastic surgeon reviewers found that the majority of patients had hip asymmetry, with raters 1, 2, and 3 documenting discrepancies in hip height in 88, 60, and 76 percent of patients, respectively. The interrater reliability was 0.713. Chi-square statistical analysis suggested that the raters were not statistically different from one another (p = 0.086). The objective analysis found asymmetry in 82 percent of patients. Conclusions The results showed that the majority of patients who present for abdominal contouring surgery have asymmetric hips. Patients are usually unaware of the unevenness of their own hips; however, they often notice postoperative discrepancies in scar height after abdominoplasty or volume differences after liposuction.

Objective In stroke survivors, a treatment-resistant problem is inability to volitionally differentiate upper limb wrist extension versus flexion. When one intends to extend the wrist, the opposite occurs, wrist flexion, rendering the limb non-functional. Conventional therapeutic approaches have had limited success in achieving functional recovery of patients with chronic and severe upper extremity impairments. Functional magnetic resonance imaging (fMRI) neurofeedback is an emerging strategy that has shown potential for stroke rehabilitation. There is a lack of information regarding unique blood-oxygenation-level dependent (BOLD) cortical activations uniquely controlling execution of wrist extension versus uniquely controlling wrist flexion. Therefore, a first step in providing accurate neural feedback and training to the stroke survivor is to determine the feasibility of classifying (or differentiating) brain activity uniquely associated with wrist extension from that of wrist flexion, first in healthy adults. Approach We studied brain signal of 10 healthy adults, who performed wrist extension and wrist flexion during fMRI data acquisition. We selected four types of analyses to study the feasibility of differentiating brain signal driving wrist extension versus wrist flexion, as follows: 1) general linear model (GLM) analysis; 2) support vector machine (SVM) classification; 3) ‘Winner Take All’; and 4) Relative Dominance. Results With these four methods and our data, we found that few voxels were uniquely active during either wrist extension or wrist flexion. SVM resulted in only minimal classification accuracies. There was no significant difference in activation magnitude between wrist extension versus flexion; however, clusters of voxels showed extension signal > flexion signal and other clusters vice versa. Spatial patterns of activation differed among subjects. Significance We encountered a number of obstacles to obtaining clear group results in healthy adults. These obstacles included the following: high variability across healthy adults in all measures studied; close proximity of uniquely active voxels to voxels that were common to both the extension and flexion movements; in general, higher magnitude of signal for the voxels common to both movements versus the magnitude of any given uniquely active voxel for one type of movement. Our results indicate that greater precision in imaging will be required to develop a truly effective method for differentiating wrist extension versus wrist flexion from fMRI data.

Objective Pilot testing of real time functional magnetic resonance imaging (rt-fMRI) and real time functional near infrared spectroscopy (rt-fNIRS) as brain computer interface (BCI) neural feedback systems combined with motor learning for motor recovery in chronic severely impaired stroke survivors. Approach We enrolled a four-case series and administered three sequential rt-fMRI and ten rt-fNIRS neural feedback sessions interleaved with motor learning sessions. Measures were: Arm Motor Assessment Tool, functional domain (AMAT-F; 13 complex functional tasks), Fugl-Meyer arm coordination scale (FM); active wrist extension range of motion (ROM); volume of activation (fMRI); and fNIRS HbO concentration. Performance during neural feedback was assessed, in part, using percent successful brain modulations during rt-fNIRS. Main results Pre-/post-treatment mean clinically significant improvement in AMAT-F (.49 ± 0.22) and FM (10.0 ± 3.3); active wrist ROM improvement ranged from 20° to 50°. Baseline to follow-up change in brain signal was as follows: fMRI volume of activation was reduced in almost all ROIs for three subjects, and for one subject there was an increase or no change; fNIRS HbO was within normal range, except for one subject who increased beyond normal at post-treatment. During rt-fNIRS neural feedback training, there was successful brain signal modulation (42%–78%). Significance Severely impaired stroke survivors successfully engaged in spatially focused BCI systems, rt-fMRI and rt-fNIRS, to clinically significantly improve motor function. At the least, equivalency in motor recovery was demonstrated with prior long-duration motor learning studies (without neural feedback), indicating that no loss of motor improvement resulted from substituting neural feedback sessions for motor learning sessions. Given that the current neural feedback protocol did not prevent the motor improvements observed in other long duration studies, even in the presence of fewer sessions of motor learning in the current work, the results support further study of neural feedback and its potential for recovery of motor function in stroke survivors. In future work, expanding the sophistication of either or both rt-fMRI and rt-fNIRS could hold the potential for further reducing the number of hours of training needed and/or the degree of recovery. ClinicalTrials.gov ID: NCT02856035.

