Search

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

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 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 and objective Patient-reported outcomes and blinded observer rating scales are subjective and unreliable but are extensively utilized to evaluate cosmetic office-based treatments, including ablative lasers. This study aims to assess the practicality of using non-invasive and minimally invasive methods for objective skin assessment following a skin rejuvenation treatment. Study design/materials and methods Twelve patients received a single 1,470/2,940 nm laser treatment for facial rejuvenation. Assessments were performed before treatment, and 7 days, 3 weeks, and 3 months post-treatment. Images were taken with the VISIA Skin Analysis System to measure wrinkles, textures, pores, ultraviolet (UV) spots, brown spots, red areas, and porphyrins. Other non-invasive skin measurements-high-resolution ultrasonography, optical coherence tomography, transepidermal water loss and BTC 2000-were used to measure epidermal/dermal thickness, blood flow, surface roughness, wrinkle depth, attenuation coefficient, elasticity, laxity, and viscoelasticity. Microbiopsies (0.33 mm in diameter or the equivalent of a 23-gauge needle) were collected for histology and gene expression of tissue rejuvenation. Results Significant improvement in facial skin aesthetics after laser treatment was recorded in UV spots, brown spots and pores after 3 weeks and in UV spots and brown spots after 3 months. The dermal attenuation coefficient decreased significantly at 3 weeks, while blood flow 0.5 to 0.7 mm below the skin surface increased significantly between 5 days and 3 weeks following treatment. Epidermal hyaluronic acid expression assessed by immunostaining and expression of inflammatory genes were elevated at 7 days post-treatment compared with untreated or 3 months post-treatment. There were no statistically significant changes in collagen or elastin-related genes between groups at the studied parameters. Conclusion Non-invasive devices can be effectively used to provide objective measurements of skin structure, pigmentation, blood flow, and elasticity to assess the efficacy of facial skin rejuvenation treatments. Furthermore, microbiopsies can objectively evaluate facial skin rejuvenation without scarring. Using non-invasive skin imaging, a single treatment with the 1,470/2,940 nm laser was observed to be effective in improving skin appearance after 3 months, namely in reducing UV spots and brown spots, without significant changes in the tissue at the molecular level, as assessed by microbiopsy. Lasers Surg. © 2020 Wiley Periodicals, Inc.

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.

Background There has been an increase in body contouring procedures following massive weight loss (MWL), including male breast reduction procedures. Treating male chest deformity after MWL using standard mastopexy techniques often leads to suboptimal results. Objectives The authors describe a technique to treat pseudogynecomastia using a modified elliptical excision and nipple-areola complex (NAC) transposition on a thinned inferior dermal pedicle as an alternative to conventional techniques. Methods A retrospective chart review from January 2011 to January 2019 identified a total of 14 male patients who underwent excision of pseudogynecomastia using the described technique. Results Patients were characterized by age, method of weight loss, pre-weight loss body mass index (BMI), post-weight loss BMI, total weight loss, grade of pseudogynecomastia, and concurrent procedures performed. Patients were followed for a period ranging from 3 months to 1.5 years (average, 8.1 months). Pre-weight loss BMI and post-weight loss BMI averaged 52.0 kg/m2 and 29.6 kg/m2, respectively. The average weight lost was 79.72 kg and the average total amount of tissue removed was 2615 g. All patients had concurrent procedures with an average operative time of 274 minutes. Four out of 14 patients (28.6%) experienced minor complications, which included asymmetry, delayed wound healing, seroma, and hyperpigmentation. There were no wound infections, hematomas, flap necrosis, or dysesthesia. Conclusions Due to several cosmetic advantages and low complication profile, our technique using a modified elliptical excision and NAC transfer on an inferior dermal pedicle is an attractive option for treating male chest deformity after MWL. Level of Evidence: 4

