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Background Minimally invasive procedures that deliver thermal energy to subcutaneous tissue offer a solution when deciding between excisional and noninvasive options to address face and neck aging-related changes. A minimally invasive helium plasma device, Renuvion, was first utilized for subdermal tissue heating to reduce skin laxity under an FDA general clearance for cutting, coagulation, and ablation of soft tissue. Objectives The purpose of this study was to demonstrate the safety and effectiveness of the helium plasma device for improving the appearance of loose skin in the neck and submental region. Methods Patients undergoing the procedure with the helium plasma device in the neck and submentum were studied. They were seen for 6 months following the procedure. The primary effectiveness endpoint for improvement in lax skin in the treatment area was determined by 2 of 3 blinded photographic reviewers. The primary safety endpoint was the level of pain after treatment. Results The primary effectiveness endpoint was met; 82.5% demonstrated improvement at Day 180. The primary safety endpoint was met; 96.9% of patients experienced no pain to moderate pain to Day 7. There were no serious adverse events reported related to the study device or procedure. Conclusions The data demonstrate benefit to patients by improvement of the appearance of lax skin in the neck and submental region. Outcomes resulted in US Food and Drug Administration 510(k) clearance in July 2022, expanding indications for the device to include subcutaneous dermatological and aesthetic procedures to improve the appearance of loose skin in the neck and submental region. Level of Evidence: 4

Background Traditional invasive suture suspension techniques have proven efficacy and durability. A previously described percutaneous placement of a neck suspension suture with light guidance has transformed this into a minimally invasive technique. This novel technique provides a major advance for minimally invasive neck rejuvenation. Objectives The authors sought to describe their experience with light-guided percutaneous neck rejuvenation over the past 4.5 years, including technique, patient selection, safety profile, and expected outcomes. Methods Data were retrospectively reviewed for all patients who underwent the procedure with 5 surgeons across 4 aesthetic plastic surgery practices from January 2018 through May 2022. Inclusion criteria were mild to moderate neck laxity, prominent anterior platysma bands, and desire to improve neck contour. Patients undergoing concurrent skin incision >5 mm (ie, open rhytidectomy or platysmaplasty) were excluded. Results A total of 391 patients meeting criteria were identified during the study period. No hematomas were documented. Four patients (1%) developed infection at the suture site, 1 resolving on antibiotics and 3 requiring suture removal. Eighteen (4.6%) developed recurrent platysmal bands, and 7 (1.8%) had residual loose skin. Four (1%) experienced transient marginal mandibular neuropraxia. Mean length of follow-up time was 240 days. Conclusions Light-guided percutaneous suture suspension is a safe and viable option for improving neck contours. Although it does not address extensive skin laxity or excess submental fat, it can be combined with energy-based tissue tightening, submental liposuction, or skin excision. In selected patients, this minimally invasive procedure provides predictable results with a low risk of complications. Level of Evidence: 3

Background Aging skin and increased skin laxity is a prevalent concern of patients. Nonsurgical treatments, such as radiofrequency, are increasing in popularity due to decreased pain, downtime, and scarring. ThermiRF (Thermi, Irving, TX) is a subdermal radiofrequency treatment for tightening skin. When applying radiofrequency treatments to the neck, it is important to avoid ablating the marginal mandibular nerve and causing nerve trauma. Objectives The purpose of this study was to locate and record the position of the marginal mandibular nerve in 72 patients undergoing subdermal radiofrequency skin tightening, to determine how often the nerve correlates to its textbook anatomic position. Methods Marginal mandibular nerves were located with a nerve stimulator and marked with the subject in both upright and recumbent positions. Photographs were taken and the nerve position in relation to the mandible was recorded. Results The marginal mandibular nerve was in its correct anatomic position above the mandible in 18% of patients. Nerve position did not shift between the upright and recumbent positions. Only 10% of patients had left-right nerve symmetry. Conclusions To avoid nerve injuries, nerve mapping prior to nonablative radiofrequency treatment is recommended. The marginal mandibular nerve is not always in its correct anatomic position or symmetric to the opposing side. Its location cannot be assumed from the textbook anatomic position or from a single-side mapping. Level of Evidence: 4

Background Laxity of the submental area is a common cosmetic complaint of the aging population. Objectives The aim of this study was to determine the safety and effectiveness of a temperature-controlled, minimally invasive percutaneous monopolar radiofrequency device to improve dermal laxity and achieve lift. Methods A total of 72 subjects (35-65 years old) with mild to moderate skin laxity in the submental area were included in this single-center prospective study. All subjects received 1 treatment at baseline with an average subdermal temperature of 63°C. The primary endpoint was the proportion of subjects with at least a 20-mm2 decrease in surface area at Day 90 based on 3-dimensional photography. Secondary endpoints included skin elasticity measured by Cutometer, assessment by a blinded physician panel from 2-dimensional photographs, and physician- and subject-reported outcomes. Results At Day 90, 72.1% (95% CI: 62.2%-84.0%; P < 0.001) of subjects achieved at least a 20-mm2 lift of the submental area. All Cutometer-measured skin elasticity values (R2, R5, R7) showed significant improvement by 180 days. The independent panel graded 74.2% of subjects as “improved” at 90 days (95% CI: 62.0%-84.2%; P < 0.001). The treatment was well tolerated, and only 1 possibly related serious adverse event was reported (pharyngeal inflammation). Conclusions Treatment with temperature-controlled monopolar radiofrequency alone is a safe and effective treatment to achieve submental lift for at least 6 months. Level of Evidence: 4

