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Background Paradoxical adipose hyperplasia (PAH), a rare side effect of CoolSculpting (cryolipolysis), is characterized by fatty enlargement of the treatment area occurring months after the procedure. Objectives The purpose of this study was to report a retrospective case series of patients diagnosed with PAH at the authors’ institution, increase the collective understanding of this complication and subsequent management, and raise the question of who should ethically perform cryolipolysis. Methods All participants diagnosed with PAH by a plastic surgeon at a large academic medical center were identified. Demographic information, medical history, procedure details, time to PAH diagnosis, and corrective surgical intervention details were collected. Mean duration of time from cryolipolysis treatment to diagnosis of PAH was calculated, along with other descriptive statistics. A scoping review of all PAH literature published in PubMed, Embase, and Web of Science was also conducted. Results Four patients diagnosed with PAH after cryolipolysis were identified for inclusion in this study. The calculated incidence of PAH at our center was 0.67%. All patients requested therapy for PAH and subsequently underwent either liposuction, abdominoplasty, or both. The mean duration of in-person follow-up time after final surgical treatment of PAH was 13.8 + 19.8 months (range, 2.8-43.5). Fortunately, no patients showed signs of PAH recurrence, and 3 out of 4 patients did not show signs of residual deformity. Conclusions Findings from this patient cohort and scoping review provide evidence that although revisions may be required, conventional body contouring methods, not in the armamentarium of non-plastic surgeon practitioners, effectively alleviated PAH. Level of Evidence: 4

Background Previous studies have sought to outline the clinical practice of hand surgeons with plastic surgery training backgrounds. Still, minimal data exist characterizing the scope of hand surgery among plastic surgeons, regardless of the subspecialty fellowship training. Methods All hand procedures logged in the Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database from 2002 to 2016 were identified by the Common Procedural Technology (CPT) code and/or “upper extremity” anatomic classification. Trends in the total number and types of procedures, facility type, admission type, modes and providers of anesthesia, and patient demographics were reviewed. Results A total of 182,137 hand procedures performed on 82,811 patients during the 15-year period were reviewed. Sixty-eight percent of procedures involved soft tissue only, and 22.7% involved only bone and/or joint. The most common procedure categories included the following: wound closure/coverage (15.8%), debridement/drainage (15.3%), nerve (13.2%), tendon (12.9%), and fracture/dislocation (12.9%). Ambulatory and office-based procedures increased over time, along with the use of local anesthetic, as well as a transition from the procedural surgeon providing anesthesia to the use of anesthesiologists and nurse anesthetists. In addition, hand procedures have remained a considerable proportion of all logged procedures but have seen a steady decline since 2014. Conclusion Plastic surgeons play an important role in the field of hand surgery, performing a wide variety of procedure types, which has remained stable over time. The trends in facility type and anesthesia characteristics have, however, varied.

Background Rhytidectomy is a popular procedure for facial rejuvenation, but an up-to-date, comprehensive, and broadly representative appraisal is lacking. Methods A cohort of patients undergoing rhytidectomy between 2008 and 2016 was identified from the Tracking Outcomes in Plastic Surgery database. Perioperative data and patient characteristics were analyzed with respect to adverse events. Multivariate logistic regression was used to identify association of complications with various risk factors. Results A total of 13,346 patients with a mean age of 60 years underwent rhytidectomies and a total of 31,206 Current Procedural Terminology procedures. Most were healthy women with an American Society of Anesthesiologists class of 1 or 2 (98 percent). On average, 2.3 procedures were performed in 3.8 hours per patient, and blepharoplasty was the most common adjunctive procedure. Fifty percent of operations were performed in office-based settings, and general anesthesia utilized in 63 percent of cases. The incidence of adverse events was 5.1 percent, with hematomas and infections as the most frequent surgical complications. Male gender, obesity, current smoker, duration, combined procedures, general anesthesia, and office-based surgery were associated with increased odds of adverse events. Conclusions This is the largest outcomes analysis of face-lift surgery in a patient population solely representative of board-certified plastic surgeons. Rhytidectomy is a very safe procedure when performed by board-certified plastic surgeons. Nevertheless, risk factors for complications are identified, several of which can be affected by surgeon choice of surgical venue, additive procedures, duration of operation, and type of anesthetic. The study provides a standard reference for professionals when counseling patients and in guiding clinical practices. Clinical question/level of evidence Risk, III.

Introduction Training residents for cosmetic surgery is challenging. This study's goal is to identify the mastopexy spectrum, comparing private and academic practice, and determine the impact on resident training and readiness. Methods An institutional review board-approved retrospective analysis of the senior author's mastopexy practice was performed: 5 years private; 5 years academics consecutively. Indications for surgery, type of surgery, and complications (return to operating room, hospital readmission, prosthesis loss, nonoperative hematoma, seroma, wound dehiscence, infection) were recorded. Surveys were sent to all graduated, board-certified plastic surgeons (all in private practice) who trained in performing mastopexy with the lead surgeon in our apprenticeship model. Results A total of 246 mastopexies were reviewed (155 in private practice and 91 in academic setting). There were 7 main indications for mastopexy identified: ptosis, postpartum atrophy, nonsurgical weight loss, surgical weight loss, asymmetry, reconstruction/balancing, revision from previous augmentation. Fisher exact test was performed. Primary mastopexy alone was significantly more prevalent in private practice (P = 0.0184). Revisional mastopexy/augmentation was significantly more prevalent in academic practice (P = 0.0047). There was no statistical difference in major or minor complications between private and academic setting (P = 0.077 and P = 0.219, respectively). All graduated trainees reported being "comfortable" or "very comfortable" performing mastopexies. Discussion Primary mastopexy is more commonly performed in a private practice setting. Mastopexy, in academics, is more likely in conjunction with reconstruction/balancing. Despite lesser representation of pure cosmetic mastopexy, trainees are well prepared for mastopexy. This indicates that principles and techniques of aesthetic surgery are adequately taught.