The purpose of this study was to assess the healing of periodontal intrabony defects treated using enamel matrix derivative (EMD) after at least 5 years of follow-up. Six patients with seven intrabony defects were included in the study. Treatment with EMD yielded a mean clinical attachment level gain of 4.3 ± 2.4 mm, a mean probing depth reduction of 4.7 ± 2.1 mm, and a mean gingival recession increase of 0.7 ± 1.8 mm. Reentry measurements showed a complete resolution of the intrabony defect in five cases, while in two cases a residual intrabony component was recorded. The present study indicates that treatment using EMD provided good clinical outcomes maintained in most cases over a period of at least 5 years.

AIMS AND OBJECTIVES To elucidate the attitudes and knowledge of nursing home (NH) staff involved in the decision-making process surrounding tube feeding for people with advanced dementia, and regarding palliative care and eating difficulties in this population. BACKGROUND Dementia's final stage is associated with eating difficulties. "Comfort feeding" is the approach endorsed by the American Geriatrics Society for those with advanced dementia and eating difficulties. Despite this, tube feeding remains a persisting practice in NHs in Israel. DESIGN A qualitative descriptive study. METHODS Twenty-seven NH employees from different sectors employed by seven NHs in northern Israel underwent semi-structured, face-to-face interviews. The COREQ checklist was used to aid with reporting and analysis of results. RESULTS In Israel, there is an emerging palliative care discourse in caring for people with advanced dementia living in the NH setting. However, many interviewed did not demonstrate an accurate understanding of this term or of the term "comfort feeding." Several barriers towards implementation of palliative care were identified and include a lack of formal education regarding nutrition in advanced dementia, socio-economic factors and their association with the two types of NHs operating in Israel (those with exclusively private funding and those reimbursed by the Ministry of Health). CONCLUSIONS Interviews with NH staff regarding eating difficulties in advanced dementia shed light on the palliative care discourse, which is in a liminal stage in many countries. The themes that emerged may help inform future recommendations regarding palliative care in general and more specifically in NH residents with advanced dementia, in countries where policy is still being developed and refined. RELEVANCE TO CLINICAL PRACTICE Understanding barriers towards implementation of a palliative approach and comfort feeding specifically could improve the care for people with advanced dementia in the NH setting.

Background Facial rejuvenation continues to be an increasing trend among males. The periorbital region deserves special mention given the overall differences in aesthetics between sexes. Objective To examine the aesthetics of the upper eyelid, lower eyelid, lateral canthus, and brow with respect to male periorbital rejuvenation. Methods The upper eyelid, lower eyelid, lateral canthus, and brow are examined, highlighting aesthetic differences in males and females. Results The authors outline principles so as to maintain a masculine appearance when treating the male upper eyelid, lower eyelid, lateral canthus, and brow. Conclusion With guiding principles, the male upper lid, lower lid, brow, and lateral canthus can be managed to achieve optimal, consistent results.

The use of tobacco-based products, most notably cigarettes, is related directly to wound healing problems and poorer outcomes in plastic surgery. Current abstracts have highlighted the potential complications from nicotine, specifically following plastic surgery in patients who choose to smoke. Recently, products that use electricity to vaporize liquid nitrogen have been gaining popularity. New rules were recently proposed that would give the federal government authority over electronic cigarettes. However, the health-related issues surrounding e-cigarettes are still largely unknown or misunderstood. These issues also extend to their impact on surgical procedures, notably their effect on plastic surgical procedures that rely heavily on the vascularity of either the host wound bed or the replacement tissue.

