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Background:. Nasal tip projection ideals have been based on the Caucasian nose; however, many racial groups have underprojected tips. Several methodologies have been described to measure ideal nasal tip projection. This study aimed to compare various methods to racially diverse groups to elucidate those best suited for race-specific facial morphology. Methods:. An openly accessible artificial intelligence image generator was used to generate images of Caucasian, Middle Eastern, and African American noses. Tip projection was manually measured using 5 different ideal tip projection methods. One-way analysis of variance with post hoc Tukey honest significant difference test evaluated differences between racial cohorts. One-sample t tests were used for comparisons to previously described aesthetic ideals, and a P value of less than 0.05 was considered statistically significant. Results:. Twenty lateral images were analyzed per racial cohort (10 men and 10 women). All racial groups—except for male Middle Eastern noses (P = 0.01)—were measured as ideal using the Byrd nasal length proportion method. Caucasian and Middle Eastern noses measured ideal using the nasolabial tip projection method. African American female noses measured ideal using the nasofacial tip projection method. Only Caucasian noses were ideal using the lip tangent method. Conclusions:. This study suggests that the ideal nasal length to tip length ratio of two-thirds (67%) has generalizability across these racial groups; the lip tangent is an excellent method for evaluating tip projection in Caucasians; and assessment of ideal tip projection in Middle Eastern and African American groups should use regional midface and lower face anatomy to account for differences in facial morphology.

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.

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.

The facelift has significantly evolved over the past several decades. What was once considered a skin only operation is now a sophisticated, elegant procedure that requires meticulous preoperative analysis, understanding of underlying anatomically based aging changes, and extreme attention to detail. According to the American Society of Plastic Surgeons, 125,697 facelifts were performed in 2017. It is not surprising that given these advances that facial rejuvenation surgery is still a very common procedure with a high degree of patient satisfaction despite the increase in nonsurgical facial aging treatments. With an improved understanding of facial anatomy including the facial retaining ligaments and intervening superficial and deep fat compartments, the modern facelift requires an anatomically targeted approach. Furthermore, the modern facelift surgeon must achieve consistently excellent results with reasonably little downtime while being aware of methods to improve the safety of this popular elective procedure. Hematoma is the most common complication after rhytidectomy with an incidence between 0.9% and 9%, with a higher incidence in males. Other potential complications include seroma, nerve injury, skin flap necrosis, siaolocele as a consequence of submandibular gland debulking, and skin flap rhytid and hairline distortion. This review aims to discuss safe, consistent, and reproducible methods to achieve success with facelift.

Summary:. Soft-tissue filler use has grown considerably related to the increasing popularity of minimally invasive cosmetic procedures. Hyaluronic acid products are currently the most utilized soft-tissue fillers. Proper working knowledge of individual products, limitations to use, and anatomic principles can improve outcomes. Prevention is key to minimize complications; however, when present, complications must be managed methodically. Complications are categorized based on the timing of presentation and include early, late, and delayed. Vascular compromise and tissue necrosis are among the most devastating complications seen with filler use. Nodules can be related to an inflammatory or infectious etiology but should be distinguished as treatment varies. Hyaluronidase is mandatory to have available as a reversal agent for hyaluronic acid products and can be used in treatment for many complications and untoward sequela.

Summary:. Trichloroacetic acid (TCA) is a versatile agent, efficacious in treating a spectrum of facial rhytids and dyschrommias at varying concentrations. TCA is commonly used in a 30%–35% concentration to achieve a medium-depth peel into the upper reticular dermis. The addition of Jessner’s solution before the TCA peel application leads to partial removal of epidermis, allowing for deeper penetration of the TCA. This combination is beneficial, as lower concentrations of TCA can be used for the same depth of peel, minimizing complications such as scarring.