Purpose Latissimus dorsi (LD) breast reconstruction is of proven efficacy. Advantages of thoracodorsal nerve transection are potential prevention of muscle spasticity/movement; disadvantages are possible long-term muscle atrophy and volume loss. This study's purpose is to provide data that would support or refute nerve transection. Methods A retrospective study of all LD breast reconstruction patients from 2011 to 2017 was done. Total number of flaps was identified, as was thoracodorsal nerve transection. Outcomes were noted for symptomatic muscle spasticity/involuntary movement, and complications inclusive of hematoma, seroma, and capsular contracture. Results A total of 125 patients had 170 flaps. Eighty-one flaps had nerve transection; 89 did not. These cohorts had no differences in comorbidities, indications of surgery (cancer vs prophylactic), irradiation, delayed/immediate reconstruction, and use of expanders. Symptomatic muscle movement/spasticity was not significantly different: 3 (3.7%) of 78 in transection and 5 (5.6%) of 84 in nontransection (P = 0.55, χ). Incidence of seroma in the transection group was notably higher (18/81; 22% vs 12%) but not statistically significant (P = 0.09, χ). No differences existed in all other outcomes. Conclusions Symptomatic spasticity or involuntary muscle movement occurs in a small number of patients with LD breast reconstruction and is not affected by thoracodorsal nerve transection. Movement after transection is likely due to aberrant nerve innervation and reinnervation. The absence of movement without transection is due to disruption of muscle position and origin after transfer. Seroma formation may be affected by increased axillary dissection required for nerve transection. These data do not support nerve transection, and therefore, it is not recommended.

INTRODUCTION Postmastectomy breast reconstruction with saline tissue expanders requires frequent saline injections. Air expanders contain an air canister and patient-operated remote to control expansion. The aim of this study was to evaluate the effectiveness of air expanders, inclusive of cost. METHODS An international review board-approved retrospective review was performed of women who underwent breast tissue expansion between January 1, 2005 and February 5, 2019. Data collected included demographics, distance from clinic, mastectomy type, breast cancer treatment, expander type, expansion duration, postoperative visits, expansion visits, and postoperative complications. We compared true, unrealized, and overall costs and efficiency measured by time for expansion completion. True cost was calculated by adding expander, saline, and needle prices. Unrealized cost was calculated by multiplying number of visits for expansion by the expense of roundtrip driving. T tests and z scores determined clinical significance. RESULTS Postoperative complication rates were not significantly different between groups. The air expansion mean true cost was US $1006.11 more than saline expansion (P < 0.001), whereas the mean unrealized cost was US $551.81 less (P = 0.008). The air expansion mean overall cost was US $461.43 more than saline expansion (P = 0.063). There was no significant difference in time to expander-to-implant exchange. CONCLUSIONS This study demonstrates that saline and air expanders have no difference in complications or ability to complete expansion. However, there is significantly higher unrealized cost of saline expansion due to needle and saline costs and travel for more frequent doctor visits. However, saline expansion overall cost is less than air expansion, but statistically insignificant. Air expanders are effective in properly selected patients.

Background A variety of regional nerve blocks have been utilized in abdominoplasty procedures, including transversus abdominis plane (TAP), intercostal, rectus sheath (RS), pararectus + ilioinguinal/iliohypogastric, quadratus lumborum, and paravertebral blocks. No consensus exists regarding the most effective nerve block modality in optimizing postprocedural comfort levels. Objectives The purpose of this systematic review was to explore the efficacy of the various abdominal nerve blocks employed in abdominoplasty surgery and to draw attention to any modality that may be superior in regards to effectiveness and/or administration. Methods Utilizing Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic review was performed to identify studies that have employed regional nerve blocks in abdominoplasty procedures. Opioid consumption, pain scores, time to ambulation, time in the recovery room, and time to first analgesia request were extracted when available. Results A total of 191 articles were reviewed, of which 8 met inclusion criteria. The nerve blocks represented included TAP, RS, pararectus + ilioinguinal/iliohypogastric, intercostal, and quadratus lumborum. All modalities were effective in reducing opioid consumption except quadratus lumborum. Conclusions TAP, RS, pararectus + ilioinguinal/iliohypogastric, and intercostal regional nerve blocks have been shown to optimize postoperative pain management in abdominoplasty procedures. The existing literature suggests that when studied against one another, TAP is more efficacious than RS and pararectus + ilioinguinal/iliohypogastric. When ultrasound guidance is unavailable, consideration should be given to TAP employing the direct visualization approach. Level of Evidence: 2

The minimal access cranial suspension (MACS) facelift is a minimally invasive face and neck lift that uses the understanding of the changes in facial anatomy as it relates to facial aging. The MACS facelift uses a shorter incision with limited subcutaneous undermining. It achieves a resuspension of the underlying neck and midface soft tissues with the use of looped, purse-string sutures in the superficial musculoaponeurotic system and platysma. These attenuated structures are anchored to the deep temporal fascia. In the properly selected patient, the MACS facelift is an effective technique with high levels of physician and patient satisfaction.

BACKGROUND Diabetes mellitus is a well-known risk factor for infection after trigger finger (TF) injection and/or release. However, the effect of preoperative hypoglycemia before TF injection or release is currently unknown. The purpose of this study is to determine the effects of preoperative hypoglycemia on infection incidence after TF injection or release. METHODOLOGY A retrospective cohort review between 2007 and 2015 was conducted using a national private payer database within the PearlDiver Supercomputer. Preoperative, fasting, glucose levels were collected for each patient, and these ranged from 20 to 219 mg/dL. Surgical site infection (SSI) rates were determined using International Classification of Diseases, Ninth Revision codes. RESULTS The query of the PearlDiver database returned 153,479 TF injections, of which 3479 (2.27%) and 6276 (4.09%) had infections within 90 days and 1 year after procedure, respectively. There were 70,290 TF releases identified, with 1887 (2.68%) SSIs captured within 3 months after surgery and 3144 (4.47%) within 1 year after surgery. There was a statistically significant increase in SSI rates in patients with hypoglycemia within 90-day (P = 0.006) and 1-year (P < 0.001) time intervals post-TF injection. Likewise, a statistically significant increase in SSI rate in patients with hypoglycemia undergoing TF release within 1 year after release was seen (P = 0.003). CONCLUSIONS Hypoglycemia before TF injection or release increases the risk for SSI. Tight glycemic control may be warranted to mitigate this risk. Further studies are needed to investigate the effect of hypoglycemia as an independent risk factor for SSI.