Background As the number of patients requiring bariatric surgery has increased, so has the demand for body contouring after massive weight loss. Surgery involving the abdomen in these patients is particularly challenging as both vertical and horizontal laxity if often present, making traditional abdominoplasty techniques less effective. Objectives The aim of this study was to review the operative technique and evaluate the preoperative comorbidities and operative decisions that may impact patient outcomes in those undergoing vertical abdominoplasty. Methods A review of the authors’ technique is described. A retrospective chart review of patients who underwent vertical abdominoplasty for significant vertical and horizontal laxity after massive weight loss by a single surgeon between June 2007 and July 2019 was performed. Preoperative parameters, operative factors, and minor and major complications were evaluated. Results Our complication rate was 81% (13/16), which were all minor. No major complications were encountered. Patients with a history of nicotine use had a 100% complication rate. There was a trend toward higher seroma formation in patients with coronary artery disease and those with a history of smoking. There was also a trend toward higher wound dehiscence in patients with renal disease. The authors found no statistically significant correlation between complications and older age, higher weight of tissue resected, higher body mass index, and medical comorbidities. Conclusions This small series helps to elucidate the role of vertical abdominoplasty in the care of patients following massive weight loss and its associated morbidity. Proper patient selection, appropriate preoperative patient counseling, and sound surgical technique help to mitigate the negative outcomes. Level of Evidence: 4

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.

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.

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.

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: Little evidence within plastic surgery literature supports the precept that longer operative times lead to greater morbidity. Objective: The authors investigate surgery duration as a determinant of morbidity, with the goal of defining a clinically relevant time for increased risk. Methods: A retrospective chart review was conducted of patients who underwent a broad range of complex plastic surgical procedures (n = 1801 procedures) at UT Southwestern Medical Center in Dallas, Texas, from January 1, 2008 to January 31, 2012. Adjusting for possible confounders, multivariate logistic regression assessed surgery duration as an independent predictor of morbidity. To define a cutoff for increased risk, incidence of complications was compared among quintiles of surgery duration. Stratification by type of surgery controlled for procedural complexity. Results: A total of 1753 cases were included in multivariate analyses with an overall complication rate of 27.8%. Most operations were combined (75.8%), averaging 4.9 concurrent procedures. Each hour increase in surgery duration was associated with a 21% rise in odds of morbidity ( P < .0001). Compared with the first quintile of operative time (

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.

Background: Injectable forms of anesthesia for nonsurgical facial rejuvenation, although efficacious, are uncomfortable for the patient. Preclinical studies have demonstrated that laser pretreatment at low energies enhances absorption of topical lidocaine. Objectives: The authors assess the safety and efficacy of laser-assisted transdermal delivery of topical anesthetic. Method: Ten patients were split into 2 groups (A and B). All patients received 15 g of BLT (20% benzocaine, 6% lidocaine, and 4% tetracaine triple anesthetic cream) for 20 minutes with no occlusion. Then the cream was removed and the first blood draw taken. Group A patients were pretreated with the full ablative laser and group B patients with a fractional ablative laser to the full face. A further 15 g BLT was applied for another 20 minutes. Group A patients then underwent full ablative laser treatment, and group B received fractionated ablative laser treatment. Blood draws were taken at 60, 90, 120, 180, and 240 minutes after the initial topical anesthetic application, and the serum was analyzed for lidocaine and monoethylglycinexylidide (MEGX) levels. Patients were asked to rate the pain felt at intervals during the procedure. Results: No patient required supplemental nerve blocks. Pain scores were equivalent at the end of the first pass for both groups ( P = .436). Group A patients had significantly lower pain scores at the start of the second laser treatment ( P = .045), but pain scores became equivalent by the end ( P = .323). Combined serum lidocaine and MEGX levels were significantly higher in group A patients up to 90 minutes (peak average of 0.61 µg/mL for group A and 0.533 µg/mL for group B; P = .0253), which corresponded to greater initial analgesic effect. Conclusions: Data from this study demonstrate that topical anesthetic for facial rejuvenation can be enhanced with laser pretreatment while maintaining safe blood serum levels. Further studies should examine optimal application amount and time to allow safe multipass facial rejuvenation without the need for invasive nerve blocks. Level of Evidence: 3 ![Graphic][1] [1]: /embed/inline-graphic-1.gif

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.