Background The shock-absorbing soft tissues of the heel are composed of dermis and specialized fat pads. Heel fat pad atrophy is common and can be painful and debilitating. In our previous work, autologous fat grafting was effective for treating pain from forefoot fat pad atrophy. Objectives The authors hypothesized that autologous fat grafting to the heel would relieve pain and improve function in patients with heel fat pad atrophy. Methods Patients with heel fat pad atrophy and associated pain were recruited and randomized into 2 groups. Group 1 received autologous fat grafting on enrollment and was followed for 2 years. Group 2 received offloading and activity modification for 1 year, then crossed over, underwent autologous fat grafting, and was followed for 1 year afterward. Outcome measures included ultrasound-measured fat pad and dermal thickness; pedobarograph-measured foot pressures and forces; and patient-reported outcomes as measured by the Manchester Foot Pain and Disability Index. Results Thirteen patients met the inclusion criteria and completed the study. Seven (12 affected feet) were randomized into Group 1; and 6 (9 affected feet) were randomized into Group 2. The average age was 55 years and BMI was 30.5 kg/m2. Demographics did not significantly differ between groups. Heel fat pad thickness increased after autologous fat grafting but returned to baseline at 6 months. However, autologous fat grafting increased dermal thickness significantly and also increased fat pad thickness under a compressive load compared with controls at 6 and 12 months. Foot pain, function, and appearance were also significantly improved compared with controls at 6 and 12 months. Conclusions Autologous fat grafting improved patient-reported foot pain, function, and appearance and may rejuvenate local soft tissues in patients with heel fat pad atrophy. Level of Evidence: 3

Background Radiofrequency (RF) technology has ushered in a new paradigm in body contouring for patients with mild to moderate skin laxity who desire fat removal without exacerbating skin laxity issues. A bipolar internal RF device, used as an adjunct to liposuction, has been found to be simpler and more accurate than previous technologies. Objectives The aim of this study was to review the authors’ clinical experience with bipolar RF-assisted liposuction (RFAL). Methods We conducted a review of our large experience with bipolar RFAL, evaluating the nuances from appropriate patient selection and specific treatment areas. The review covered 745 patients treated from January 2017 to January 2020 at 2 centers. A retrospective chart review was performed of the first and last 50 patients treated at each center (for a total of 100 patients in each group) to assess trends in outcomes and adverse events. Results Results were generally excellent from physician evaluation, and overall patient satisfaction was high (96%). The two most common adverse events were temporary swelling (9%) and nodules (8.5%). Selected examples of a variety of cases are reviewed. Conclusions The ability to tighten skin with a minimally invasive tool adds much to the contemporary approach to the body-contouring patient with skin laxity. Adverse events were minimal and greatly decreased after an initial short learning curve. Bipolar RFAL is a strong addition to our surgical armamentarium and has become an essential tool for our practices. Level of Evidence: 4

Cellulite is characterized by dimpled contour alterations of the skin and is present in approximately 85% to 90% of postpubertal females. Although the pathophysiology of cellulite remains to be fully elucidated, experimental evidence indicates a multifactorial process involving the number and types of fibrous septae, microvascular dysfunction, subcutaneous inflammation, decreased dermal thickness with age, and fat deposition. Cellulite is a major cosmetic concern for many women, and a number of both noninvasive (eg, massage, cosmeceuticals, laser therapy) and minimally invasive techniques (eg, subcision, collagenase injection) have been evaluated to improve the appearance of the affected skin. However, evidence for many of these treatments is limited, largely due to the lack of a validated, convenient tool for the standardized evaluation of cellulite severity. Various imaging modalities have been employed to characterize cellulite severity and the impact of treatment, but only 2-dimensional and 3-dimensional digital photography have been adequately validated. However, in many cases, imaging findings do not correlate with subjective measures of cellulite severity. A number of cellulite rating scales have been developed; some provide only a qualitative measure, whereas others do not fully capture all clinically relevant aspects of cellulite, including the perspective of the patient. There remains an unmet need for global adoption of a validated scale that can be utilized easily by clinicians and patients in clinical and research settings. We propose features that should be included in an ideal rating scale for assessment of cellulite severity.

Microneedling and soft-tissue filler injections have been used independently to improve acne scarring. The effectiveness of a combined approach using microneedling followed by polymethylmethacrylate (PMMA)-collagen gel has not been carefully studied.The goal of this study was to assess the effectiveness and safety of microneedling alone versus microneedling followed by injection of PMMA-collagen gel filler for correction of atrophic facial acne scars.We conducted a multicenter, open-label, randomized, prospective study on subjects with distensible atrophic acne scars in the face to determine whether microneedling with PMMA-collagen gel is a superior acne scar treatment over microneedling alone. Forty-four subjects received 3 microneedling treatments over a 12-week period followed by randomization to treatments with PMMA-collagen gel (treatment group) or no further treatment (control group).At 24 weeks, the treatment group achieved a statistically significant improvement in acne scores over microneedling alone. The improvement continued at 36 weeks. At 24 weeks, the treatment group showed a strong trend in improvement on the Physician Global Aesthetic Improvement Scale compared with microneedling alone.

We present our institution's protocol for evaluating and transplanting thoracic organs from COVID-19 positive donors and report the outcomes to date. Hearts from donors testing positive for COVID-19 on any test were eligible for transplantation at our institution provided the donor exhibited no evidence of hypercoagulability or COVID-19 induced hyperinflammatory state during terminal hospitalization. Lungs were eligible if the donor first tested PCR positive on nasopharyngeal swab (NPS) for COVID-1920 days prior to procurement and had a negative lower respiratory tract specimen. We performed 14 thoracic transplants in 13 recipients using organs from COVID-19 positive donors. None of the recipients or healthcare members acquired COVID-19. No recipients suffered unexpected acute rejection. Patient survival is 92% to date, with graft survival 93%. The use of hearts from COVID-19 positive donors may be safe and effective. Transplantation of lungs is unresolved but may be cautiously pursued under the restricted circumstances.