Background Aesthetic surgery is a critical component of academic plastic surgery. As institutions are placing increased focus on aesthetic surgery, there is an opportunity to identify factors that facilitate the creation and maintenance of successful aesthetic plastic surgery programs. Objectives The aim of this study was to conduct a national survey to evaluate the current state of academic aesthetic surgery and to identify factors that contribute to success. Methods A REDCap 122-question survey was developed and validated by members of the Academic Aesthetic Surgery Roundtable (AASR). The national survey was distributed to department chairs and division chiefs with active ACGME-approved plastic surgery programs (n = 92). Responses underwent Pearson’s chi-squared, Wilcoxon rank-sum, and postselection inference analyses. AASR members convened to interpret data and identify best practices. Results Responses were received from 64 of 92 queries (69.6%). The multivariate analysis concluded traits associated with successful academic aesthetic surgery practices included the presence of aesthetic surgery–focused, full-time faculty whose overall practice includes >50% aesthetic surgery (P = 0.040) and nonphysician aesthetic practitioners who provide injection services (P = 0.025). In the univariate analysis, factors associated with strong aesthetic surgery training programs included resident participation in faculty aesthetic clinics (P = 0.034), aesthetic research (P = 0.006), and discounted resident aesthetic clinics (P < 0.001). Conclusions The growth of academic aesthetic surgery practices represents a significant opportunity for advancement of resident training, departmental financial success, and diversification of faculty practices. By identifying and sharing best practices and strategies, academic aesthetic surgery practices can be further enhanced.

Supplemental Digital Content is available in the text., Background: Both the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) and the American Society of Plastic Surgeons Tracking Operations and Outcomes for Plastic Surgeons (TOPS) databases track 30-day outcomes. Methods: Using the 2008–2016 TOPS and NSQIP databases, we compared patient characteristics and postoperative outcomes for 5 common plastic surgery procedures. A weighted TOPS population was used to mirror the NSQIP population in clinical and demographic characteristics to compare postoperative outcomes. Results: We identified 154,181 cases. Compared with NSQIP patients, TOPS patients were more likely to be younger (47.9 versus 50.0 years), have American Society of Anesthesiologists class I-II (92.1% versus 74.6%), be outpatient (66.0% versus 49.3%), and be smokers (18.7% versus 11.7%). TOPS had extensive missing data: body mass index (40.6%), American Society of Anesthesiologists class (34.9%), diabetes (39.3%), and smoking status (37.2%). NSQIP was missing

Purpose: Despite making up 20-25% of hand surgeons with subspecialty certification in the field, little data exists characterizing the clinical practice of hand surgery among plastic surgeons. This study sought to evaluate hand surgery cases in the national Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database. Methods: All hand procedures logged in the TOPS database between 2002 and 2016 were identified by CPT code and/or “upper extremity” anatomic classification. Trends in the total number and types of procedures, facility type, admission type, modes and providers of anesthesia, and patient demographics were reviewed. Results: A total of 182,137 hand procedures performed on 82,811 patients were logged during the 15-year period reviewed. Sixty-eight percent of procedures were classified as involving soft tissue only, and 22.7% involved only bone and/or joint. The most common procedure categories included: wound closure/coverage (15.8%), debridement/drainage (15.3%), nerve (13.2%), tendon (12.9%), and fracture/dislocation (12.9%). This category breakdown remained relatively stable over time. Evaluation of longitudinal trends identified an increase over time in procedures performed in the ambulatory and office-based settings and the use of local anesthetic, as well as a transition from the procedural surgeon providing anesthesia to the use of anesthesiologists and nurse anesthetists. The average patient ASA increased from 1.27 to 1.83. Conculsions: Plastic surgeons play an important role in the field of hand surgery, performing a large breadth of procedure types, which has remained stable over time. The trends in facility type and anesthesia characteristics have, however, varied.

BACKGROUND Integrative medicine (IM) is currently used by 40% of Americans. Our objective is to examine the prevalence and perception of IM utilization in patients being evaluated for elective plastic surgery. METHODS In July 2014, 402 consecutive patients presenting to plastic surgery clinics at the University of Florida, Veterans Affairs (VA), and Private Practices in Gainesville, Florida were requested to complete a survey regarding utilization of and attitudes towards IM. RESULTS The survey completion rate was 75.5% (n = 331). The respondents' mean age was 48.5 years, and they were primarily white (75%), married (48%), and educated with at least a college degree (58%). The respondents were distributed between the university (74%), VA (15%), and private practice (11%). There was an equal mix of reconstructive (52%) and cosmetic (48%) visits. Overall IM utilization was 80.0%. Integrative medicine use correlated with having a college degree (P = 0.0002) and being middle age (40-64 years, P < 0.005). A higher utilization rate of IM in the private sector (87.0%) compared with the university (76.1%) and VA (71.0%) was not statistically significant (P = 0.17). Similarly, higher IM utilization in cosmetic patients compared with reconstructive patients (81% vs 74%) was not statistically significant (P = 0.56). The majority of patients stated a strong belief in self-healing techniques (71%, P < 0.005), and they desired (61%) that their physician should be familiar with these techniques (P < 0.005). CONCLUSIONS The IM utilization is highly prevalent among plastic surgery patients regardless of reason for visit (cosmetic versus reconstruction) or practice setting (private versus academic versus VA). Increasing awareness of IM usage and potential impact on outcomes is especially important for academic and VA plastic surgeons. Moreover, an opportunity exists to study how certain aspects of IM can positively impact plastic surgery care.