Background After stroke, wrist extension dyscoordination precludes functional arm/hand. We developed a more spatially precise brain signal for use in brain computer interface (BCI's) for stroke survivors. New method Combination BCI protocol of real-time functional magnetic resonance imaging (rt-fMRI) sequentially followed by functional near infrared spectroscopy (rt-fNIRS) neurofeedback, interleaved with motor learning sessions without neural feedback. Custom Matlab and Python code was developed to provide rt-fNIRS-based feedback to the chronic stroke survivor, system user. Results The user achieved a maximum of 71 % brain signal accuracy during rt-fNIRS neural training; progressive focus of brain activation across rt-fMRI neural training; increasing trend of brain signal amplitude during wrist extension across rt-fNIRS training; and clinically significant recovery of arm coordination and active wrist extension. Comparison with existing methods Neurorehabilitation, peripherally directed, shows limited efficacy, as do EEG-based BCIs, for motor recovery of moderate/severely impaired stroke survivors. EEG-based BCIs are based on electrophysiological signal; whereas, rt-fMRI and rt-fNIRS are based on neurovascular signal. Conclusion The system functioned well during user testing. Methods are detailed for others' use. The system user successfully engaged rt-fMRI and rt-fNIRS neurofeedback systems, modulated brain signal during rt-fMRI and rt-fNIRS training, according to volume of brain activation and intensity of signal, respectively, and clinically significantly improved limb coordination and active wrist extension. fNIRS use in this case demonstrates a feasible/practical BCI system for further study with regard to use in chronic stroke rehab, and fMRI worked in concept, but cost and some patient-use issues make it less feasible for clinical practice.

Patients with prior umbilical stalk detachment, secondary to limited abdominoplasty or prior umbilical hernia repair, may in the future be candidates for full abdominoplasty. In these patients, a circumferential incision around the umbilicus detaches the remaining cutaneous blood supply, prompting concern for umbilical viability. Minimal literature exists to guide clinical decision-making for these patients. Inquiries were made to Louisiana Society of Plastic Surgery members and the Plastic Surgery Education Network online forum of the American Society of Plastic Surgeons. Metrics obtained included patient age, sex, nature of primary surgery, time between umbilical stalk detachment and secondary full abdominoplasty, complications, and whether rectus plication was performed at the time of secondary surgery. Eleven physicians provided complete documentation for 18 cases. All patients healed without evidence of umbilical ischemia or necrosis. Average patient age was 40.6 years. Average interval between procedures was 3.6 years. Sixty-seven percent of patients had the umbilicus delayed before the secondary procedure, with the median delay time being 18 days. Rectus fascia was plicated during secondary surgery in 72 percent of patients. This is the first reported series of patients undergoing full abdominoplasty after prior umbilical stalk detachment. It is also the first time the Plastic Surgery Education Network online forum has been used to collect research data, highlighting its potential as a valuable research tool. The data set was obtained from a wide range of practices, which allows for consideration of various technical solutions when this or other diverse clinical scenarios are encountered. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.

Minimally invasive procedures in an aesthetic practice have grown over the past decade. Plastic surgery practices are embracing the incorporation of injectables and lasers as adjuncts to their surgical procedures. The use of botulinum toxin, hyaluronic acid fillers, and lasers has made a significant impact on the authors' practice. The authors describe the important considerations, consultation goals, and procedural steps with injectables and fillers. The novel use of deoxycholic acid injections is also described. The authors strongly think that as options continue to expand, plastic surgeons will benefit from taking an active role in adopting these new innovations.

The present study evaluated the association between oxidative parameters in embryo cryopreservation medium and laboratory and clinical outcomes. This prospective laboratory study was conducted in an IVF unit in a university-affiliated hospital with 91 IVF patients undergoing a frozen-thawed embryo transfer cycle. Following thawing, 50 μL of embryo cryopreservation medium was retrieved from each cryotube and tested by the thermochemiluminescence (TCL) assay. TCL amplitudes after 50 (H1), 150 (H2), and 280 s (H3) were recorded in counts per second (CPS) and the TCL ratio determined for comparison with implantation and pregnancy rates. A total of 194 embryos were transferred in 85 frozen-thaw cycles. Twenty-one pregnancies (24.7 %) occurred. Implantation and overall and clinical pregnancy rates were higher when the median TCL H1 amplitude was