Background The appearance of a youthful neck is lost with age causing excessive skin laxity, a loss of subcutaneous fat, prominence of platysmal banding, and jowling. In view of the success obtained with laser treatment for neck rejuvenation, the authors have recently taken an algorithmic approach to developing a 7-category classification system of the aging conditions throughout the anatomic spectrum of three areas: skin, fat, and muscle. This system will correlate with specific treatment options. Objective The objective of the study was to confirm the 7-category classification system and treatment approaches based on clinical outcome data for treatment of the mandibular and submandibular areas, specifically for skin tightening and laser lipolysis after a single 1440-nm laser treatment. Methods Patients were treated with a single treatment of PrecisionTX™ 1440-nm wavelength laser on their necks. Baseline and posttreatment photographs were taken and evaluated by 3 blinded reviewers using the Cervicomental Angle Scale (CAS). Results Subjects were rated grades II-III (2.9 ± 0.8) on average at baseline and grades I-II (1.3 ± 0.5) at follow-up. The average improvement was a mean score of 1.5 ± 0.07. Patients, 23/25 (92%), showed at least a 1 score improvement. Conclusions This study confirms a new minimally invasive treatment approach based on a unique classification system with no adverse events reported and high patient satisfaction. Level of Evidence 4

Purpose To determine whether there are changes in nerve conduction studies (NCS) of the median nerve after distal radius fracture (DRF) and to determine how operative fixation through a volar approach with a locking plate contributes to nerve conduction changes. We hypothesized that a considerable percentage of patients would have electrodiagnostic evidence of median neuropathy at the wrist after fracture, but fixation with a volar locked plate would not worsen the electrodiagnostic findings. Methods This was a prospective cohort study of 14 neurologically asymptomatic patients who underwent surgical treatment of an isolated DRF using a volar plate. All patients underwent surgery within 2 weeks of injury. On the day of surgery and at the 6-week follow-up, patients were clinically examined, Quick–Disabilities of the Arm, Shoulder, and Hand questionnaire was completed, and patients underwent NCS using a handheld device with the unaffected limb, which was used as a comparison. Preoperative and postoperative nerve function were compared with the unaffected limb as a baseline. Results Patients without symptoms after DRF had a 28% incidence of prolonged latencies compared with reference values for the device used. Distal sensory latencies of the median nerve were 3.64 ± 0.32 ms in the unaffected arm, 3.76 ± 0.70 ms before surgery, and 3.81 ± 0.52 ms after surgery. Distal motor latencies of the median nerve were 3.91 ± 0.59, 3.60 ± 0.68, and 3.88 ± 0.36 ms in respective arms and time points. Quick–Disabilities of the Arm, Shoulder, and Hand scores improved from 77 before surgery to 46 at 6 weeks. Conclusions Asymptomatic patients may satisfy nerve conduction criteria for median neuropathy at the wrist after DRF; however, open reduction and treatment with a volar locked plate has no significant effect on NCS findings. Type of study/level of evidence Prognostic II.

Background Adipose-derived stem cells (ASCs) are capable of secreting regenerative growth factors and replacing multiple tissue types. Although current literature suggests that ASCs accelerate wound healing and reduce scarring, the dose-response relationship has not been adequately investigated in large animals. We sought to establish a porcine model to optimize dose and delivery. Methods Four-centimeter circular, full thickness excisional wounds were created on the backs of Yorkshire pigs. Fluorescently labeled allogeneic porcine ASCs were injected into the superficial wound bed and around the wound perimeter at high (3.0 × 106 cells/cm2; n = 8), medium (1.0 × 106 cells/cm2; n = 8), and low (0.3 × 106 cells/cm2; n = 8) doses. Control wounds received saline injections (n = 8) or no treatment (n = 8). Dressings were changed twice per week, and wound closure was tracked by surface area tracing. Animals were sacrificed at 1 and 2 wk. Wounds were harvested for real-time quantitative reverse transcriptase polymerase chain reaction, immunohistochemistry, and ASC tracking. Results Labeled ASCs integrated into treated wounds by 1 wk in a dose-dependent fashion. Epithelial coverage was achieved by 14 d in all wounds. Wounds receiving high-dose ASCs exhibited thicker granulating neodermis at 7 d and greater wound contraction at 14 d. real-time quantitative reverse transcriptase polymerase chain reaction revealed improved collagen 1:collagen 3 (Col1:Col3) ratio in the medium-dose group and enhanced α-smooth muscle actin in the high-dose group at 14 d. Western blot demonstrated increased cluster of differentiation 31 protein at 2 wk in wounds receiving >106 cells/cm2. Conclusions Doses up to 3.0 × 106 cells/cm2 were well-tolerated. High-dose ASCs accelerate wound contraction, enhance neovascularization, and may improve scar quality in excisional wounds healing by secondary intention. Doses greater than those previously used may be necessary to achieve desired effects.