BACKGROUND Microsurgery is performed using either the operating microscope or loupe magnification. Use of the operating microscope is considered the "criterion standard"; however, loupes are emerging as a safe and reliable technique to perform microsurgery. The purpose of this study was to analyze the safety of microsurgery under loupe magnification compared with the microscope. Previous studies discussing the safety of loupe magnification during microsurgery have been published; however, this is the first study to compare free flap outcomes from 2 surgeons at the same institution, each using their respective technique. METHODS The outcomes were compared by retrospective chart review of 116 patients, and 148 microvascular free tissue transfers were performed between January 1, 2013, and July 15, 2016, by 2 surgeons (D.S.) and (M.L.). Patients' demographics, free flap failure rate, and other surgical complications were analyzed. Statistical significance was determined by unpaired t test, and χ analysis was used to determine statistical significance in proportions between groups. RESULTS Thirty-eight percent of flaps were performed under ×3.5 loupe magnification and 62% under the operating microscope. Most free flaps used were deep inferior epigastric perforator or muscle sparing transverse rectus abdominis flaps (52%) for breast reconstruction, remainder of free flaps included ALT, radial forearm, and latissimus dorsi for a variety of reconstructive applications. There was no significant difference between the loupes and microscope groups in intraoperative anastomotic revision rate (27% vs 17%), postoperative arterial or venous thrombosis (4.4% vs 2.6%, 5.4% vs 2.2%), flap loss (3.6% vs 2.2%), or median length of stay (6 days vs 6.5 days). The loupe magnification group had statistically significant shorter setup time (20 minutes, P < 0.01). CONCLUSIONS Consistent with previously reported studies, we found no statistical difference in free flap outcomes and safety under loupe magnification compared with the operating microscope. This is the first study to demonstrate these findings with 2 microsurgeons both in their first 3 years in practice, with similar training and experience, operating at the same institution and given the same resources, each using either microscopes or loupes for microsurgery.

BACKGROUND Poland syndrome typically presents as a unilateral congenital complete or partial absence of the pectoralis major muscle, variably with other associated anomalies. Reconstruction of the defect typically concentrates on aesthetic restoration with functional outcomes being unsuccessful or limited. We present an innovative means of true muscle transfer that provided functional benefit to increase upper extremity strength. CASE REPORT A 16-year-old adolescent boy with Poland syndrome manifesting as left pectoralis major muscle agenesis wished to undergo functional reconstruction. He wanted to play on his high school football team, but could not meet the minimum weightlifting requirements. An ipsilateral latissimus dorsi muscle bipolar functional transfer was done with bone-anchored inset into the sternum and humerus so that muscle flexion would replace the absent pectoralis major. A progressive weight training program was then instituted postoperatively. At 9 months, a significant increase in left upper extremity strength was confirmed. The patient ultimately was able to surpass the weightlifting requirements for his high school football team, and joined the team. CONCLUSIONS Our highlighted procedure restored functional outcome using both plastic surgical principles and orthopedic techniques for muscle and tendon repair: bipolar muscle transfer and load-bearing muscle inset. Heretofore, transfer of the latissimus for provision of pectoralis major function has not been reported. Functional reconstruction was possible due to stable, bipolar muscle transfer with load-bearing muscle attachments into cortical bone of the anterior sternum and anteromedial aspect of the humerus. The techniques described should be within the skill set of most plastic surgeons, so that functional restoration for those with Poland syndrome is possible and accessible.

INTRODUCTION Multiple techniques exist for reduction mammoplasty, but no singular consensus exists as to which method is the most effective in providing an aesthetically pleasing breast. We reviewed our institution's reduction mammoplasty experience over a 2-year period to evaluate aesthetic and surgical outcomes comparing superiorly based pedicles with skin excisions resulting in either an inverted T or vertical scar. METHODS An IRB-approved retrospective review of our institution's surgical database identified patient characteristics and outcomes of all breast reductions performed over a 2-year period (n = 104). A subgroup analysis of patients with complete preoperative and postoperative photographs (n = 56) evaluated postoperative aesthetics on a scale of 1 to 5 (1, poor; 5, excellent). RESULTS Techniques included a superomedial pedicle with an inverted T-pattern skin excision (n = 81) and pure vertical reduction (n = 23). There was no significant difference in complications between techniques. Common patient risk factors (age, body mass index [BMI], and smoking status) did not correlate with postoperative complications. In the photograph analysis subgroup, inverted T scar pattern reductions had a significantly better scar quality score (3.5 vs 3.2, P < 0.05). In analysis of all subjects, volume of tissue resected was a significant factor in determining overall aesthetic score, with resections of less than 1300 g being significantly associated with an overall aesthetic score of 4 or higher. Logistic regression demonstrated patient age younger than 40 years was a significant contributor to aesthetic score of 4 or higher (P < 0.05). DISCUSSION We reviewed our institution's experience with 2 common breast reduction techniques. Better scarring was associated with inverted T scar pattern versus vertical pattern. Additionally, rather than pedicle type or skin excision pattern, patient age and weight of tissue resected were the most important contributors to an aesthetically optimal outcome. This study suggests that a single superlative technique does not exist. Rather, inherent patient characteristics are most important in provision of the best aesthetic outcome.

INTRODUCTION Unanticipated postoperative readmissions are a grading metric directly linked to both the quality of patient care and physician reimbursement. However, little data exist to define factors responsible for these readmissions in the plastic surgery patient population. This study aims to identify patient risk factors contributing to unanticipated postoperative readmissions to optimize perioperative patient care and mitigate negative financial impact upon providers. METHODS We present an institutional review board-approved study retrospective review of 819 plastic surgery patients undergoing operative procedures performed at our institution between January 1, 2013, and December 31, 2014. All unanticipated readmissions within 30 days of an operation were identified and subjected to statistical analysis in an effort to determine whether these readmissions were associated with identifiable patient risk factors. RESULTS One hundred forty-nine (18.1%) of the 819 investigated patients underwent readmission, reoperation, or both within 30 postoperative days. Seventy-four (9%) patients required hospital readmission, alone; 55 (6.7%) underwent readmission with operative intervention; and 20 (2.4%) required outpatient operative intervention without readmission. Readmitted patients were significantly more likely to have a positive smoking history (P = 0.009), hypertension (P = 0.0008), congestive heart failure (P = 0.0015), chronic obstructive pulmonary disease (P = 0.023), a higher mean age (P = 0.0001), and a higher Charlson Comorbidity Score (P = 0.0001). CONCLUSIONS These results identify risk factors associated with unanticipated postoperative readmissions specific to a plastic surgery patient population. With this information, practitioners can allocate appropriate perioperative resources and planning for patients at increased risk for readmission, thereby improving delivery of patient care and satisfying quality metrics linked to practitioner reimbursement.

