CON—Research Before Starting Your Practice
Ehab Akkary, MD, FACS, FAACS
Disclosures: Nothing to disclose.
Category: Practice Management
Certificate of need (CON) originated in 1974 after passing the National Health Planning and Resources Development Act. The CON was thought of as a method to decrease health care costs, increase quality and access to care. In a short period of 10 years, CON proved to be a failure and a monopoly tool serving the exact opposite of its intended goals and different states started to gradually get rid of this antiquated legislation. The CON tends to protect larger hospitals and harm patients and tax payers. However, most states still need to catch up and get rid of their CON which is a difficult task as CON tends to protect large hospitals who can simply lobby to keep it in place. Currently, there are 35 states that still have CON laws but the restrictions of these laws vary from one state to another.
It is very important, before starting your Cosmetic Surgery practice, to check if the state has CON laws. If so, then you need to research what falls under CON as this varies greatly from one state to another and can significantly restrict your practice or add unneeded financial burden.
Take-Home Message: In this presentation, we will analyze the different CON laws in different states to help physicians avoid the unnecessary negative effects and burden of these antiquated monopoly laws on their practice.
Abdominoplasty and Managing the Surgical Umbilicus “Happy Belly Button Technique”
Gregory Alouf, MD
Disclosures: Nothing to disclose.
Category: Body Contouring
Abdominoplasty and umbilicoplasty are one of the most commonly performed cosmetic surgeries around the world. The abdominoplasty scar can be hidden under a bathing suit; however, scars from surgery on the umbilicus can be difficult to manage. The ultimate goal is to create a scarless umbilicus. Dr. Alouf created the “Happy Belly Button Technique” to address this issue. During his lecture, he will describe this surgical technique.
Take-Home Message: To be able to perform an abdominoplasty and umbilicoplasty and create a scarless Belly Button.
Labia Majora Fat Grafting
Jamila Atannaz, MD
Disclosures: Nothing to disclose.
Category: Male/Female Genitourinary
Labia majora fat grafting
Autologous fat grafting has been used in plastic surgery for both reconstructive and aesthetic purposes of the face, breast, and body. Fat grafting is being use more frequently nowadays for female genitalia aesthetic surgery, in particular, rejuvenation of the labia majora. Indications and technique will be discussed to optimize outcome.
Fat grafting gives excellent results for labia majora augmentation in a patient with loss of tone and volume in the labia majora. The procedure is safe provides a stable result in volume restoration.
Take-Home Message: Autologous fat grafting (AFT) has evolved to become a tool to improve both aesthetic appearance and tissue function of the labia majora.
Rhinophyma Correction
Mark F. Baucom, MD, FAAD
Disclosures: Nothing to disclose.
Category: Rhinoplasty
This talk will cover surgical correction of rhinophyma under local anesthesia. Rhinophyma is a disfiguring form of acne rosacea characterized by enlargement of the sebaceous glands resulting in sometimes dramatic nasal tip irregularity and enlargement. I will present a number of cases corrected through surgical reduction and resurfacing.
Take-Home Message: Cosmetic surgeons can change people’s lives by successful management of this disfiguring condition.
The Use of Localized Oxygen Injection Therapy (LOIT) to Ameliorate Compromised Healing: A Case Study
Daniel A. Bienstock, MD, DMD and Scott Blyer, MD, FAACS
Disclosures: Nothing to disclose.
Category: Scars and Wound Healing
Introduction: The cornerstone of biologic healing after cosmetic surgery pertains to the proper oxygen delivery to the tissues. Delayed healing is a risk that can occur while any wound is healing. It is well known that hypoxia to the wound margins may result in poor healing and necrosis. Oxygen is required for proper function of key mechanisms of healing including fibroblast activity and collagen synthesis.1
In cosmetic surgery, perhaps a more commonly faced area of poor wound healing is after abdominoplasty in the area just above the mons pubis.2 This is because this region is farthest from the blood supply after the panniculus has been undermined.2 Many techniques for managing this have been suggested in the literature, and it often depends on the size of the area involved. Proper care of the compromised area with dressings, debridement of the area, and Vacuum-assisted closure (VAC) therapy are known techniques.2 If necessary, once the area heals by secondary intention, the resultant area can be addressed with a scar revision technique. A tool that has been documented in the literature to improve wound healing is the use of hyperbaric oxygen therapy (HBO). The HBO is the administration of oxygen to the patient using a specialized chamber whereby the patient inhales 100% oxygen at an increased pressure above 1 atm. The goal is to increase oxygen delivery to the healing tissues.3 The HBO is a time-intensive treatment that requires a specialized center, equipment, and staff. While there are documented potential benefits, this modality may be impractical in many circumstances. Furthermore, if poor healing is detected postoperatively, receiving urgent HBO therapy is unlikely. A novel approach which brings some of the concepts of HBO therapy to the office is to inject oxygen directly to the healing tissues. This allows for “point-of-care” style oxygen therapy in the office. A needle connected to an oxygen source is injected at and nearby the site of unfavorable healing. A case study with signs of delayed healing after an abdominoplasty is presented here and the favorable effects of localized oxygen injection therapy (LOIT) are illustrated.