AIM To assess the clinical and radiographic outcomes applying a combined resective and regenerative approach in the treatment of peri-implantitis. MATERIALS AND METHODS Subjects with implants diagnosed with peri-implantitis (i.e., pocket probing depth (PPD) ≥5 mm with concomitant bleeding on probing (BoP) and ≥2 mm of marginal bone loss or exposure of ≥1 implant thread) were treated by means of a combined approach including the application of a deproteinized bovine bone mineral and a collagen membrane in the intrabony and implantoplasty in the suprabony component of the peri-implant lesion, respectively. The soft tissues were apically repositioned allowing for a non-submerged healing. Clinical and radiographic parameters were evaluated at baseline and 12 months after treatment. RESULTS Eleven subjects with 11 implants were treated and completed the 12-month follow-up. No implant was lost yielding a 100% survival rate. At baseline, the mean PPD and mean clinical attachment level (CAL) were 8.1 ± 1.8 mm and 9.7 ± 2.5 mm, respectively. After 1 year, a mean PPD of 4.0 ± 1.3 mm and a mean CAL of 6.7 ± 2.5 mm were assessed. The differences between the baseline and the follow-up examinations were statistically significant (P = 0.001). The mucosal recession increased from 1.7 ± 1.5 at baseline to 3.0 ± 1.8 mm at the 12-month follow-up (P = 0.003). The mean% of sites with BoP+ around the selected implants decreased from 19.7 ± 40.1 at baseline to 6.1 ± 24.0 after 12 months (P = 0.032). The radiographic marginal bone level decreased from 8.0 ± 3.7 mm at baseline to 5.2 ± 2.2 mm at the 12-month follow-up (P = 0.000001). The radiographic fill of the intrabony component of the defect amounted to 93.3 ± 13.0%. CONCLUSION Within the limits of this study, a combined regenerative and resective approach for the treatment of peri-implant defects yielded positive outcomes in terms of PPD reduction and radiographic defect fill after 12 months.

UNLABELLED Statistics reflect that pregnancies are occurring at a later age, multiple births are becoming more common, and a sizeable population--with a keen interest in nutrition, fitness, and a continued desire to retain a youthful figure--is aging. Consequently, postpartum reshaping is a priority for many women, enough so that the phrase "mommy makeover" has entered the vernacular. In this article, the senior author's practice was evaluated to explore patient goals, methods, and outcomes in reshaping the postpartum abdomen. A literature review was conducted to assess the state of the art in methods to meet these goals. The postpartum patient often uses her prepregnancy appearance as a barometer for her postpregnancy goals. Although aging is one force motivating women to pursue abdominoplasty, the majority desires the correction of changes related to pregnancy. The abdomen and breasts are the regions most visibly affected by pregnancy, although numerous aesthetic units of the trunk and surrounding regions concern patients seeking postpartum body contouring and they may be part of the patient's perception and idealization of her appearance. Abdominoplasty is central to postpartum body contouring, and numerous strategies such as concurrent flap, flank, or mons pubis liposuction and waistline enhancement methods are integral components of it. Consideration should also be given to the multiple body areas affected by pregnancy that may enhance the patient's overall appearance. In the appropriate context, multiple procedures can be safely and effectively combined to address the various regions affected by postpartum changes. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.

Abdominoplasty and breast surgery are frequently appealing to patients as combined procedures. The practice of combining abdominoplasty with other procedures originates from abdominoplasty performed in conjunction with intraabdominal or gynecologic surgery. Initially, the focus of combined surgery was on ensuring safety and minimizing local (e.g., wound healing) complications. As surgeons began combining abdominoplasty with distant procedures such as breast surgery, because the individual procedures have little adverse impact on one another and are not altered because of the combination, concerns with systemic morbidity surpassed the initial focus on avoiding local complications. Prevention of venous thromboembolism became a paramount concern. The authors perform abdominoplasty in conjunction with other procedures more frequently than in isolation, reflecting broader societal demand. Indeed, because of the effects of pregnancy and aging, abdominoplasty is being performed in conjunction with breast surgery with frequency sufficient to have driven the term "mommy makeover" into mainstream parlance. Consideration regarding length of surgery and the other recommendations in this report allows for the safe and successful execution of this common combination.

BACKGROUND Surgeon observation suggested that mastopexy alone resulted in decreased cup size. The purpose of this investigation was to assess change in cup size in women undergoing mastopexy alone. METHODS A retrospective review of a single surgeon's experience from February of 2002 to May of 2011 was completed. Patients underwent mastopexy alone (specimen weight

Barbed sutures first received US Food and Drug Administration approval for soft tissue approximation in 2005 and early adopters readily embraced this device to develop new techniques. It has become apparent that the advantages are more than just "skin deep." Superficial and deep fascia, cartilage, tendon, joint capsule, and fibrous periprosthetic capsules can also be manipulated. Barbed sutures have revolutionized our approach to facial rejuvenation and body contouring by enhancing our ability to quilt and powerfully lift tissue. The elimination of surgical drains and shorter surgical times has made this a true boon for plastic surgeons as well as many other surgical specialists. This article summarizes some of the current and evolving applications of this exciting new tool.