Summary:. Mass communication has undergone a “new media” revolution, which includes the rise of digital, online, and social media. The impact of new media on academic processes, however, has been underappreciated. The rise of Web-based virtual platforms has profoundly impacted the way plastic surgeons publish, store, exchange, and analyze scholarly biomedical information. This new media academic phenomenon refers to electronic mechanisms with the capacity to supplant traditional publication methods, which typically rely on printed documents in the physical domain. Although such tools can be efficient and user-friendly, they also make users vulnerable to exploitation. Notable examples reveal a relative lack of regulation, oversight, reliable rating scales, user authentication, and ethical accountability in the virtual space. As with any new technique, education is key and knowledge is power. In this article, online resources related to healthcare and the practice of plastic surgery are reviewed and summarized, including open access, mega-indices, whitelists, and electronic alerts. New media provides powerful knowledge-sharing tools that can help execute scholarly endeavors, communicate between professionals, and educate the public. However, it is essential for plastic surgeons to appreciate the caveats of new media academic processes to avoid unscrupulous practices of those that may seek to manipulate these Web-based systems. This article outlines the key pitfalls associated with online information streams to better inform plastic surgeons how to navigate new media-based scholarly processes.

Summary:. Middle Eastern rhinoplasty requires especially precise preoperative planning to achieve a successful result. Among all aesthetic surgery procedures, there is a higher demand for rhinoplasty among Middle Eastern cultures. The key is to maintain the ethnicity of the patients while meeting their goals. In this brief overview, common features in Middle Eastern patients and Middle Eastern rhinoplasty techniques in men and women are highlighted.

Background:. Brow lift has been a part of plastic surgeons’ armamentarium for over a century. Although there are multiple different techniques available, there has been a dearth of literature comparing which technique is better and has lesser complications. In this study, we performed a systemic literature review of all brow lift techniques to determine and compare complication rates of each technique. Methods:. We performed a computerized search of brow rejuvenation techniques using the MEDLINE database. Data regarding the type of brow lift procedure, number of patients, and complications were collected. Results:. The systematic review was performed in December of 2017. A total of 326 articles were identified initially, and 76 studies remained after final review. The review showed highest revision rate in the hairline brow lift (7.4%), highest numbness rate in the direct brow lift (5.5%), highest asymmetry rate in the temporal/lateral brow lift (1.5%), and highest alopecia rate in the endoscopic brow lift (2.8%). In addition, we found 5 studies in nonsurgical brow rejuvenation (3 botulinum toxin, 1 fat injection, 1 radiofrequency). Conclusion:. Our study shows that each brow technique has a different complication profile, and it is important for plastic surgeons to understand the difference. Furthermore, the study demonstrated the lack of randomized prospective outcome studies and standardization of outcome measures in brow rejuvenation. We believe this information would be the key and next frontier in providing technically safe and long-lasting aesthetic outcomes for the patients.

Background: Fat grafting has been increasingly utilized in both aesthetic and reconstructive surgical procedures, yet the basic scientific understanding of fat grafting has lagged behind the pace of clinical innovation and utilization. This lack of basic scientific understanding has perhaps manifested itself in the wide range of graft viability reported across the literature. This study attempts to further the underlying mechanisms of fat graft take and viability through the comparison of the subcutaneous plane and the local fat pad in athymic rats. Methods: Lipoaspirate from a consenting patient was grafted into 2 locations in the subcutaneous plane and into the 2 inguinal fat pads in each of 4 athymic rats. Specimens were then collected after 47 days, and immunohistochemistry was utilized to determine angiogenesis in the fat grafts as a measure of fat graft take. Data were analyzed using the Student’s t test and analysis of variance followed by multiple comparisons. Results: There was no statistically significant difference (P = 0.2913) between the inguinal fat pad and the subcutaneous plane when measuring neovascularization. Analysis of variance comparing the graft locations also indicated no statistically significant difference when comparing each of the rats. Conclusions: Investigation into fat graft injection location indicates that there is no statistically significant difference in angiogenesis signals between the subcutaneous plane and the local fat pad in the athymic rat model. Further research should aim to continue to close the gap between clinical practice and basic scientific understanding of fat grafting.