BACKGROUND: Liposuction is one of the most performed cosmetic surgery procedures. In a previously reported study, gold-nanoparticle (GNP) laser-assisted liposuction (NanoLipo) was shown to improve procedure parameters and outcomes in a porcine model. OBJECTIVES: An ex vivo human liposuction model was developed to assess the ease, efficacy, and outcomes of NanoLipo, and to further explore its mechanism of action in facilitating liposuction. METHODS: NanoLipo was compared to a control without GNPs in sets of fresh, nonperfused, anatomically symmetric, matched tissue specimens from 12 patients. A subset of three experiments was performed under single-blinded conditions. Intraoperative assessments included lipoaspirate volume, percentage of free oil, ease of removal, and temperature rise. Specimens were palpated, visualized for evenness, and graded with and without skin. Postoperative assessment included viability staining of the lipoaspirate and remaining tissues. Microcomputed tomography was used to assess the distribution of infused GNPs within the tissues. RESULTS: NanoLipo consistently removed more adipose tissue with more liberated triglycerides compared to control. NanoLipo specimens were smoother, thinner, and had fewer and smaller irregularities. Infused solutions preferentially distributed between fibrous membranes and fat pearls. After NanoLipo, selective structural-tissue disruptions, indicated by loss of metabolic activity, were observed. Thus, NanoLipo likely creates a bimodal mechanism of action whereby fat lobules are dislodged from surrounding fibro-connective tissue, while lipolysis is simultaneously induced. CONCLUSIONS: NanoLipo showed many advantages compared to control under blinded and nonblinded conditions. This technology may be promising in facilitating fat removal. LEVEL OF EVIDENCE: 5: [Image: see text]

Minimally invasive devices are a departure from standard laser therapies, because energy is delivered directly below the skin through a 1-mm incision. Lasers can affect such tissues as fat for enhanced disruption, coagulation of small blood vessels, and skin tightening at the right temperatures. Minimally invasive radiofrequency devices can tighten skin but can also improve neck muscle laxity. These devices can achieve results not possible with traditional external devices and, because the skin is not penetrated with energy, a much improved healing profile is seen as well.

A new temperature-controlled device has been used as a percutaneous radio frequency probe to treat lax submental and other facial areas. It has significant advantages over other esthetic devices as it provides the dual benefit of fat lipolysis and skin tightening. Our goal here is to present consensus recommendations for treating the aging neck.A panel of 11 expert physicians convened in Dallas, Texas, on October 15, 2016 to arrive at a consensus on the best current practice for submental skin tightening and contour improvement. Prior to the meeting, a comprehensive review of the literature was performed and a survey was sent to esthetic dermatologists and plastic surgeons who were queried about various aspects of neck rejuvenation.The literature search revealed 10 different technologies for neck rejuvenation evaluated in double-blind (n = 2) and single-blind (n = 1) clinical trials and other clinical evaluations (n = 21). The survey was sent via an email to 1248 individuals and was completed by 92 respondents. Review of the data and discussion by meeting attendees generated eight consensus recommendations.Subdermal monopolar radio frequency represents an effective means for disrupting fat volume and skin tightening of the face, neck, and jawline. For suitable patients, this treatment can be used to achieve significant esthetic improvements.

Fat grafting has emerged as the treatment of choice for soft-tissue augmentation and reconstruction. Variability of volume retention remains the greatest challenge for this technique, often requiring multiple operations to achieve the desired volume. Graft that is placed greater than 2 mm from the recipient bed will undergo necrosis. Improved understanding of the architecture of fat within the recipient bed is paramount to improving outcomes. The impact of cannula diameter on graft architecture is unknown.Fat was harvested by liposuction and stained with methylene blue. Stained fat was grafted into 4 × 2 × 1-cm sections of excised abdominal tissue with 12-, 14-, 16-, and 19-gauge Coleman cannulas at three different volumes: 0.1, 0.5, and 1.0 cc. Each tissue block was sectioned for stained graft visualization. The diameter of each deposit and percentage with a radius greater than 2 mm were recorded.With an injection volume of 0.1 cc, no fat deposits had a radius greater than 2 mm, regardless of cannula size. A graft volume of 0.5 cc created globules greater than 2 mm with larger cannulas (0 percent with 19-gauge, 2.9 percent with 16-gauge, 6.1 percent with 14-gauge, and 4.3 percent with 12-gauge). Injecting 1.0 cc resulted in a significant increase in the percentage of fat parcels expected to undergo central necrosis (16 percent with 19-gauge, 21 percent with 16-gauge, 26 percent with 14-gauge, and 44 percent with 12-gauge).Injection cannulas of 14-gauge or larger are more likely to create deposits with dimensions that may be susceptible to central necrosis when injecting 1.0 cc per pass. Smaller cannula sizes or lower volumes per pass should be considered.Therapeutic, V.

Laser resurfacing is a very popular procedure worldwide. Full field and fractional lasers are used in many aesthetic practices. There have been significant advances in laser resurfacing in the past few years, which make patient treatments more efficacious and with less downtime. Erbium and carbon dioxide and ablative, nonablative, and hybrid fractional lasers are all extremely effective and popular tools that have a place in plastic surgery and dermatology offices.

Intense pulsed light (IPL), also known as pulsed light and broad band light, is a nonlaser light source used to treat a variety of vascular and pigmented lesions, photo damage, active acne, and unwanted hair. Current IPL systems are much improved from older-generation devices with better calibration, integrated cooling, and improved tuning. These devices are extremely popular because of their versatility and are often the first devices recommended and purchased in many offices.

Background Although primary graft dysfunction (PGD) is a leading cause of mortality and morbidity early post-heart transplant, relatively little is known regarding mechanisms involved in PGD development. Methods and Results We examined the relationship between cardiac troponin I (cTnI) concentrations in the preservation solution from 43 heart transplant procedures and the development of PGD. Donor hearts were flushed with cold preservation solution (University of Wisconsin [UW] or Custodiol) and stored in the same solution. cTnI concentrations were measured utilizing the i-STAT System and normalized to left ventricular mass. Recipient medical records were reviewed to determine PGD according to the 2014 ISHLT consensus conference. Nineteen patients developed PGD following cardiac transplantation. For both UW and Custodiol, normalized cTnI levels were significantly increased ( P = .031 and .034, respectively) for those cases that developed PGD versus no PGD. cTnI levels correlated with duration of ischemic time in the UW group, but not for the Custodiol group. Donor age and donor cTnI (obtained prior to organ procurement) did not correlate with preservation cTnI levels in either UW or Custodiol. Conclusions Increased preservation solution cTnI is associated with the development of PGD suggesting preservation injury may be a dominant mechanism for the development of PGD.