The authors present their minimally invasive gluteopexy technique, using polypropylene 2-0 sutures with 10 absorbable polylactic cones in their distal section (Silhouette Lift, Irvine, California) to improve the anteroposterior projection of the gluteal region. Histological study of the reaction of adipose tissue surrounding the cones previously has shown that, 3 months after insertion of the sutures, fibrous scar tissue is sufficiently developed to resist the weight of the tissues. On the basis of this finding, the authors decided to perform the gluteopexy with sutures, in 2 surgical steps. During the first step, the sutures are inserted in the adipose tissue without any proximal fixation. In the second step, performed 3 months after the first procedure when the fibrous reaction is more solid, the sutures are tightened to obtain the gluteopexy. Among the advantages of this technique are its simplicity, the fact that it produces no traumatic effects, and the fact that it can be performed with local anesthetic, reducing surgical time. It is also possible to combine this procedure with lipofilling or liposuction techniques.

The evolution of barbed suture technologies and their application in the field of plastic surgery is now in its third decade. Much has been learned along the way. Initial excitement was often followed by disappointment as we learned more about the limited longevity of minimally invasive procedures and complications arising from various suture designs of the past. Some of the early designs, developed primarily for use in aesthetic facial procedures, included free-floating, bidirectionally barbed, nonabsorbable sutures; unidirectional barbed, nonabsorbable sutures; anchored, bidirectional, nonabsorbable double-threaded sutures; and a technology combining a nonabsorbable knotted thread and absorbable cones. More recently, a new, absorbable, unidirectional barbed suture design has become available. However, it should be noted that very limited data are available for any of the modified suture designs used in this field, and much of what has been published is based on the experience of a single user. The author has used the bidirectionally barbed Quill Knotless Tissue-Closure Device (Angiotech Pharmaceuticals, Inc, Vancouver, British Columbia, Canada), the most common barbed suture in both facial and other aesthetic plastic surgery procedures, with considerable success in various open aesthetic facial procedures, including suspension of the brow and midface, platysmaplasty, and lateral neck suspension. It is the author's experience that completion of 1 to 2 cases with this technology is sufficient to achieve competency in the closure techniques discussed in this article and that time savings can be realized using this device in various breast and body contouring procedures, including mastopexy, reduction mammoplasty, abdominoplasty, bodylift, and brachioplasty.

Examination of abdominal contour surgery candidates permits categorization of patients (the abdominolipoplasty system of classification and treatment) according to their treatable soft tissue layers of skin, fat, and muscle into the appropriate treatment level. Typically, postpartum abdominal wall changes are most thoroughly addressed by abdominoplasty. The indications and goals for abdominoplasty with liposuction (lipoadminoplasty) or without liposuction are presented. Surgical markings, technique, pain management, and postoperative care are described.

The use of neuromodulators for therapeutic and cosmetic indications has proven to be remarkably safe. While aesthetic and functional adverse events are uncommon, each anatomic region has its own set of risks of which the physician and patient must be aware before treatment. The therapeutic usages of botulinum toxins now include multiple specialties and multiple indications. New aesthetic indications have also developed, and there has been an increased utilization of combination therapies to combat the effects of global aging. In the second article in this continuing medical education series, we review the prevention and treatment of adverse events, therapeutic and novel aesthetic indications, controversies, and a brief overview of combination therapies.

Botulinum toxin is a potentially deadly anaerobic bacterial toxin that acts by inhibiting release of acetylcholine at the neuromuscular junction, thereby inhibiting contraction of the exposed striated muscle. There are currently 4 botulinum toxin preparations approved by the US Food and Drug Administration (FDA): onabotulinumtoxin, abobotulinumtoxin, incobotulinumtoxin and rimabotulinumtoxin. While significant overlap exists, each product has unique properties and specifications, including dosing, diffusion, and storage. Extensive physician knowledge of facial anatomy, coupled with key differences of the various neurotoxin types, is essential for safe and successful treatments. The first article in this continuing medical education series reviews key characteristics of each neurotoxin, including new and upcoming agents, and provides an anatomic overview of the most commonly injected cosmetic sites.