Background Highly cited publications are referred to as citation classics and can signify important contributions to a discipline. Although citation classics in plastic surgery have been identified, none were published before 1960. Citation classics in earlier periods may contain the historical roots or intellectual origins of the field. We set out to identify such scholarly works and analyze their characteristics. Methods A novel technique of citation analysis, referred to as reference publication year spectroscopy, was used to analyze the literature. The spectrogram revealed distinct peaks before 1960, which corresponded to 20 citation classics. These 20 references were then analyzed with respect to historical context, topic of interest, anatomical region, originality, and if authors were named for their findings (eponyms). Results Twenty distinct citation classics (published from 1851 to 1959) were identified, accounting for 430 literature citations. Salmon's "Arteres de la Peau" was the most cited reference, followed by Gillies' "Principles of Plastic Surgery" and Neuber's "Fat Grafting." The theme of angiosomes was highly represented. Most citation classics dealt with reconstruction of acquired defects (37%) and primarily focused on the head and neck regions (45%). Thirty-five percent of clinical studies were noted for their originality, and 5 studies earned their authors' eponymous distinctions. Conclusion The roots of modern plastic surgery began in the late 19th century with early efforts to describe cutaneous vasculature. Historical studies that either establish principles or lead to an advancement in our reconstructive methods have the best chance of achieving classical status.

Background Mastopexy and reduction mammaplasty are often limited by the patient's poor native soft tissue quality, resulting in ptosis recurrence and loss of rejuvenated surgical results. Surgical scaffolds and acellular dermal matrices are used in these procedures to provide physical and mechanical stabilization of weakened or compromised tissue. GalaFLEX scaffold, made from poly-4-hydroxybutyrate (P4HB), is a next-generation product for soft tissue reinforcement that resorbs gradually while aiding tissue regeneration to achieve excellent outcomes. Objectives To assess the clinical performance of GalaFLEX scaffold in soft tissue reinforcement during elective mastopexy and reduction mammaplasty. Methods This multicenter, single-arm, observational study assessed product performance and outcomes of GalaFLEX scaffold when used in breast surgery. Outcomes included ptosis correction and maintenance, associated adverse events, patient and surgeon satisfaction, and mammographic and ultrasound imaging evaluation. Results At 6 centers in the US, 62 of 69 enrolled patients were treated. Of this population, 89.7% had successful ptosis correction and maintenance at 1 year, with high patient and surgeon satisfaction for breast shape, droop/sag of the breast, and maintenance of results at 1 year. There were 5 adverse events deemed related to the device (8.0%), including nerve pain, breast swelling, ptosis, and 2 instances of asymmetry. Conclusions GalaFLEX scaffold safely and successfully supports and elevates breast tissue in mastopexy and reduction mammaplasty, with maintained support at 1 year. Surgeon and patient satisfaction were high. No mammogram or ultrasound interference was detected. Level of Evidence 4

BACKGROUND Facial rejuvenation is an elective procedure commonly performed to combat the consequences of normal aging. The senior author's practice initially consisted of traditional facelifts with superficial muscular apopneurotic system plication and/or superficial muscular apopneurotic system flap. After the development of the minimal access cranial suspension (MACS) technique by Tonnard et al., the senior author transitioned to an almost exclusive MACS facelift practice. The purpose of this study was to determine the efficacy of the MACS technique versus the traditional facelift approach and objectively incorporate these results into practice. METHODS A retrospective cohort study design was performed to identify all patients who underwent a facelift by the senior author between January 1, 2013, and December 31, 2015. Patient demographics, comorbidities, type of procedure, complications, revision surgery, and objective surgeon satisfaction were among the parameters recorded. This was compared with an historical cohort of the senior author's earlier experience. RESULTS There was a statistically significant decrease in the use of the MACS facelift procedure between this study and the senior authors' seminal study. Within this study cohort, compared with conventional facelift, the MACS technique was done on younger patients, proved to have significantly shorter operative time, mean follow up, and allowed for additional concurrent non-facial procedures when compared with the traditional approach (all comparisons significant at P < 0.05). However, continued postoperative neck laxity, submental pleating, and periocular pleating were seen with the MACS technique. CONCLUSIONS The current study shows that the MACS technique is better suited for young patients with lesser cervical bulk or laxity and provides an opportunity for concurrent nonfacial procedures. Objective assessment with recognition of the limitations of the MACS technique versus the traditional facelift approach has led to a change in the senior author's practice. Although the MACS lift incurs shorter procedure time and quicker recovery, it does demonstrate limitations when it comes to marked skin laxity and bulky necks/platysmal banding. Both techniques are used with in line with the respective limitations and advantages.

Introduction Minimal access cranial suspension (MACS) facelifts provide the potential advantage of less invasiveness with quicker recovery. However, there is deficient literature documenting its usefulness and limitations. Purpose This study aimed to evaluate the MACS lift for effectiveness in facial rejuvenation. Methods Institutional review board approved record review of all facelift patients treated August 2006 to October 2011 by a single surgeon. Results Eighty-eight facelifts were done, 8 conventional and 80 MACS. Average age was 59 years with 97% being women. Average body mass index and American Society of Anesthesiology classification score were 25 and 1.6 Kilograms per meter squared, respectively. The only significant complications noted were 3 hematomas that required drainage: all in the MACS group (3.41%); and 1 temporary buccal branch paresis. Other facial procedures were done on all the conventional patients and 59 (74%) of the MACS patients. Notably 8 (10%) of the MACS patients had a nonfacial procedure done concurrently. Average operative times were significantly longer for the conventional lifts at 4:03 compared to 2:39 for all the MACS lifts (: -0.002); 2:05 for MACS alone. Follow-up averaged 6 months (4 to 49). Average return to work in the MACS group was 2 weeks. All conventional lift patients had a high level of satisfaction. Of the MACS patients, 3 expressed disappointment due to residual facial skin laxity or inadequate neck contouring. Conclusions MACS lift is effective, providing a high level of patient satisfaction due to aesthetic results, combined with rapid recovery and return to normal activities. Compared to conventional facelift, the reduced operative time makes concurrent nonfacial procedures more feasible. Effectiveness has limitations in those with marked skin laxity and/or marked cervical lipodystrophy.