Background: Animal models are often used to assess interventions that might improve fat grafting outcomes; however, there is great variability in the models. The authors sought to determine the predictive value of the immunocompromised mouse model for fat grafting so that experiments could be standardized and optimized. Methods: Human lipoaspirate injections at different volumes and time points were assessed in a nude mouse model and compared with control injections of nonviable fat. Volume retention and explant histologic score were compared. In a separate study, interanimal reproducibility was determined by implanting a highly consistent hydrogel and measuring variability in volume retention. Results: Injection volume significantly affects adipose resorption kinetics at 6 and 12 weeks. Masson trichrome staining revealed that macrophages were unable to infiltrate large (1 ml) grafts, and oil cysts were not absorbed by 18 weeks, which interfered with interpretation of volume retention data. Nonviable tissue was resorbed when grafts were 0.3 ml, and quantification of graft histologic viability correlated well with graft retention at all study time points. Interanimal variability was measured to be 8.44 percent of the mean retention volume for small graft volumes. Conclusions: Human fat graft retention in the immunodeficient mouse correlates with graft viability in small, 0.3-ml-volume grafts. However, centralized oil cysts in nonviable 1.0-ml grafts were not resorbed by 18 weeks and thus volume measurements were confounded and not significantly different from viable samples. In addition, tissue injury scores increased in initially healthy fat grafts at 18 weeks, possibly because of a delayed immune reaction.

The neck is a prominent indicator of aging. Loss of subcutaneous fat, prominence of platysmal banding, jowling along the mandibular border, and excessive skin laxity due to loss of collagen and elastin are common conditions that are treated. Laser technology provides additional benefits when treating the first two anatomical layers of the neck.A 7-category classification system of anatomic skin layers of the lower face was developed. Based on the classifications treatments include the use of laser, ultrasonic technology, and toxins.A classification system offering surgical and nonsurgical treatments including a 1440-nm laser fiber with a specifically designed tip to allow targeted energy delivery managed through a thermal sensing device.Treatment options correlate with the presence and severity of conditions. Categories 1 and 2 have only a fat excess condition. Laser application alone, without skin intervention, is utilized. The amount of fat with subsequent aspiration follows guidelines of categories 2 through 5. The 1440-nm laser helps in all treatments. The surgeon may elect to address skin tightening with surgical tightening in categories 6 and 7. Modalities such as toxins and focused ultrasound can be used to address muscle laxity.

Background Treatment of cellulite using a 1440-nm YAG wavelength laser with side-firing fiber has proven safe and effective, lasting at least 6 months. Objectives The authors evaluate the safety and efficacy of a single, subdermal procedure to treat the underlying structure of cellulite for at least 1 year. Methods Fifty-seven patients underwent a 3-step cellulite treatment with a 1440-nm Nd:YAG laser with a side-firing fiber and temperature-sensing cannula. Efficacy was measured by the blinded evaluators to distinguish baseline photos from those taken at 12 months posttreatment, with results on a 5-point, 2-category ordinal photonumeric scale when comparing baseline photos to 12 months posttreatment. Subject and physician satisfaction was assessed based on completion of a satisfaction survey. Adverse events (AE) were recorded throughout the study. Twelve month data were analyzed and compared to 6 month data. Results Evaluators chose baseline photographs 97% on average from 6 (−1, +2) months and 91% from the 12 (−3, +2) months posttreatment photographs. At 6 (−1, +2) months, the average improvement score was 1.7 for dimples and 1.1 for contour irregularities. At 12 (−3, +2) months, the average improvement score was 1.4 for dimples and 1.0 for contour irregularities. The average satisfaction score for the physician was 5.6 and the patient was 5.3 on a 6-point scale. Conclusions A single, 3-step, minimally invasive laser treatment using a 1440-nm Nd:YAG laser, side-firing fiber, and temperature-sensing cannula to treat the underlying structure of cellulite proved to be safe and maintained effectiveness at least 1 year post treatment. Level of Evidence: 2 ![Graphic][1] Therapeutic [1]: /embed/inline-graphic-1.gif

Purpose: To demonstrate the utility of orbital ultrasound in the evaluation and management of suspected orbital vascular lesions. Methods: Clinical case series of 15 patients with suspected orbital vascular lesions seen in the Neuro-ophthalmology clinic of the Wilmer Eye Institute. The techniques of standardized echography (combined use of a contact B-scan and standardized A-scan) were performed by an experienced echographer, and data obtained were compared with other available imaging modalities to determine appropriate management. Patients were monitored for improvement, stability, or worsening of symptoms and signs. Results: Based on echographic data obtained, 6 patients underwent surgery, 9 were observed over a follow-up period of 0–14 (mean 3.3) years. All patients demonstrated improvement or remained stable, and no complications developed from misdiagnosis during subsequent follow-up. Conclusions: Orbital ultrasound provides reliable imaging parameters and can be used as the primary imaging modality when evaluating suspected orbital vascular lesions.