In the industrialized part of the world, an increasing number of people live the old age without too many restrictions due to illness or physiological impairment. This group is known asthe young elderly. On the contrary, a consistent part of seniors develops a greater number of medical conditions and become more and more dependent, these arethe old elderly. The first cause of tooth lost in industrialized word is periodontitis that generally strikes people older than 40 years and determines serious detriment of the stomatognatic organ. Smoking and stress are risk factors for periodontitis that are common and shared between young, adult, and older age. Diabetes mellitus, obesity, and osteoporosis are very frequent pathological situations in older age. They have been identified as cofactors in the progression of periodontitis. Many dental associations recognize the importance of continued research on oral fluids diagnostics and welcome the development of rapid point-of-care tests providing accurate measurements of clinically validated biomarkers. At present, well-studied molecules associated with host response factors and with derived tissue destruction mediators have been proposed as diagnostic biomarkers for periodontitis detected in the oral fluids.

BACKGROUND: Nikolsky's sign is a clinical sign which is elicited by a horizontal, tangential pressure to the mucosa and/or skin resulting in blisters extending and separating or peeling away. Few data are currently available in the literature about its usefulness, specificity, and sensitivity in the diagnosis of either oropharyngeal or cutaneous bullous diseases. The purpose of this study was to determine the sensitivity and specificity of the gingival Nikolsky's sign in the identification of an autoimmune blistering disease. METHODS: Over a period of 13 years, we recruited 566 patients with autoimmune oral bullous and non-bullous diseases who possessed either maxillary or mandibular gingival mucosal lesions. All patients were subjected to a test causing a gingival Nikolsky's sign at their first visit during the diagnostic algorithm and in the active disease phase before commencing treatment. RESULTS: A total of 566 patients (184 with and 382 without bullous lesions) had at least gingival involvement. A positive gingival Nikolsky's sign resulted in 100 (17.7%) of 566 patients: 86 patients with bullous lesions (53 with pemphigus vulgaris, eight with mucous membrane pemphigoid, 22 with bullous/mixed lichenoid lesions, and three with erythema multiforme) and 14 with non-bullous lesions (12 with non-bullous lichenoid lesions and two with systemic lupus erythematous/mixed connective tissue disease). Thus, the specificity of Nikolsky's sign was higher (96.3%) than the sensitivity (46.7%). CONCLUSION: The results of this study support the use of Nikolsky's sign of the gingival mucosa as a viable test to establish the presence of oral bullous diseases.

The introduction of liposuction in the 1980s permanently altered the landscape of body contour surgery. The abdomen became a ''group'' of contour procedures that were referred to as the abdominolipoplasty system of classification and treatment (Types I-IV). This article describes a full (Type IV) abdominoplasty with or without liposuction is performed. When extensive abdominal liposuction is performed in conjunction with a full abdominoplasty, it is also known as lipoabdominoplasty. The article also describes 10 "special situations" in the abdominoplasty population.

The key points to remember about abobotulinumtoxinA are as follows: BoNTA-ABO (abobotulinumtoxinA [Dysport]; Medicis Aesthetics, Scottsdale, AZ) and BoNTA-ONA (onabotulinumtoxin A [Botox Cosmetic]; Allergan, Irvine, CA) are both derivatives of botulinum toxin A produced from different strains of the bacterium Clostridium botulinum through proprietary manufacturing processes, and both are approved by the US Food and Drug Administration (FDA). BoNTA-ABO and BoNTA-ONA, which are both type A botulinum toxins, should be further differentiated from Myobloc (Solstice Neurosciences, San Francisco, CA), which is the only FDA-approved type B botulinum toxin. BoNTA-ABO, as with other derivatives of botulinum toxin, produces a chemodenervation of the muscle by preventing the release and binding of acetylcholine at the neuromuscular endplate. The paralytic effect of BoNTA-ABO, as with other derivatives of botulinum toxin, produces a relaxation of the underlying muscle with the associated benefit of reducing dynamic rhytids of the overlying skin. BoNTA-ABO units are not interchangeable with BoNTA-ONA units. An understanding of the proper dosing and familiarity with the use of either botulinum toxin in aesthetic applications is required to produce results that are both safe and consistent. Spread of the toxin is dependent on solution volume and injection technique (physically pushing the toxin from the area of injection). Diffusion of the toxin is largely dependent on toxin dose and receptor concentration; unbound toxin moves down a concentration gradient. Beyond the treatment of glabellar rhytids, there are few, if any, randomized, double blind, placebo-controlled studies on the aesthetic uses of BoNTA-ABO. This guide summarizes what is known and serves as a basis for clinical use and continued understanding.