Background: Interplay between the components of a lipoplasty system (suction pump, suction tubing, collection canister, and cannula) determines liposuction efficiency. However, in clinical practice, none of the components are more important than the cannula. Cannula design including port design, port placement, and shaft characteristics is the single most influential contributor to flow resistance and dramatically effects speed of aspiration and final contour. Many variations on port design and placement are available, yet functional enhancements to the cannula shaft have largely been ignored. We have engineered a set of novel cannulas addressing vital elements of cannula design in the effort to enhance aspiration efficiency and efficacy. Methods: Two novel cannula designs (dual- and multiport, in-line configuration), created using a unique proprietary manufacturing process, were evaluated against a popular industry standard design (tri-port, Mercedes configuration) to assess aspiration efficiency. Cannulas with shaft diameters of 3, 4, and 5 mm were attached to a standardized lipoplasty system and evaluated in real time for their ability to aspirate a viscous applesauce medium over a 5-minute time course. For each cannula, we calculated (1) the cross-sectional area of the cannula shaft, (2) single and total port area, (3) port-to-shaft ratio, and (4) theoretical resistance. Results: The relationship between the cannula shaft and cannula port(s) directly influenced flow dynamics. Comparing medium uptake time, aspiration efficiency and the aspiration curves demonstrated a significant improvement of the 2 novel cannulas over the standard cannula in the 5- and 4-mm designations. In the 3-mm group, a difference in uptake time remained. However, a significant difference in aspiration efficiency was only seen between the dual-port novel cannula and tri-port Mercedes standard cannula. Further, differences in the aspiration curves between all 3-mm cannulas approached but did not reach significance. Conclusions: We have developed 2 novel cannulas that maximize port features and seek to minimize the internal shaft resistance. Both designs demonstrate enhanced aspiration and uptake compared with an industry standard design.

Summary: Since Illouz’s presentation of a technique for lipoplasty at the 1982 Annual Meeting of the American Society of Plastic and Reconstructive Surgeons, liposuction has become one of the most commonly performed aesthetic surgery procedures. The evolution of liposuction has seen refinements in technique and improvement of patient safety-related standards of care. Based on long-term experience with body contouring surgery, 5 principles of advanced liposuction are presented: preoperative evaluation and planning, intraoperative monitoring—safety measures, the role of wetting solutions and fluid resuscitation, circumferential contouring and complication prevention, and outcomes measurement.

Background: After surgery it is often recommended that patients should refrain from strenuous physical activity for 4–6 weeks. This recommendation is based on the time course of wound healing. Here, we present an overview of incisional wound healing with a focus on 2 principles that guide our postoperative recommendations: the gain of tensile strength of a wound over time and the effect of mechanical stress on wound healing. Methods: A systematic search of the English literature was conducted using OVID, Cochrane databases, and PubMed. Inclusion criteria consisted of articles discussing the dynamics of incisional wound healing, and exclusion criteria consisted of articles discussing nonincisional wounds. Results: Experiments as early as 1929 laid the groundwork for our postoperative activity recommendations. Research using animal models has shown that the gain in tensile strength of a surgical wound is sigmoidal in trajectory, reaching maximal strength approximately 6 weeks postoperatively. Although human and clinical data are limited, the principles gained from laboratory investigation have provided important insights into the relationship among mechanical stress, collagen dynamics, and the time course of wound healing. Conclusion: Our postoperative activity recommendations are based on a series of animal studies. Clinical research supporting these recommendations is minimal, with the most relevant clinical data stemming from early motion protocols in the orthopedic literature. We must seek to establish clinical data to support our postoperative activity recommendations so that we can maximize the physiologic relationships between wound healing and mechanical stress.

Summary: The etiology of age-related facial changes has many layers. Multiple theories have been presented over the past 50–100 years with an evolution of understanding regarding facial changes related to skin, soft tissue, muscle, and bone. This special topic will provide an overview of the current literature and evidence and theories of facial changes of the skeleton, soft tissues, and skin over time.

Summary:. Face-lift techniques have evolved beyond the concept of lifting and now include incorporating superficial and deep filling of facial fat compartments to address volume deflation and aging. In addition to traditional face-lift methods involving the excision and tightening of skin and the underlying soft tissues, the following ancillary procedures have become paramount in achieving an optimal result: blending the lid-cheek junction; chin augmentation; lobule augmentation; hand rejuvenation; perioral rejuvenation; chemical peels; and laser resurfacing. We presented a summary of these integral techniques.