Background: Cellulite is characterized by a thickened hypodermal fat layer, along with hypodermal fat lobules that extend upward into the dermis, expanding and stretching the fibrous septae that separate the fat lobules. Eventually, the septae sclerose, contract, and harden, holding the skin at an inflexible length while the surrounding tissue continues to expand. Objectives: The author evaluates the efficacy, safety, and duration of clinical benefit associated with a pulsed laser that delivers 1440-nm energy to the dermal-hypodermal interface for the treatment of cellulite. The changes in the dermal structure that affect the appearance of cellulite are also examined. Methods: Ten healthy women with cellulite on their thighs enrolled in a prospective Institutional Review Board–approved study conducted in the author’s private plastic surgery clinic. Patients received a single treatment with a 1440-nm pulsed laser. Energy was delivered to the subdermal tissue through a fiber that was designed for side firing and enclosed in a cannula. Treatment addressed the thickened hypodermal fat layer, hypodermal fat lobules that extended upward into the dermis, and fibrous septae by thermal subcision. Results: The mean age of the patients was 47 years ± 5.4 years. Mean skin thickness (as shown by ultrasound) and skin elasticity were shown by objective measurements to increase significantly at one, three, six, and 12 months. Subjective physician and subject evaluations indicated improvement, high subject satisfaction, and minimal adverse effects. Conclusions: In this study, a single treatment with the 1440-nm pulsed laser improved the appearance of cellulite, an improvement that persisted through at least one year of follow-up with minimal adverse effects. Level of Evidence: 3

The use of nickel-titanium rotary files has been accepted worldwide. One of the major concerns about its use is the chance of file separation. Two types of failure have already been identified: cyclic fatigue and torsional failure. A scanning electron microscope analysis was performed on a recent case of file separation. The scan was used to show the main characteristics of torsional failure and to compare these characteristics with a known example of cyclic fatigue type failure. The clinical reasons that may lead to such failure are also discussed.

Transplantation of autologous skeletal myoblasts (SKMB) into infarcted heart (or cellular cardiomyoplasty, CCM) augments myocardial performance in animal models of myocardial infarction. However, the effect of CCM in the setting of ventricular aneurysm has not been evaluated. This study analyzes the effects of transplanted SKMB on regional wall motion in a rabbit model of postinfarct ventricular aneurysm. We hypothesize that CCM, performed early after myocardial infarction, prevents the progression of dyskinetic wall motion.Twenty-six rabbits underwent apical left ventricular cryoinfarction and soleus muscle biopsy for in vitro isolation of skeletal myoblasts. At 2 weeks postinfarct, the presence of ventricular aneurysm was detected in 23/26 animals by sonomicrometry and micromanometry. Seventeen of 23 animals were randomized to receive either 108 autologous myoblasts (CCM) or vehicle. Regional stroke work, percent systolic shortening, and synchronicity of regional wall motion were determined prior to, and four weeks following, injection (CCM; n = 9; vehicle, n = 8). Wall motion was evaluated under baseline and stress (dobutamine, 10 (g/kg/min) conditions. Six animals did not undergo randomization, but their hearts were used to measure the size of infarction.Four weeks following treatment of animals with ventricular aneurysm, systolic contractile activity was present in most animals treated with myoblasts but in none treated with vehicle (5/7 versus 0/6, respectively, P0.05). Dobutamine tended to accentuate the differences seen at baseline between the groups.This study demonstrates a high incidence of systolic contractile activity in a previously aneurysmal region of myocardium following CCM and may represent a novel therapy for the prevention and treatment of postinfarct aneurysm.

Over the past few decades, lasers have gained increasing use in medicine. Clinical indications for the use of lasers in plastic surgery include facial rejuvenation, tattoo removal, hair removal, and improvement in various congenital and acquired skin abnormalities. With the advent of new lasers, patients of all ethnic backgrounds can be treated effectively.

We enjoyed reading the article by Handle et al entitled “Minimal-Scar Handlift: A New Surgical Approach.” Their technique is certainly a worthwhile addition to the plastic surgery literature and a procedure that we may elect to utilize in select patients. The basic idea behind their approach—namely, excising skin and leaving the scar hidden—is an essential tenet of plastic surgery. It is what many of us aim for in our aesthetic surgery practices on a daily basis for many anatomical areas. However, as the authors note, excisional procedures solve only some of the problems of the aging body, leaving unaddressed losses of skin elasticity, bone, muscle, and fat, as well as changes in position of these structures. Plastic surgeons have made great strides in the last 10 years in terms of nonsurgical rejuvenation with lasers and other energy devices, as well as fillers and toxins. The ultimate goal of any rejuvenation procedure is to restore elasticity and multiple-level volume loss with no scars—we think of this as the “holy grail” of cosmetic surgery. However, we are currently unable to currently achieve complete rejuvenation with nonsurgical procedures alone, regardless of anatomical area. Studying the “state of the science” in terms of a nonsurgical approach to the aging hand is indicative of where technology is today in regard to aesthetic restoration, and it gives us a good idea of where we might go in the future. Features of the aging hand include color …

Major surgical body contouring procedures have several inherent drawbacks, including hospitalization, anesthetic use, pain, swelling, and prolonged recovery. It is for these reasons that body contouring through noninvasive and minimally invasive methods has become one of the most alluring areas in aesthetic surgery. Patient expectations and demands have driven the field toward safer, less-invasive procedures with less discomfort, fewer complications, and a shorter recovery. In this article, the current minimally invasive and noninvasive modalities for body contouring are reviewed.