The use of knotless barbed sutures has shortened operation times for wound closure. In experimental models, their use in tendon surgery is still under investigation. This study looks at the use of barbed sutures in a porcine model for fascial repair when compared with traditional absorbable suture to further extend their clinical use.Six animals were included in this study. Each had two paramedian incisions, down to the fascia at the junction between the lateral edge of the rectus abdominis muscle and the transverse abdominis/oblique muscles of the abdominal wall. One fascial incision was closed with 2-0 Quill polydioxanone barbed suture and the other was closed with the control suture 1-0 PDS II (polydioxanone). The overlying skin was closed with Quill polydioxanone barbed suture for both incisions. At 6 weeks, the fascia was excised and the suture lines were tested for tensile strength.There were no wound infections and no incisional hernias. The Quill polydioxanone barbed suture had a mean tissue tensile strength of 265.59 N (range, 206.86 to 306.38 N) and the control suture (polydioxanone) had a mean tissue tensile strength of 227.28 N (range, 132.79 to 290.35 N). The difference was not statistically significant (p = 0.341).This study demonstrated that barbed sutures for fascial repair have equivalent tensile strength when compared with traditional nonbarbed sutures, with no adverse events such as wound dehiscence or incisional hernia. This preclinical study lends support to the practice of using barbed sutures for indications such as rectus sheath plication.

Introduction Studies examining the histopathological changes that occur in human skin following fractional laser treatment have been performed mainly in animals or abdominal tissue prior to abdominoplasty. This study looks at the effect of double pulse fractional CO2 laser compared to single pulse treatments to assess differences in tissue injury in the face and abdomen. Methods Twelve healthy subjects randomized into two groups, had two 1 cm2 areas (infraumbilical and forehead) treated with the fractional CO2 laser (Deep Fx, Lumenis). Settings used were 15 mJ double pulse, and 30 mJ single pulse, 300 Hz, 10% density and compared to the historic control of 15 patients treated at 15 mJ single pulse [Bailey et al. (2011), Lasers Surg Med 43: 99–107]. Treated sites were biopsied and analyzed with H&E and TUNEL staining to measure width and depth of the microthermal zones (MTZ) of ablation. Results When comparing 15 mJ double pulse to single pulse there were significant differences both in depth (abdominal skin, P = 0.002 and facial skin, P = 0.001) and width (facial skin, P = 0.0002) of MTZ. When comparing double pulsing at 15 mJ with single pulsing at 30 mJ there were significant differences between MTZ depths in the abdomen (P

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.

Introduction Clinical laser settings have traditionally been calibrated on abdominal skin to predict and anticipate patterns of injuries in facial skin. This experimental approach has limitations as facial skin and abdominal skin have differences that may influence the depth of laser injury. Objective The primary objective of this study is to analyze the acute pattern of laser injury in abdominal skin and facial skin samples from the same subject and detail the anatomical and biophysical properties that can influence the laser tissue interaction. The secondary objective is to develop a conversion factor that will allow the prediction laser column depths in facial skin based upon laser column depths in abdominal skin. Methods Fifteen healthy subjects were consented and screened. Two 2 mm spots on the face and abdomen were identified and measured and treated with a fractional CO2 laser (Lumenis Ltd, Yokneum, Israel), with an energy setting of 15 mj, 300 Hz at a density of 10. Treatment areas were biopsied and analyzed histologically using hematoxylin and eosin and TUNEL staining. Results Facial skin and abdominal skin have several significant anatomical and biophysical differences (concentration of pilosebaceous units, sebum concentration, and moisture content). Facial tissue demonstrated divergence of laser energy around pilosebaceous units and lateral spread of laser energy along blood vessels. These differences cause attenuation (28%) of the laser energy and result in column depths that are significantly (P

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.