The first part of this article familiarizes the reader with the evolution of mesotherapy, injection lipolysis, and the use of phosphatidylcholine and deoxycholate for subcutaneous fat reduction. There is an emphasis on the underlying basic science of fat metabolism and the biochemistry of phosphatidylcholine, so that practitioners will be able to understand future published research on these topics. The second half details some personal experience with injection lipolysis.

Patients requesting abdominoplasty often have concomitant umbilical hernias and may request simultaneous treatment. The vascularity of the umbilicus is potentially at risk during these combined procedures. In this study, the authors present a technique for treating umbilical hernias at the time of abdominoplasty surgery using the Ventralex hernia patch.A total of 11 female patients with a mean age of 39.4 years (range, 28 to 51 years) undergoing abdominoplasty with umbilical hernia repair with the Ventralex patch were included.The mean body mass index was 27.6 kg/m (range, 20 to 34 kg/m). No vascular compromise of the umbilicus was seen. The hernia repair did not alter the abdominoplasty results. One patient had transient umbilical swelling postoperatively that resolved within 6 months postoperatively.The authors present a series of umbilical hernia repairs in abdominoplasty patients using a minimal access incision by means of the rectus fascia and the Ventralex patch that is fast and reliable and preserves the blood supply to the umbilicus.

There is increasing evidence that an involuntary hospital admission and treatment can undermine the therapeutic relationship. While good relationships with staff are important factors influencing long-term recovery, there is little information on how people experience their relationships with staff while under an involuntary treatment order (ITO). Twenty-five involuntary inpatients were interviewed about their experiences of an ITO. The interviews were analysed by a general inductive approach. Participants described the following themes: (i) the ITO admission was a daunting and frightening experience; (ii) staff behaviours and attitudes shaped their experiences in hospital; (iii) importance of staff listening to their concerns; (iv) importance of having a space to make sense of their experiences; (v) importance of staff ability to look beyond their illness and diagnosis; and (vi) importance of staff working in partnership. These findings highlight that when using recovery principles, such as an empathic engagement with the patients' lived experience, forging partnerships with patients in treatment decision-making to enhance agency, an involuntary treatment order does not have to limit the ability to establish positive relationships.

Soft tissue augmentation has become a cornerstone of facial rejuvenation. The bovine collagens were historically considered the "gold standard" as they had an extensive safety history and were effective. However, because of their brief duration and the approximate 1.0% to 3.0% incidence of hypersensitivity, alternatives were sought. A new class of agents, the hyaluronans, was recently granted approval by the Food and Drug Administration. The hyaluronans are indicated for injection into the mid to deep dermis for correction of moderate to severe facial wrinkles and folds (eg, the nasolabial folds). The hyaluronans have two derivations: nonanimal stabilized hyaluronic acid (NASHA) and an additional formulation of avian origin. Both are considered major advancements as they are not species specific and therefore theoretically do not elicit humoral or cell-mediated immune reactions. To date there have been a few reports of allergic reactions to the NASHA hyaluronans, primarily to Restylane. We report what to our knowledge is the first hypersensitivity reaction to the second brand of NASHA, Captique.

BACKGROUND MSR1, PTEN, and KLF6 have been implicated as candidate susceptibility genes for prostate tumorigenesis. METHODS Three hundred Jewish prostate cancer patients were screened for alterations in these genes. RESULTS MSR1 was conserved in all patients. PTEN screening revealed a novel missense mutation and a silent change. Five KLF6 alterations were detected in 17 patients, including Q160X, the only nonsense KLF6 germline mutation described to date in a cancer patient. The KLF6 IVS1-27G>A polymorphism, recently associated with prostate cancer risk, was detected in 11.9% of the patients and 17.3% of the controls (P = 0.043). IVS1-27A allele frequency was significantly lower in prostate cancer patients (P = 0.030), specifically in Ashkenazi patients (P = 0.047) compared to controls. CONCLUSIONS We found no evidence that MSR1 and PTEN germline mutations are associated with prostate cancer risk in Jews. The negative association between KLF6 IVS1-27A and prostate cancer risk supports a population-specific effect of susceptibility alleles in prostate tumorigenesis. Prostate 66: 1052–1060, 2006. © 2006 Wiley-Liss, Inc.