A bipedicle ischaemic rat skin flap model was used to study the effects of daily topical applications of platelet-derived growth factor (PDGF) on the healing of ischaemic wounds. Levels of tumour necrosis factor-alpha (TNFA), interleukin 1-beta (IL1B) and both the latent and active forms of matrix metalloproteinase 2 (MMP2) and 9 (MMP9) were measured. Full-thickness wounds were made on a total of 72 adult male Sprague-Dawley rats. Each group of 18 rats with normal and ischaemic wounds received either vehicle or 0·01% recombinant PDGF-BB. Additional applications were made on the wounds on a daily basis. Wound areas were measured at 0, 1, 3, 5, 7 9 and 13 days after wounding. Ischaemia caused a delay in wound healing as well as an increase in TNFA, IL1B and both the pro and active forms of MMP2 and MMP9. PDGF accelerated the rate of wound healing in both normal and ischaemic wounds and negated the effect of ischaemia. PDGF reduced the TNFA concentration in both normal and ischaemic wounds, and the rate of wound healing closely resembled the pattern of TNFA protein expression. PDGF also reduced both the magnitude and duration of the increases in IL1B and both the pro and active forms of MMP2 and MMP9 induced by ischaemia.

Background The current gold standard therapy for hidradenitis suppurativa (HS) is surgical resection. However, despite complete resection, the reoperation rate is reported as high as 54% due to wound infections and disease recurrences. Our hypothesis is that this high recurrence rate is related to retained disease and infected tissue not included in soft tissue resection, namely the lymph nodes. Therefore, performing a superficial lymphadenectomy with nodal microbacterial analysis would remove all infected tissue, eradicate the disease, and allow more specific targeted antibiotic therapy. Methods From 2004 to 2009, 11 patients underwent 15 wide en bloc resections including superficial lymphadenectomy with flap reconstruction for axillary HS. A retrospective review was performed with the following outcomes assessed: culture results, hospital stay, and recurrences of HS. Results Patients were followed up for an average of 4.3 years. During this time, there were no wound complications or disease recurrences. Positive bacterial cultures occurred in 12 of 14 nodes with results that differed from the soft tissue purulence. This led to a 75% change in antibiotic regimen. Superficial abscess cultures were uniformly covered, whereas only 3 of 12 nodal cultures where sensitive to our empiric antibiotic coverage. No patients developed lymphedema or any loss of function in the involved upper extremity. Conclusions Axillary HS has traditionally been a challenge due to the morbidity of care and high recurrence. Our data show that an en bloc resection with a superficial lymphadenectomy and subsequent antimicrobial therapy based on both the soft tissue and the lymph nodes can provide a definitive cure.

The lower body lift (LBL) is a comprehensive body contouring procedure done after massive weight loss. Because of the magnitude of the operation and demands of subsequent care, it has traditionally been viewed as an inpatient procedure. However, it is believed that with surgical experience combined with fine tuning of perioperative and postoperative care, lower body lifting is safe as an outpatient in properly selected patients.In this article, we retrospectively review and evaluate our series of 35 patients (19 outpatient and 16 inpatient), who have undergone lower body lifting after massive weight loss. Operative technique, perioperative management, and postoperative care are reviewed.Compared to the inpatients, the body mass index of the outpatients was significantly less: 24.99 compared to 30.89 kg/m, respectively (P = 0.002 χ value 7.886). Reoperations did not occur in any of the 19 outpatient LBL procedures, but were necessary in 6 of the 16 inpatients, all for wound closure (P0.001 χ value 25.811). No patient in either group had thromboembolic occurrences, clinically apparent hematomas, and none required transfusions.Outpatient LBL is safe and effective when performed on the properly selected patient. Avoidance of hospitalization has importance in minimizing nosocomial infections or other complications. There is also potential great influence on access to care due to reduced costs associated with outpatient surgery centers, compared to hospitals. As such, a financial barrier is alleviated to many who cannot otherwise afford these procedures after weight loss.

Introduction Skin flap necrosis after mastectomy can be a devastating complication significantly affecting patient outcomes. Routine vascular analysis (fluorescein or laser angiography) of mastectomy skin flaps in all patients has been advocated but is of questionable cost-effectiveness. The purpose of this study was to identify the incidence and causative risk factors for mastectomy skin flap necrosis and thereby calculate the fiscal reality of intraoperative vascular screening. Methods This is an institutional review board-approved retrospective study of all patients from 2007 to 2013 who underwent mastectomy related to breast cancer. Skin flap necrosis was defined as major if it necessitated return to the operating room. Data analysis was done for determination of causative factors of necrosis, including age, body mass index, smoking, previous irradiation, coronary artery disease, chronic obstructive pulmonary disorder, hypertension, gastroesophageal reflux disease, hyperlipidemia, obstructive sleep apnea, asthma, diabetes, thyroid disease, history of lumpectomy, and breast reduction or augmentation. During this time, intraoperative vascular screening was not done. Results Five hundred eighty-one patients underwent 616 mastectomies with a total of 34 necrotic events (5.5%)-16 major and 18 minor. Analyses via Student t tests, univariate analyses, χ testing, and logistic regression showed that history of smoking was the only patient factor associated with postoperative necrosis (P = 0.008). More frequently represented in the necrosis group, but without statistical significance, are previous lumpectomy (P = 0.069) and immediate reconstruction (P = 0.078).For the entire study period, the actual cost to the hospital for major necrotic events was $7,123.10 or $445.19 for each of the 16 major necrotic events and $209.50 for all 34 necrotic events. Per-patient cost-effective screening would need to be less than $11.54 for all patients, $100.33 for highest risk patients (smokers), and $21.65 for highest risk patients (smokers, previous lumpectomy, and immediate reconstruction). Conclusions Vascular screening other than clinical judgment of all patients is not cost effective. However, intraoperative vascular evaluation of high-risk patients is recommended before reconstruction and/or closure. These financial data that incorporate true costs and revenue can guide the use of newer, more expensive technology such as laser angiography and can be extrapolated to other institutions.

