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Background Limited surgical literature currently exists that evaluates postoperative complications after cosmetic surgery in adolescents. Objectives The purpose of this study was to determine the incidence of major postoperative complications in adolescent patients undergoing cosmetic surgery and compare their complication rates to older patients. Methods A prospective cohort of patients undergoing cosmetic surgical procedures between 2008 and 2013 was identified from the CosmetAssure database. Demographics, clinical characteristics, surgical procedures, and major complications in adolescent patients (age 10-19 years) and older patients (≥20 years old) were compared. Risk factors analyzed included age, gender, body mass index, smoking, diabetes, type of surgical facility, procedure by body region, and combined procedures. Results Overall, 3519 adolescents and 124,409 older patients underwent cosmetic surgical procedures. The adolescent cohort contained more men (20.0% vs 6.0%, P < 0.01), lower mean body mass index (22.6 ± 4.1 vs 24.4 ± 4.6, P < 0.01), lower prevalence of diabetes (0.8% vs 1.9%, P

We appreciate Dr Swanson's careful reading and comments1 on our recently published articles2,3 and take this opportunity to emphasize the study design, analytical methods, interpretation, and importance of these studies derived from the CosmetAssure data (Aesthetic Surgeons' Financial Group, Birmingham, AL). The goal of a cohort study is to identify an outcome-free population, determine its exposure status at baseline, and then follow it over time until the outcome of interest occurs. Because exposure is identified before the outcome, cohort studies (prospective or retrospective) have a temporal framework to assess causality and thus have the potential to provide the strongest scientific evidence.4 The distinguishing feature of a prospective cohort, such as the CosmetAssure database, is that at the time that the subjects are enrolled and baseline exposure information is collected, none of the subjects has developed any of the outcomes of interest.5 Additionally, as in CosmetAssure, information on all subjects is collected in the same way using identical questions and data collection methods in order to have accurate information about exposures before outcome develops in any of the subjects. However, data analysis cannot take place until outcomes have occurred and, thus, is always retrospective regardless of how the cohort was determined. In contrast, in retrospective cohort studies both exposure status and outcome are ascertained retrospectively.6 In order to ascertain exposure status, the investigator has to go back to preexisting data that was not necessarily acquired in a precise, predetermined way.5 The existing data may be incomplete, inaccurate, or inconsistently measured between subjects.4 This is particularly relevant in designing multicenter cohorts because information may be recorded differently in different electronic health record platforms and some practices may still be using paper charts making data abstraction more challenging. Thus, the primary disadvantage of retrospective …

Background Variation in the anatomical position of the inframammary fold (IMF) in women remains poorly studied. Objectives The purpose of this study was to evaluate the incidence of asymmetry between IMF locations on the chest wall of women undergoing breast augmentation and to determine breast measurements associated with IMF asymmetry. Methods Three-dimensional imaging analysis of the breasts was performed in 111 women with micromastia, using the Vectra Imaging SystemTM. The following measurements were recorded: vertical distance between right and left IMF (inter-fold distance), vertical distance between nipples (inter-nipple distance), and difference between projection of right and left breasts in anterior-posterior direction. Results Asymmetry between the right and left IMF positions was found in the majority of patients (95.4%), with symmetry only found in 5 patients (4.6%). In the majority of patients (60.3%), the right IMF was located inferior to the left IMF with median inter-fold distance 0.4 cm (range, 0.1, 2.1 cm). In 39 patients (35.1%), the left IMF was located inferior to the right with median inter-fold distance 0.4 cm (range, 0.1, 1.7 cm). There was strong correlation between the degree of asymmetry of IMF and asymmetry of nipple areola complex (NAC) positions ( r = 0.687, P < .01). Conclusions The majority of women with micromastia demonstrate asymmetry of the IMF, which correlates with asymmetry of NAC location. The authors propose a classification system based on most commonly observed IMF locations as types I (right IMF inferior to left), type II (left IMF inferior to right) and type III (both IMF located on the same level). Level of Evidence 4![Graphic][1] Diagnostic [1]: /embed/inline-graphic-1.gif

