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Summary:. Exosomes, or extracellular vesicles, represent the latest cell-free addition to the regenerative medicine toolkit. In vitro preclinical studies have demonstrated the safety and efficacy of exosomes, which vary based on source and biomanufacturing, for a myriad of potential therapeutic applications relevant to skin and soft tissue reconstruction. Primary search was performed in September 2021 on the MEDLINE database via PubMed and Ovid, with focus on articles about therapeutic application of exosomes or extracellular vesicles. In total, 130 articles met criteria for applicability, including early-stage clinical trials, preclinical research studies with in vivo application, and articles applicable to plastic and reconstructive surgery and dermatology. Most studies used animal models of human disease processes, using either animal donor cells to isolate exosomes, or human donor cells in animal models. Exosome technology has catapulted as an acellular therapeutic vehicle with off-the-shelf accessibility. These features eliminate prior threshold for broad adoption of regenerative cell-based therapies into surgical and medical practice. To date, there are no exosome products approved by the US Food and Drug Administration. This review highlights exosomes as the new frontier in regenerative medicine and outlines its preclinical therapeutic applications for cutaneous repair and restoration.

Summary:. Fibrous dysplasia is a benign fibro-osseous process affecting the skeletal system, with resulting cystic and fibrous tissue expansion. Craniofacial fibrous dysplasia represents a small subset of monostotic disease, accounting for approximately 10%–25% of all such cases. Involvement of the frontal, temporal, and sphenoid bones has most commonly been described, with a limited number of reported cases citing disease isolated to the nasal bones. The case reported here is differentiated by the degree of expansion of the bilateral nasal bones and the required clinical management of the bony vault in the setting of gross nasal asymmetry.

Background:. Allograft adipose matrix (AAM) offers a novel, off-the-shelf, and readily available natural option in the treatment of facial soft tissue volume and reconstructive deficits. AAM is a natural soft tissue supplement or replacement that can support cushioning and volume correction. A prospective multicenter pilot study evaluated AAM in facial volume restoration. Methods:. Eleven women (mean age of 55.8 ± 10.9 y) with midface volume deficit were followed up for 24 weeks after AAM treatment in this institutional review board–approved multicenter pilot study. The clinical safety and efficacy of the AAM treatment were evaluated using clinical scales and three-dimensional quantitative facial photography. Results:. AAM was safe to address facial volume deficits, with minor site-related adverse events and discomfort that resolved within 2–4 weeks. Observations also revealed facial volume improvements throughout the study with 91% positive responders. At week 24, the subject facial satisfaction scores revealed an 86% increase compared to baseline, along with a statistically significantly improved midface fullness compared to baseline. Conclusion:. AAM offers a natural and safe option for midface volume restoration and supports overall satisfaction and volume improvements.

Background: Mastopexy and reduction mammaplasty are commonly performed procedures in plastic surgery with many variations in incision pattern, pedicle design, and additional support maneuvers. Aesthetically pleasing on table results are widely accomplished; however, the longevity of the outcome and sustained correction of ptosis or pseudoptosis is not universal. A systematic review of mastopexy and reduction mammaplasty procedures was performed to investigate which techniques provided the greatest long-term correction of ptosis. Methods: A broad search of the literature was performed using the PubMed database from inception to December of 2021. Study characteristics, number of patients, number of breasts, technique, outcome, and average follow-up time were extracted for analysis. Study quality was assessed using the Newcastle–Ottawa Scale when applicable. Results: The primary search yielded 1123 articles. After two levels of screening, 24 articles were identified for analysis. This included 16 case series, seven cohort studies, and one randomized controlled study. From these studies, 1235 patients and 2235 breasts were analyzed. The majority of articles reported on a change in the nipple to inframammary fold and sternal notch to nipple distances. Conclusions: In the analytical studies, superior and superomedial pedicles tended to provide greater long-term stability than inferior pedicles. Mesh, dermal suspension flaps, and muscular slings showed promise in providing additional support over standard techniques. No single procedure is ideal for all patients; however, this systematic review provides a valuable description of techniques and long-term outcomes to guide surgical planning.