Background: Both erbium (Er:YAG) and carbon dioxide (CO2) devices are commonly-used, efficient laser systems for aggressive skin resurfacing procedures. The devices each have different adjustable parameters (density, spot size, number of pulses, pattern, etc) and utilize variable energy capabilities to tailor individual treatments depending on the skin pathology and goals of treatment. Overall, the consensus has been that multiple-pass erbium treatments needed for efficacious wrinkle reduction had similar downtime and comorbidity to the traditional CO2 treatments. Unfortunately, there were limited data comparing the histological differences and changes throughout the wound-healing process over time between the two treatment methods. Objectives: The authors compare the difference in injury following treatment with five novel fractional ablative laser systems in vivo. Differences in damage pattern, treatment depth, and degree of surrounding cellular injury following treatment with each device at common clinical settings are evaluated in a side-by-side histopathologic comparison. Methods: Prior to planned excisional surgery, the panni of 20 abdominoplasty patients were treated with five novel ablative fractional carbon dioxide or Er:YAG laser systems at various clinical parameters, in accordance with the manufacturers’ treatment guidelines. After tissue removal two to four hours later, the skin was biopsied and processed for histopathologic evaluation. Specimens were stained with hematoxylin and eosin, along with a terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labeling (TUNEL) assay, to highlight the degree of irreversible cellular injury. Results: The acute damage profile differed between the fractional Er:YAG and CO2 devices with respect to depth of penetration and extension of coagulation surrounding the microcolumns. The damage pattern was dependent on the parameters set with each device (eg, fluence, pulses, density, pulse width). The TUNEL-stained sections demonstrated more collateral cellular injury surrounding the ablated columns with the CO2 devices than with the Er:YAG systems. Conclusions: Following treatment with the fractional Er:YAG and CO2 devices, deep tissue injury with various coagulative and ablative properties was observed, and it was confirmed that carbon dioxide and erbium devices result in different patterns of injury. As such, each may be better suited for different clinical situations. It is important for practitioners to understand the limitations of a specific device, as well as the tissue injury following a given treatment pattern or protocol, to appropriately tailor their treatment algorithm for a given patient. This extensive histopathologic evaluation of the acute characterization of injury across devices is helpful in clarifying the differences/similarities in laser-tissue interaction following treatment in an in vivo human model.

Liposuction has evolved tremendously over the past three decades. Since its introduction by Illouz it has progressed into one of the most popular procedures in plastic surgery. The objective of this CME is to provide a foundation of knowledge with respect to anatomy, physiology, preoperative, intraoperative, and postoperative management of patients scheduled to undergo liposuction. A review of both the immediate and delayed complications related to liposuction is addressed, as well as relevant surgical site-specific pearls for patients undergoing liposuction. Finally a summary of the various operative techniques available for surgeons is discussed along with information related to relevant emerging technology in body contouring.

To ensure that patients receive appropriate thromboembolic prophylaxis, other specialties have begun using risk stratification models. Because these models do not include plastic surgery patients, research must be directed toward exploring the risk associated with these operations. A systematic review of the literature was performed to address these issues.A thorough search for all articles discussing abdominal contouring surgery was conducted. Data were collected from this institution through a retrospective chart review and included in the analysis. Procedures were divided into four groups, dependent on what was reported, as follows: abdominoplasty alone, abdominoplasty with an intraabdominal procedure, abdominoplasty with another plastic surgical procedure, and circumferential abdominoplasty. Frequencies of venous thromboembolism were recorded. Chi-square analysis was performed to examine for statistical differences.One hundred fourteen articles were reviewed; 30 articles were included in the analysis. Circumferential abdominoplasty was associated with the highest venous thromboembolism rate (3.40 percent). This was statistically higher than the thromboembolic rate of abdominoplasty (0.35 percent) (p0.0001) and abdominoplasty with concomitant plastic surgery (0.79 percent) (p0.0001). Abdominoplasty combined with an intraabdominal procedure was associated with the second highest rate of thromboembolism (2.17 percent). This rate was higher than abdominoplasty alone (p0.001) and abdominoplasty with concomitant plastic surgery (p = 0.02).Circumferential abdominoplasty and abdominoplasty performed in combination with an intraabdominal procedure were demonstrated to have significantly increased risk for venous thromboembolism. Patients undergoing these procedures should be risk stratified and have perioperative prophylaxis managed accordingly. It is suggested that both of these operations be placed into a higher exposing risk category within the modified Davison-Caprini risk assessment model.