Objective To report visual acuity during the first three years after iodine 125 (I125) brachytherapy for medium-sized choroidal melanoma and to identify important baseline and treatment factors associated with posttreatment visual acuity in a group of patients who were treated and observed prospectively as part of a large, randomized clinical trial. Design Observational case series within a randomized, multicenter study. Participants Patients enrolled in the Collaborative Ocular Melanoma Study randomized trial of I125 brachytherapy versus enucleation had choroidal melanoma of at least 2.5 mm but no more than 10.0 mm in apical height, and no more than 16.0 mm in largest basal dimension. One thousand three hundred seventeen patients enrolled from February 1987 through July 1998; 657 patients were assigned to I125 brachytherapy. Visual acuity data for 623 patients who received I125 brachytherapy as randomly assigned and who have been observed for at least 1 year were analyzed for this report. Methods Under study protocol, an ophthalmic evaluation, including best-corrected visual acuity measurement of each eye, was performed at baseline, every 6 months thereafter for 5 years, and once yearly thereafter. Two poor vision outcomes, visual acuity of 20/200 or worse that was confirmed at the next follow-up examination and loss of six lines or more of visual acuity from baseline that was confirmed at the next follow-up examination, were analyzed to identify baseline and treatment characteristics that were associated with posttreatment visual acuity. Results At baseline, median visual acuity in the eye with choroidal melanoma was 20/32, with 70% of eyes having 20/40 or better and 10% of eyes having 20/200 or worse visual acuity. Three years after I125 brachytherapy, median visual acuity was 20/125, with 34% having 20/40 or better and 45% having 20/200 or worse visual acuity, including eyes that were enucleated within 3 years of treatment. Life-table estimates of percentages of patients who lost six or more lines of visual acuity from baseline, a quadrupling of the minimum angle of resolution, with this finding confirmed at the next 6-month follow-up examination, were 18% by 1 year, 34% by 2 years, and 49% by 3 years after treatment. Life-table estimates of percentages of patients with baseline visual acuity better than 20/200 whose visual acuity decreased to 20/200 or worse, confirmed at the next follow-up examination, were 17% by 1 year, 33% by 2 years, and 43% by 3 years after treatment. As soon as a poor vision outcome was observed, improvement of visual acuity to a level that no longer met the definition for a poor vision outcome was rare. Greater baseline tumor apical height and shorter distance between the tumor and the foveal avascular zone (FAZ) were the factors most strongly associated with loss of six or more lines of visual acuity after treatment. These two factors and baseline visual acuity also were strongly associated with visual acuity 20/200 or worse after treatment. Patient history of diabetes, presence of tumor-associated retinal detachment, and tumors that were not dome shaped also were associated with greater risk for both of the poor vision outcomes. Conclusions Forty-three percent to 49% of treated eyes had substantial impairment in visual acuity by 3 years after I125 brachytherapy, defined as a loss of six or more lines of visual acuity from the pretreatment level (49% of eyes) or visual acuity of 20/200 or worse (43% of eyes) that was confirmed at the next 6-month examination. Patients with a history of diabetes and patients whose eyes had thicker tumors, tumors close to or beneath the FAZ, tumor-associated retinal detachment, or tumors that were not dome shaped were those most likely to have a poor visual acuity outcome within 3 years after I125 brachytherapy.

Background and Objectives Osteosarcoma is a primary malignancy of bone. Current therapy includes neoadjuvant chemotherapy, surgery, and postoperative (adjuvant) chemotherapy. Prolonged treatment with chemotherapeutic agents may place patients at increased risk for complications including secondary malignancy. The authors have had promising results with neoadjuvant therapy and surgery alone in the treatment of osteosarcoma. This study retrospectively examines neoadjuvant therapy and surgery alone for the treatment of primary osteosarcoma of bone with no evidence of distant metastases. Methods Fifty-four patients, with localized osteosarcoma of bone received neoadjuvant therapy followed by definitive surgical resection. Thirty-five patients received chemotherapy after surgery (adjuvant group) and nineteen patients were followed without postoperative chemotherapy (no adjuvant group). Results Tumor necrosis was predictive of survival. Kaplan–Meier analysis revealed the use of postoperative chemotherapy was not a predictor of improved outcome. Four patients in the adjuvant therapy group died of secondary malignancy compared with none of the no adjuvant therapy group. Patient age, sex, race, and tumor location were not predictive of survival. Conclusions The use of adjuvant chemotherapy in the treatment of localized osteosarcoma of bone did not increase survival after neoadjuvant therapy and definitive surgical therapy. Instead, there was an increased incidence of secondary malignancy after its use. J. Surg. Oncol. 2001;78:162–170. © 2001 Wiley-Liss, Inc.

We are in a state of evolution in long-term hair removal. Safe and effective technology is now available. Lasers will always become smaller, faster, and perhaps more effective. For those interested in offering this procedure, evidence indicates that we are beyond the experimental phase. The treating physician should carefully review current available technology and receive proper training specific to that system.

The hair removal market is evolving rapidly. The goal has always been long-term epilation. Success is dependent on understanding hair biology and physiology and on knowledge of laser physics, skin optics, and tissue preservation with respect to these emerging laser technologies. These topics will be reviewed, as will specific categories of laser systems in the hair removal arena and the clinical aspects of laser hair removal today.

Supplemental Digital Content is available in the text., Background: Conventional suction-assisted lipectomy (SAL) often results in contour irregularity. Selective photothermal heating of adipose tissue by polymer-coated gold nanorods energized by an external near-infrared exposure at 800 nm is introduced in this work to facilitate fat removal. Methods: The effects of NanoLipo were examined in food-grade porcine abdominal tissue (skin, fat, and fascia) by histology. The efficacy of NanoLipo was compared with that of conventional SAL in vivo in Yucatan mini pigs by quantification of removed subcutaneous tissue and fatty acids and ultrasound measurement of adipose layer thickness. Results: NanoLipo led to the appearance of disruptions in adipose tissue that were not apparent in control groups in ex vivo samples. NanoLipo allowed removal of more subcutaneous tissue (~33% vs ~25% of removed material, P < 0.05) and approximately twice as much free fatty acids (~60% vs ~30% of removed tissue, P < 0.05) in comparison with conventional SAL. Most importantly, NanoLipo led to a greater decrease in adipose layer thickness at 1 month post surgery (P < 0.001). Conclusions: NanoLipo facilitates removal of a greater quantity of fat and requires less suction time (4 vs 10 minutes) than conventional SAL. As the safety of poly(ethylene-glycol)-coated gold nanorods is well-established, a clinical trial is currently being organized.