Introduction:. Previous systematic reviews evaluating piezoelectric osteotomy are of critically low quality. We conducted a high-quality systematic review and meta-analysis to evaluate outcomes for piezoelectric versus conventional osteotomy. Methods:. The study protocol was published a priori (PROSPERO: CRD42021287877). MEDLINE, Embase, Web of Science, and CENTRAL were searched for studies comparing piezoelectric versus conventional osteotomes and reporting at least one outcome of interest (clinical or patient-reported outcomes, PROs). Methodological quality and risk of bias were assessed using GRADE and Cochrane’s RoB-2/ROBINS-I tools, respectively. Random effects models were applied. Results:. Of 347 articles, 10 studies (nine randomized controlled trials; one prospective cohort study) including 554 patients were included. Piezoelectric osteotomy was associated with significantly reduced edema [standardized mean difference (SMD), −0.67; 95% confidence interval (CI), −1.03 to −0.30; P < 0.0004], ecchymosis (SMD, −0.93; 95% CI, −1.13 to −0.73; P < 0.00001), and pain (SMD, −1.48; 95% CI, −2.07 to −0.88; P < 0.00001) compared with standard osteotomy. Odds of mucosal injury were significantly lower following piezoelectric osteotomy (odds ratio, 0.06; 95% CI, 0.01 to 0.52; P = 0.01). There was no difference in duration of osteotomy (SMD, 3.15; 95% CI, −1.82 to 8.12; P = 0.22) or total procedure duration (SMD, 0.46; 95% CI, −0.43 to 1.36; P = 0.31). One study reported PROs, favoring piezoelectric osteotomy. Conclusion:. This systematic review and meta-analysis provides support (albeit weak, due to low-quality evidence) for piezoelectric over conventional osteotomy, for reducing morbidity in the early postoperative period. High-quality level I data reporting PROs will optimize shared decision-making/informed consent.

Summary:. Noninvasive body contouring has seen a precipitous rise in popularity since its advent in the early 2000s. With this rise in popularity, there has been an expansion in the types and number of noninvasive devices for muscle hypertrophy and fat lipolysis. The Transform radiofrequency and electrical muscle stimulation device is a newly introduced device for noninvasive abdominal body contouring. The present study is a prospective clinical trial evaluating the efficacy of the Transform device on abdominal circumference. Fifteen patients were enrolled and received three treatment sessions with the Transform device. On average, patients saw changes in abdominal circumference (−0.43 cm, P = 0.48), caliper pinch thickness (−6.07 mm, P = 0.0036), and ultrasound fat thickness (−5.40 mm, P < 0.001) at 3 months posttreatment with minimal discomfort and high patient satisfaction. Ultimately, this study demonstrates that the Transform device is a safe and effective noninvasive option for fat lipolysis and muscular hypertrophy.

Background:. Despite the increased popularity of platelet-rich plasma (PRP) in plastic surgery, there is no detailed analysis on the level of evidence on PRP use in plastic surgery. As the number of applications of PRP in plastic surgery increases, it is important for plastic surgeons to understand the scientific and validated evidence behind its use. Therefore, we performed a literature review to identify current level of evidence on platelet-rich plasma in plastic surgery. Methods:. We performed a computerized search of platelet-rich plasma in plastic surgery using the MEDLINE, Cochran Library, and EMBASE databases. Data regarding the type of study, PRP application, and outcomes were collected. Then, the level of evidence was assigned using the American Society of Plastic Surgeons Level of Evidence Rating. Results:. Our search identified 105 articles, and about 78.1% of studies were lower-quality studies: 37 level-III articles (35.2%), 32 level-IV articles (30.5%), and 13 level-V articles (12.4%). There were only 6 level-I articles and 17 level-II studies. Level-I studies were on facial rejuvenation using a laser, carpal tunnel release, cleft lip repair, trauma wounds, breast reconstruction using latissimus dorsi, and hair regrowth. Conclusions:. Our review of the literature shows that the level of evidence on PRP use in plastic surgery is low (21.9%). Nevertheless, we believe level-III to level-V studies are still valuable, as performing high-level quality studies in plastic surgery is difficult due to variability in surgical techniques, experiences, and materials.

Background:. The use of radiofrequency in aesthetics has increased in popularity since the early 2000s. To date, there have been limited studies investigating the effect of thermal energy secondary to radiofrequency treatment. The purpose of this study was to evaluate perfusion and lymphatic assessment tools pre and post bipolar and fractional radiofrequency treatment. Methods:. A retrospective IRB-approved study was conducted between January 2019 and April 2019. Patients who were independently deemed appropriate candidates for radiofrequency soft tissue remodeling were evaluated. Diagnostic perfusion and lymphatic imaging obtained were reviewed using indocyanine green (SPY, Stryker) and optical coherence tomography (Vivosight OCT). Results:. A total of 63 patients were treated during the study period, of which 37 had diagnostic perfusion and lymphatic imaging. Average patient age was 47 (STD 12), 95% (35/37) of patients were women, and no patients were active smokers. In total, 27% (10/37) of patients were post-surgical patients with recurrent laxity, 32% (12/37) did not have enough skin laxity to justify traditional excisions procedures, and 41% (15/37) may have been candidates for excisional procedures but were willing to accept more moderate results to avoid excisions surgery. Indocyanine green perfusion and lymphatic assessment for bipolar and fractional radiofrequency, as well as optical coherence tomography pre and post radiofrequency, did not show compromise from thermal injury. Conclusions:. This study supports safety of radiofrequency in terms of preservation of tissue perfusion and lymphatic drainage. This correlated to our low clinical incidence of burns, prolonged swelling, or tissue ischemia.