Background The number of men undergoing cosmetic surgery is increasing in North America. Objectives To determine the incidence and risk factors of major complications in males undergoing cosmetic surgery, compare the complication profiles between men and women, and identify specific procedures that are associated with higher risk of complications in males. Methods A prospective cohort of patients undergoing cosmetic surgery between 2008 and 2013 was identified from the CosmetAssure database. Gender specific procedures were excluded. Primary outcome was occurrence of a major complication in males requiring emergency room visit, hospital admission, or reoperation within 30 days of the index operation. Univariate and multivariate analysis evaluated potential risk factors for major complications including age, body mass index (BMI), smoking, diabetes, type of surgical facility, type of procedure, and combined procedures. Results Of the 129,007 patients, 54,927 underwent gender nonspecific procedures, of which 5801 (10.6%) were males. Women showed a higher mean age (46.4 ± 14.1 vs 45.2 ± 16.7 years, P < 0.01). Men had a higher BMI (27.2 ± 4.7 vs 25.7 ± 4.9 kg/m2, P < 0.01), and were more likely to be smokers (7.1% vs 5.7%, P < 0.01) when compared to women. Men demonstrated similar overall major complication rates compared to women (2.1% vs 2.1%, P = 0.97). When specific complications were analyzed further, men had higher hematoma rates, but lower incidence of surgical site infection. Additionally, major complications after abdominoplasty, facelift surgery, and buttock augmentation were noted to preferentially affect males. On multivariate analysis, independent predictors of major complications in males included BMI (RR 1.05), hospital or ambulatory surgery center procedures (RR 3.47), and combined procedures (RR 2.56). Conclusions Aesthetic surgery in men is safe with low major complication rates. Modifiable predictors of complications included BMI and combined procedures. Level of Evidence 2

Background Major complications following aesthetic breast surgery are uncommon and thus assessment of risk factors is challenging. Objectives To determine the incidence and risk factors of major complications following aesthetic breast surgery and concomitant procedures. Methods A prospective cohort of patients who enrolled into the CosmetAssure (Birmingham, AL) insurance program and underwent aesthetic breast surgery between 2008 and 2013 was identified. Major complications (requiring reoperation, readmission, or emergency room visit) within 30 days of surgery were recorded. Risk factors including age, smoking, body mass index (BMI), diabetes, type of surgical facility, and combined procedures were evaluated. Results Among women, augmentation was the most common breast procedure (n = 41,651, 58.6%) followed by augmentation-mastopexy, mastopexy, and reduction. Overall, major complications occurred in 1.46% with hematoma (0.99%) and infection (0.25%) being most common. Augmentation-mastopexy had a higher risk of complications, particularly infection (relative risk [RR] 1.74, P < 0.01), than single breast procedures. Age was the only significant predictor for hematomas (RR 1.01, P < 0.01). Increasing age (RR 1.02, P = 0.03) and BMI (RR 1.09, P < 0.01) were risk factors for infection. Concomitant abdominoplasty was performed in 4162 (5.8%) female patients and was associated with increased risk of complications compared to breast procedures or abdominoplasty performed alone. Among men, correction of gynecomastia was the most common breast procedure (n = 1613, 64.6%) with a complication rate of 1.80% and smoking as a risk factor (RR 2.73, P = 0.03). Conclusions Incidence of major complications after breast cosmetic surgical procedures is low. Risk factors for major complications include increasing age and BMI. Combining abdominoplasty with any breast procedure increases the risk of major complications. Level of Evidence 2.

Background The proportion of elderly patients in North America is increasing. This has resulted in an increased number of elderly patients undergoing cosmetic procedures. Objectives The purpose of this study was to determine the incidence of postoperative complications in elderly patients (age ≥65) undergoing elective aesthetic plastic surgical procedures compared with younger patients. Methods A total of 183,914 cosmetic surgical procedures were reviewed using the prospectively enrolled cohort of patients in the CosmetAssure database. Comorbidities and postoperative complications in elderly and younger patient groups were recorded and compared. A separate analysis of postoperative complications was performed in the octogenarian subgroup (age ≥80). Results A total of 6786 elderly patients who underwent cosmetic procedures were included in the study. Mean ages (±standard deviation) in elderly and younger patients were 69.1 ± 4.1 and 39.2 ± 12.5 years, respectively. The elderly patient population had more men, a higher mean body mass index (BMI), a higher prevalence of diabetes mellitus (DM), and fewer smokers compared with the younger patients. The overall postoperative complication rate was not significantly different between elderly and younger patients. When stratified by type of cosmetic procedure, only abdominoplasty was associated with a higher postoperative complication rate in elderly compared with younger patients. The most common postoperative complications in elderly patients were hematoma and infection. The overall postoperative complication rate in octogenarians was 2.2%, which was not significantly different from the younger population. Conclusions Cosmetic procedures in elderly patients, including octogenarians, remain safe with an acceptable complication rate compared to younger patients. Level of Evidence 3![Graphic][1] Risk [10.1093/asj/sjv071][2] [1]: /embed/inline-graphic-1.gif [2]: /lookup/doi/10.1093/asj/sjv071