Fractional photothermolysis is extremely popular in skin rejuvenation and remodeling procedures. However, the extent of thermal cellular injury beyond the borders of the coagulated microcolumns produced with fractional phototherapy is undefined.Six abdominoplasty patients were pretreated with the Lux1540 Fractional Erbium device (Palomar, Inc., Burlington, Mass.) at various clinical laser settings. After tissue excision, the panni were immediately biopsied. Biopsy specimens were fixed in formalin, embedded in paraffin, sectioned, and evaluated with the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labeling (TUNEL) procedure for cellular necrosis/apoptosis. Tissue was sectioned horizontally and longitudinally to help define the depth and distribution of the microcolumns of injury in a three-dimensional plane.The extent of cellular necrosis/apoptosis at variable depths within the epidermis and dermis was demonstrated successfully with the TUNEL technique. After the Lux1540 treatment, TUNEL-positive nuclei were identified in a vertically oriented fashion that extended from the epidermis into the papillary and reticular dermis, highlighting the areas of injury. The TUNEL-positive nuclei defined lesions that were approximately 175 to 225 microm in diameter and penetrated to variable depths (200 to 900 microm), depending on the fluence used for treatment (18 to 100 mJ).TUNEL immunofluorescent labeling provided an accurate assessment of cellular damage within and surrounding the microthermal zones of coagulated collagen with respect to column depth and width. Because of its specificity, the TUNEL assay can be a useful adjunct to other histologic stains used to characterize cellular damage and matrix denaturation in skin treated with any fractional ablative or nonablative laser device.

Background: Injectable hyaluronic acid fillers (HAFs) and laser/light procedures have become increasingly popular for noninvasive facial rejuvenation in many cosmetic practices. However, the effect of laser/light treatments on HAFs is unknown. Objective: Our objective was to examine the effect of laser/light treatments on HAFs in a porcine model. Methods: The abdomens of 6 Yorkshire pigs were injected with 3 different HAFs: Restylane (Medicis, Scottsdale, AZ), Perlane (Medicis), and Juvederm (Allergan, Santa Barbara, CA). Two weeks after injection, the injection sites were treated with 1 of 7 common laser/light ablative or nonablative devices. Following laser treatment, 8-mm punch biopsies were collected from the treated tissue and fixed for histopathologic evaluation. Sections were stained with hematoxylin–eosin and alcian blue stains for identification of the preinjected HAF. Results: The filler was identified in different areas of the dermis in different sections. The Sciton intense pulsed 560 nm filter (Sciton, Palo Alto, CA), the Sciton Nd: YAG, Lux1540 (Palomar Medical Technologies, Burlington, MA), or ActiveFX (Lumenis, Yokneum, Israel) treatments showed no sign of interaction with superficial or deep dermal filler. No evidence of morphologic changes to the filler or the surrounding tissues was observed. Obvious interaction between the HAFs and the laser injury was demonstrated in sections treated with the deep ablative systems fractional erbium 2940 (Profractional; Sciton) and DeepFX CO2, (Lumenis). However, no uncharacteristic tissue injury or morphologic change in the filler was appreciated in any of the preinjected specimens. Conclusions: Injected HAFs were unaffected by the nonablative laser/light and superficial ablative treatments. The more aggressive deeper laser treatments demonstrated laser/filler interaction and may have a clinical effect on the longevity of the filler and/or efficacy of laser treatments. Novel ablative fractional lasers have the capability of deep dermal penetration, and this should be taken into consideration when planning to use them in combination with soft tissue fillers for noninvasive facial rejuvenation.