Summary:. The Coronavirus Disease 2019 (COVID-19) pandemic has presented a major threat to public health worldwide alongside unprecedented global economic and social implications. In the absence of a “gold standard” treatment, the rapid development of a safe and effective vaccine is considered the most promising way to control the pandemic. In recent years, traditional vaccine technologies have seemed insufficient to provide global protection against the rapid spread of emerging pandemics. Therefore, the establishment of novel approaches that are independent of whole pathogen cultivation, cost-effective, and able to be rapidly developed and produced on a large scale are of paramount importance for global health. This article summarizes the current efforts to develop a COVID-19 vaccine, including the ongoing and future anticipated clinical trials. We also provide plastic and reconstructive surgeons with insight into the novel technologies currently utilized for COVID-19 vaccine development, focusing on the very promising viral-vector-based and gene-based vaccine technologies. Each platform has its own advantages and disadvantages related to its efficacy and ability to induce certain immune responses, manufacturing capacity, and safety for human use. Once the fundamental key challenges have been addressed for viral-vector-based and gene-based vaccines, these novel technologies may become helpful in winning the fight against COVID-19 and transforming the future of health care.

Background:. One-stage augmentation mastopexy is a challenging procedure, with the highest cited revision rates in plastic surgery. This is because when mastopexy and augmentation are performed together, they lead to opposing forces, which must be balanced carefully to avoid complications. The goal of this study was to revisit a previously described predictable and safe approach to one-stage augmentation mastopexy, and provide long-term updated results. Methods:. One hundred seventy-one patients who underwent augmentation mastopexy, performed by a single surgeon (R.J.R.), were included in this retrospective review between January 2005 and January 2019. Wise pattern mastopexy with wide pedicle was performed before placement of a small subpectoral implant. Demographic information, preoperative breast measurements, intraoperative technique, implant choice, and postoperative complications were analyzed. Specifically, postoperative measurement of vertical limbs was performed to assess long-term elongation of the lower breast pole. Results:. Cumulative complication rate was 11.7%. This rate decreased to 6% in the last 88 patients in this series as the technique matured. The most common complication was revision for implant size exchange. Long-term follow-up demonstrated elongation of nipple-to-inframammary fold distance by 1.0–2.2 cm. There was no recurrence of ptosis requiring reoperation. Conclusions:. This one-stage augmentation mastopexy technique provides a safe and reliable surgical approach with predictable and minimal elongation of the lower breast pole. The reoperation rate of this technique is less than half of >20% revision rate currently cited in the literature.

Summary:. The use of radiofrequency for soft tissue tightening has increased over the past 10 years. Both minimally invasive and noninvasive devices are frequently in use. This article describes the different types of radiofrequency technology and the current evidence behind their safety and efficacy.

Background:. Left-handed surgeons experience difficulty with tools designed for use in the right hand. The purpose of this study was to examine instrument laterality and to survey the experiences of left-handed plastic surgery trainees. Methods:. Count sheets for plastic surgery trays (reconstructive, microsurgery, rhinoplasty, craniofacial) were acquired from Tisch Hospital, NYU Langone Health. Instruments with right-handed laterality were tallied. A survey was also distributed to plastic surgery residents and fellows to determine hand preference for surgical tasks, and those who identified as left-handed described how handedness impacted their training. Results:. Right-handed laterality was seen in 15 (31.3%) of the 48 reconstructive instruments, 17 (22.7%) of the 75 rhinoplasty instruments, and 22 (31.0%) of the 71 craniofacial instruments. One-hundred percent of the 25 microsurgery instruments were ambidextrous. There were 97 survey responses. Trainees (17.5%) were identified as left-handed and were more likely than right-handed trainees to report operating with both hands equally or with the opposite hand (47.1% versus 1.3%; P < 0.001). Left-handed trainees were significantly more likely than right-handed trainees to use their nondominant hand with scissors (P < 0.001), electrocautery (P = 0.03), and needle drivers (P < 0.001) and when performing tissue dissection (P < 0.001) and microsurgery (P = 0.008). There was no difference in use of the nondominant hand between right and left-handed trainees for knot tying (P = 0.83) and in use of the scalpel (P = 0.41). Conclusions:. Left-handed plastic surgery trainees frequently encounter instruments designed for the nondominant hand, with which they adaptively perform several surgical tasks. Mentoring may help trainees overcome the laterality-related challenges of residency.

Summary:. This invited Special Topic article outlines the authors' evolution and technique to optimize consistent results in rhinoplasty.