Epidemiologic and genetic studies support the considerable effect of heritable factors on prostate tumorigenesis, although to date, no unequivocal susceptibility gene has been identified. The extensive study of RNASEL in prostate cancer patients worldwide has yielded conflicting results. We reevaluated the role of the RNASEL 471delAAAG Ashkenazi founder mutation in 1,642 Ashkenazi patients with prostate, bladder, breast/ovarian, and colon cancers; Ashkenazi controls; and in non-Ashkenazi prostate cancer patients and controls. The entire RNASEL coding sequence was also screened using denaturing high-performance liquid chromatography and multiplex ligation–dependent probe amplification for possible sequence variations or copy number changes in a population of prostate cancer patients. The 471delAAAG mutation was detected in 2.4% of the Ashkenazi prostate cancer patients; in 1.9% of patients with bladder, breast/ovarian, and colon cancers; and in 2.0% of the Ashkenazi controls. Seven additional variants were detected in RNASEL, including a novel potentially pathogenic splice site mutation, IVS5+1delG, although none were associated with increased prostate cancer risk. Multiplex ligation–dependent probe amplification analysis showed two RNASEL gene copies in all 300 prostate cancer patients tested. We estimated that the RNASEL 471delAAAG founder mutation, which was detected in 2% of the Ashkenazi Jews, originated between the 2nd and 5th centuries A.D., compared with the less frequent (1%) BRCA1 185delAG founder mutation, which originated hundreds of years earlier. Taken together, our analysis does not support a role for the RNASEL 471delAAAG Ashkenazi mutation nor for the other alterations detected in RNASEL in prostate cancer risk in Jewish men. (Cancer Epidemiol Biomarkers Prev 2006;15(3):474–9)

The American Society for Aesthetic Plastic Surgery recently reported that there were nearly 12 million cosmetic procedures (2.1 million surgical and 9.7 million nonsurgical) performed in the United States in 2004. Almost 900,000 of the nonsurgical procedures were soft-tissue augmentation procedures using hyaluronic acid fillers. Restylane (Medicis Aesthetics, Inc., Scottsdale, Ariz.), nonanimal stabilized hyaluronic acid, was approved for use in the United States in December of 2003. Although the use of all fillers increased from 2003 to 2004, use of hyaluronic acid fillers increased nearly 700 percent. The dramatic increase in all cosmetic procedures reflects the growing trend, especially with increasing job competition, to maintain a youthful lifestyle and appearance. Basic recommendations for aesthetic use of Restylane were established based on short- and long-term efficacy and safety studies (Medicis Aesthetics, package insert). With the widespread and growing use of Restylane, a cross-sectional panel of experts with extensive clinical experience, including cosmetic dermatologists and surgical specialists (cosmetic, plastic, and ocular), convened to develop consensus guidelines for the use of Restylane. This supplement reviews the aesthetic affects of aging on the face, the role of fillers in facial soft-tissue volume replacement, and general principles for the use of Restylane, including patient comfort and assessment techniques. Specific recommendations for Restylane use in each potential target area, including type of anesthesia, injection techniques, volume for injection, use in combination with other procedures, and expected longevity of corrections, are provided. Techniques for optimizing patient outcomes and satisfaction and for minimizing and managing expected problems and potential complications are described.

Nuvaring (Organon Kenilworth NJ) is a vaginal contraception ring inserted by the patient. It was approved by the Food and Drug Administration in 2001 for the prevention of pregnancy. The intent of this paper is to increase the awareness of Nuvaring among plastic surgeons and to explore the risks associated with its use. We report the cases of two cosmetic surgery patients. These patients developed deep venous thrombosis and pulmonary emboli in the postoperative period while using Nuvaring. The very advantages of the Nuvaring-the ease of use the avoidance of daily administration and the insertion and removal of the device by the patient-may lead to the failure of patients to recollect being on a vaginal ring for contraception. LEVEL OF EVIDENCE: 4 Risk. (c) 2015 The American Society for Aesthetic Plastic Surgery Inc. Reprints and permission: journals.permissions@oup.com.