Venous thromboembolism (VTE) is a serious complication in postoperative patients which can have life-threatening and debilitating consequences. Abdominoplasty has one of the highest rates of VTE of any plastic surgery procedure. The perceived risk for postoperative bleeding due to the large surface areas involved in abdominoplasty have led many surgeons to avoid using chemoprophylaxis in these patients. However, with the recent movement toward quality in healthcare and the popularization of “never events,” this topic has been reevaluated in the literature. Previous guidelines would recommend the use of SCDs in the OR with the optional use of unfractionated heparin postoperatively. Recent publications from several groups have shown efficacy and safety in postoperative use of low-molecular-weight heparin in high-risk groups. Our group recently evaluated the use of LMWH both pre- and postoperatively with no increase in bleeding complications or hematoma. Based on these findings, our current protocol is to give all patients undergoing abdominoplasty enoxaparin 40 mg SQ on call to the OR and once daily for 2 days postoperatively.

Medical research has a long history of joint venture between commercial entities and nonindustry researchers. Significant concern exists among accrediting bodies for medical education and federal granting agencies that conflicts of interest (COIs) exist that affect the validity of the research. This study evaluates the legitimacy of this concern.All clinical breast and cosmetic articles in Plastic and Reconstructive Surgery and Annals of Plastic Surgery were reviewed for calendar year 2013. If a financial disclosure was present, the article was then reviewed to determine if the subject/findings were in favor of the commercial conflict and, if so, whether the study was valid. To assess plastic surgery versus other specialties, articles from Dermatology and Journal of Bone and Joint Surgery were similarly reviewed from January to April of 2013.Two hundred seventy-two clinical articles were reviewed. Only 15 (5.5%) had a true COI: the article's findings favored the commercial interest of at least 1 author: for each journal, Plastic and Reconstructive Surgery, 7.7%; Annals of Plastic Surgery, 3.3%; Dermatology, 2.2%; Journal of Bone and Joint Surgery, 7.5%. Conflicts of interest were not statistically significant between pooled articles of plastic surgery versus dermatology/orthopedics. However, COI was statistically greater (P = 0.05) in Plastic and Reconstructive Surgery compared with Annals and Dermatology.Despite public and regulatory concerns, this assessment demonstrates that the peer-review process of leading journals polices true COIs. Published articles provide sound research despite presumed COIs. As such, the integrity and validity of published research remain high.

Objective In recent years, there has been a transition in plastic surgery residency training. Many programs across the country are now using integrated training modalities vs. independent training programs. This change in residency training has brought into question the effectiveness of integrated residency programs, in which medical students immediately enter the plastic surgery specialty upon graduation. This study assessed plastic surgery residency program directors and faculty members׳ viewpoints on the transition to integrated training programs and the effect this transition has had on the training of plastic surgery residents. Design An anonymous 13-question survey was formulated using a pilot survey sent to members of the plastic surgery department at the University of Florida. The final survey was then electronically sent via SurveyMonkey.com to 92 current plastic surgery residency program directors. Program directors were identified via program lists provided by the American Council of Academic Surgeons. Program directors were then asked to forward the survey to faculty members of their respective institutions. Responses collected were analyzed via SurveyMonkey.com and Microsoft Excel. Setting University of Florida College of Medicine, Department of Plastic Surgery. Participants Plastic surgery residency program directors as identified by the American Council of Academic Surgeons. Results A response rate of 40.2% was achieved via 37 of the 92 plastic surgery program directors responding to the electronic survey. An additional 6 anonymous faculty members also responded to the survey, 13.9% of all responses. Institutions indicated that the majority was using integrated residency programs, with some institutions using both integrated and independent training programs simultaneously. Most respondents indicated that they supported the transition to the integrated residency program at their respective institutions. Respondents indicated several reasons as to why or why not programs have transitioned to the integrated program, with lack of funding being the primary indication of not making the transition. Upon responding with their level of agreement to several statements, respondents indicated that they agreed that the integrated training program is superior to the independent program and is not negatively effecting the specialty. Conclusions The transition to the integrated plastic surgery residency program is continuing to grow. Most respondents in this survey indicated their belief in the superiority of the integrated program. However, a large proportion of respondents stated that they neither agreed nor disagreed with several of the provided statements concerning which residency program is superior. Thus, further research is needed to discern whether or not the integrated program is in fact superior to the independent residency training program.

BACKGROUND Abdominoplasty is one of the highest risk plastic surgery procedures for venous thromboembolism complications (VTE). Current recommendations for VTE prophylaxis are sequential compression devices (SCDs) in the OR and optional use of subcutaneous heparin after surgery. Subcutaneous heparin has been shown to be safe in other surgical groups. However, the large raw surface areas and dissection involved in abdominoplasty has been a relative contraindication for preoperative chemoprophylaxis. However, the period while the patient is under general anesthesia and immediately following the procedure is likely the highest risk time period for VTEs. The purpose of this study is to determine if preoperative chemoprophylaxis is safe in these patients. METHODS All patients undergoing abdominoplasty by the senior author from January 1, 2005 to January 1, 2012 were retrospectively reviewed. All patients whose operation took place between January 1, 2005 and January 18, 2008 were given SCDs before the induction of anesthesia and heparin (unfractionated) 5000 units s.q. on call to the OR. All patients whose operation took place between January 19, 2008 and January 1, 2012 received enoxaparin (low molecular weight heparin) 40 mg s.q. on call to the OR and then daily for 2 days postoperatively. These groups were evaluated in regards to overall complication rate, incidence of VTE, and bleeding complications. RESULTS A total of 151 patients underwent abdominoplasty during the study period. One hundred one patients received the SCD/heparin protocol and 50 had the enoxaparin protocol. The groups were similar in regard to pre-morbid conditions and risk factors for VTE. There were no VTEs diagnosed in either group. The overall incidence of any complication was similar between the 2 groups (19% vs. 14%, P = 0.503) and similar to other published series. The most common complications were seroma, cellulitis, and minor wound dehiscence. The incidence of bleeding complications was similar between the 2 groups (1% vs. 0%, P = 1.0). CONCLUSIONS The use of preoperative chemoprophylaxis in patients undergoing abdominoplasty can be done without an increase in bleeding complications or overall complication rate. Furthermore, enoxaparin can also be used preoperatively and continued for 2 more days during the period of time of maximum immobility with easy administration for outpatients via use of a prescription home use kit.