Atrial septal defects (ASDs) are typically asymptomatic in infancy and early childhood, and elective defect closure is usually performed at ages of 4 to 6 years. Severe pulmonary hypertension (PH) complicating an ASD is seen in adulthood and has only occasionally been reported in small children. A retrospective study was undertaken to evaluate the incidence of severe PH complicating an isolated ASD and requiring early surgical correction. During a 10-year period (1996 to 2006), 355 pediatric patients underwent treatment for isolated ASDs either surgically or by catheter intervention at 2 tertiary referral centers. Two hundred ninety-seven patients had secundum ASDs, and 58 had primum ASDs with mild to moderate mitral regurgitation. Eight infants were found with isolated ASDs (6 with secundum ASDs and 2 with primum ASDs) associated with significant PH, accounting for 2.2% of all patients with ASDs at the centers. These 8 infants had invasively measured pulmonary artery pressures of 50% to 100% of systemic pressure. They were operated in the first year of life and had complicated postoperative courses requiring specific treatment for PH for up to 16 weeks postoperatively. The ultimate outcomes in all 8 infants were good, with persistent normalization of pulmonary pressures during midterm follow-up of up to 60 months (median 28). All other patients with ASDs had normal pulmonary pressures, and the mean age at defect closure was significantly older, at 6.2 years for secundum ASDs and 3.2 years for primum ASDs. In conclusion, ASDs were rarely associated with significant PH in infancy but then required early surgery and were associated with excellent midterm outcomes in these patients.

Background . Left ventriculotomies are sometimes used during intracardiac congenital defect repair. Acute changes in left ventricular function after longitudinal or apical ventriculotomy were assessed using dynamic pressure-dimensional data. Methods . Ultrasonic dimension transducers along the major, minor, and septal free wall axes and micromanometers were placed in 24 piglets. Pressure-volume data were collected during caval occlusions at baseline and 60 minutes after warm cardiopulmonary bypass alone or with longitudinal ventriculotomy or apical left ventriculotomy. Hemodynamics, contractility, and contraction geometry were analyzed. Results . Cardipulmonary bypass caused decreased compliance in all groups, with equally decreased preload and cardiac output. Heart rate increased, but ventriculotomy led to a significantly greater increase. Longitudinal ventriculotomy produced a greater loss of stroke volume and ejection fraction than apical ventriculotomy. Contractility assessed by the preload recruitable stroke work relationship showed no difference between groups; however, all groups showed a slight increase in unit myocardial power at 60 minutes. Axis fractional shortening revealed that the septal freewall is responsible for 50% of stroke volume and that this axis is significantly impaired after longitudinal ventriculotomy. Conclusion . Apical left ventriculotomy impairs the less important major axis only and is predicted to be better tolerated.

Purpose: To report initial mortality findings from the Collaborative Ocular Melanoma Study (COMS) randomized clinical trial of pre-enucleation radiation of large choroidal melanoma. Methods: Patients were evaluated for eligibility at one of 43 participating centers in the United States and Canada. Eligible consenting patients were assigned randomly at the time of enrollment to standard enucleation or to external radiation of the orbit and globe prior to enucleation. Eligibility was confirmed at the COMS Coordinating Center, Echography Center, and Photograph Reading Center. Adherence to the radiotherapy protocol was monitored at the Radiological Physics Center. The diagnosis of choroidal melanoma was confirmed following enucleation by a three-member Pathology Review Committee. Patient accrual began in November 1986 and was completed in December 1994; 1,003 patients enrolled. Patients have been followed at annual clinical examinations. Cause of death was coded by a Mortality Coding Committee whose members were not involved in the care of COMS patients; the clinical trial was monitored by an independent Data and Safety Monitoring Committee. Results: A total of 1,003 patients were enrolled; 506 were assigned to enucleation alone and 497 to pre-enucleation radiation. Treatment groups were well balanced on baseline characteristics. Only nine patients were found to be ineligible after enrollment, seven in the interval between randomization and enucleation and two after enucleation based on histopathology. All but nine patients were treated as assigned; in only six of 491 eyes treated with pre-enucleation radiation was there a major deviation from the radiotherapy protocol. With 5-year outcome known for 801 patients enrolled (80%), the estimated 5-year survival rates and 95% confidence intervals (CIs) were 57% (95% CI, 52% to 62%) for enucleation alone and 62% (95% CI, 57% to 66%) for pre-enucleation radiation. Among the baseline covariates evaluated, only age and longest basal diameter of the melanoma affected the prognosis for survival to a statistically significant degree. The risk of death among patients treated with pre-enucleation radiation relative to those treated with enucleation alone after adjustment for baseline characteristics of patients, eyes, and tumors was 1.03 (95% CI, 0.85 to 1.25). Of 435 deaths classified by the Mortality Coding Committee, 269 patients had histologically confirmed melanoma metastases at the time of death. Estimated 5-year survival rates for this secondary outcome were 72% (95% CI, 68% to 76%) for enucleation alone and 74% (95% CI, 69% to 78%) for pre-enucleation radiation. Conclusions: No survival difference attributable to pre-enucleation radiation of large choroidal melanoma, using the COMS fractionation schedule, has been demonstrated to date in this randomized trial. The trial had statistical power of 90% to detect a relative difference in mortality rates between the two treatment arms of 20% or larger. A smaller difference is possible, but a clinically meaningful difference in mortality rates, whether from all causes or from metastatic melanoma, is unlikely.