Objective vascular assessment is frequently required before microvascular reconstruction involving the lower extremities. The purpose of this study was to evaluate the reliability of magnetic resonance angiography (MRA) for preoperative assessment before free flap surgery. Five patients underwent preoperative MRA: one before fibula harvest for oromandibular reconstruction, and four before muscle free flap reconstruction of the lower extremity. In all patients, the tibioperoneal trunk, anterior tibial, posterior tibial, and peroneal arteries were well visualized to the ankle, including pathological occlusions. The radiographic findings were demonstrated at surgery and were confirmed to be accurate. These findings facilitated and guided the surgical procedure. This study strongly suggests the accuracy and surgical relevance of MRA before free flap surgery. MRA is desirable over angiography because of its noninvasive nature. It may also be better than ultrasonography because the latter is highly dependent on the technician (particularly in identifying the peroneal artery). MRA may likely replace angiography as the objective procedure of choice before microvascular surgery.

Fetal wound healing proceeds rapidly with minimal inflammation and fibroplasia and little or no scar formation. These observations have led to the hypothesis that fetal wound healing more closely resembles regeneration rather than adult wound repair. To test this hypothesis, this study used ultrastructural analysis of fetal and adult fibroblasts and collagen to gain greater insight into differences in the healing processes. Full-thickness, primarily closed linear incisions were created dorsally on 24-day gestational age fetal rabbits (n = 9). The fetuses were killed 5 days later, and the wounds were excised and evaluated with transmission electron microscopy. Similarly, uninjured fetal skin of the same gestational age was obtained and analyzed. Adult rabbit dermal wounds were analyzed after 8 days of healing. Resting adult dermal fibroblasts had features of quiescent, inactive cells, whereas adult wound fibroblasts were highly active and filled with secretory vesicles. In contrast, both fetal normal dermal and wound fibroblasts appeared highly active and contained numerous secretory vesicles. In the adult wound, collagen fibril diameter was only 45% of the diameter of normal dermal collagen. However, fetal wound collagen fibrils were basically the same as normal dermal collagen, having a diameter that was 82% of the size of dermal collagen. These observations suggest that fetal wound fibroblasts do not require activation from an inactivated state and that fetal wound collagen deposition undergoes more rapid organization and maturation. These findings have significance in extending our understanding of the rapidity and functional superiority of fetal wound healing compared with adult wound healing.

Wound healing in many tissue types is essentially the same as that which occurs in skin. The repair processes that occur in bone, tendon, the alimentary tract, skin grafts, and bone grafts are substantially different from cutaneous wound repair. Because surgeons frequently encounter these tissues, it is essential to understand how they heal.

A bipedicle ischaemic rat skin flap model was used to study the effects of daily topical applications of platelet‐derived growth factor (PDGF) on the healing of ischaemic wounds. Levels of tumour necrosis factor‐alpha (TNFA), interleukin 1‐beta (IL1B) and both the latent and active forms of matrix metalloproteinase 2 (MMP2) and 9 (MMP9) were measured. Full‐thickness wounds were made on a total of 72 adult male Sprague–Dawley rats. Each group of 18 rats with normal and ischaemic wounds received either vehicle or 0·01% recombinant PDGF‐BB. Additional applications were made on the wounds on a daily basis. Wound areas were measured at 0, 1, 3, 5, 7 9 and 13 days after wounding. Ischaemia caused a delay in wound healing as well as an increase in TNFA, IL1B and both the pro and active forms of MMP2 and MMP9. PDGF accelerated the rate of wound healing in both normal and ischaemic wounds and negated the effect of ischaemia. PDGF reduced the TNFA concentration in both normal and ischaemic wounds, and the rate of wound healing closely resembled the pattern of TNFA protein expression. PDGF also reduced both the magnitude and duration of the increases in IL1B and both the pro and active forms of MMP2 and MMP9 induced by ischaemia.

Free flap reconstruction in children is often undertaken with trepidation due to a variety of perceived technical difficulties and variable reports of success. The present report examines the efficacy of free tissue transfer in children, with particular attention given to the use of fasciocutaneous flaps in burn reconstruction. Over a 12-year period, 38 free flaps were done on 30 patients with an average age of 10 years (range, 16 months-17 years). Twenty-five flaps were done for burn deformities ; 6 were done for chronic back wounds ; 2 each were done for chronic lower extremity wounds, lower extremity traumatic defects, and a craniofacial deformity ; and 1 flap was done following the resection of a large thigh vascular malformation. The vast majority of the flaps (84%) were fasciocutaneous : 13 groin, 9 scapula, 5 radial forearm, and 4 others. The mean hospital stay was 10 days and there were 11 major complications (29%). Five of 6 flaps were salvaged by reoperation following vascular thrombosis. Six flaps were unsuccessful (84% total success). Three of these flaps were aborted intraoperatively due to technical difficulties, while 3 others were lost postoperatively due to cellulitis, thrombosis, and patient-inflicted flap removal. During follow-up (range, 1-103 months), 39% of patients underwent a minor secondary revision of the flap reconstruction. This series demonstrates the efficacy of free tissue transfer in children in providing the majority of these patients with a successful, one-stage reconstruction with morbidity similar to that reported for adult patients. Moreover, the use of fasciocutaneous free flaps for pediatric burn reconstruction is shown to provide a durable and aesthetically superior treatment of these difficult problems.