Treatment: The patient is a 46-year-old African American woman who is 9 days status post full or traditional abdominoplasty. She has no chronic medical conditions and no smoking history. She has had one pregnancy which led to a natural spontaneous vaginal delivery resulting in a healthy child. Surgical history is significant for liposuction 6 years prior to presentation. On physical examination it was noted that the patient exhibited signs of venous congestion and undesirable healing along the central portion of the horizontal incision just above the area of the mons pubis. The surface was mixed red/white, firm, and mildly edematous. On palpating the area, a capillary refill of 5 seconds is noted. The LOIT was offered to the patient and the patient agreed. The protocol established at our facility was used for this patient which is as follows. A 30-gauge hypodermic needle is attached to flexible tubing which is connected to a wall oxygen flowmeter set at 3 L/min. The needle is introduced through one entry point and spread along the extent of the involved area and slightly beyond. The needle is placed to the depth of the subcutaneous tissue. The oxygen is then delivered to each area for a few seconds then the needle is repositioned and is repeated until the entire intended area is treated. The needle is then withdrawn and the needle entry point is held closed with a finger until adequate clotting has ensued. The patient then returns the following day to re-evaluate and determine whether another session is indicated. In this patient, 4 sessions were administered over 4 consecutive days. The area began to heal nicely over the next several days and signs of improved perfusion were noted. The area became softer, less red and capillary refill was improved to 1 to 2 seconds. The patient felt much improved and no signs of overt necrotic tissue were evident.
Discussion: Localized oxygen injection therapy (LOIT) affords the ability to delivery oxygen to healing tissues in a very minimally invasive fashion. When a patient’s wound is exhibiting signs of poor healing, a quick and effective treatment that is readily available is ideal. The LOIT is minimally invasive, with minimal associated risks and cost. It is a practical alternative to HBO that can be administered quickly, perhaps as soon as poor healing is noted. We have noted favorable results at our surgical center using our protocol. The mechanism of delivering the oxygen is similar conceptually to that of carboxytherapy. Carboxytherapy involves the injection of purified carbon dioxide to the tissues.4 The carbon dioxide combines with the water in the tissues and a subsequent decrease in pH leads to the Bohr effect which increases the release of oxygen.4 The LOIT directly places oxygen at the tissues. The patient described in this case study did not have any clear risk factors such as a smoking history. If that had been the case, perhaps it would be reasonable to consider even preoperative HBO. However, given the complex nature of each person’s healing trajectories, having tools available to be used at a moment’s notice is highly desirable. Another consideration, depending on the severity of the condition, LOIT can be used to bridge the patient while awaiting HBO therapy to begin. Aside of HBO there are other oxygen therapy options available on the market. Topical oxygen therapy is available; however, many of these devices are best used with an open wound such as diabetic ulcerations. Few practical options exist when the wound is closed. Moreover, being able to treat the compromised wound while it is still closed and perhaps prevented the wound from opening would be another reason to employ oxygen therapy as soon as possible.
In conclusion, LOIT provides the ability to safely and effectively administer oxygen to improve healing in an outpatient setting in a minimally invasive manner. The use of LOIT was a helpful adjunct in the care of the compromised healing presented in this case study.
References
1. Francis A, Baynosa R. Hyperbaric oxygen therapy for the compromised graft or flap. Adv Wound Care. 2017;6:23-32.
2. Nahai F and Nahai F. The Art of Aesthetic Surgery: Principles and Techniques. 3rd ed. Thieme Medical and Scientific Publishers; 2005.
3. Friedman T, Menashe S, Landau G, et al. Hyperbaric oxygen preconditioning can reduce postabdominoplasty complications: a retrospective cohort study. Plast Reconstr Surg Glob Open. 2019;7:e2417.
4. Bagherani N, Smoller BR, Tavoosidana G, Ghanadan A, Wollina U, Lotti T. An overview of the role of carboxytherapy in dermatology. J Cosmet Dermatol. 2023;22:2399-2407. doi:10.1111/jocd.15741
Take-Home Message: The use of localized oxygen injection therapy (LOIT) provides the ability to safely and effectively administer oxygen directly to a surgical wound to improve healing in an outpatient setting in a minimally invasive manner. The use of LOIT was a helpful adjunct in the care of the patient presented in this case study with a poorly healing wound after abdominoplasty.
The Use of Trichloroacetic Acid to Reduce the Recurrence of Capsular Contracture
Daniel A. Bienstock, MD, DMD, Justo Concepcion, MBA, PA-C, and Scott Blyer, MD, FAACS
Disclosures: Nothing to disclose.
Category: Breast
Introduction: One of the most common complications of breast implant surgery is the occurrence of capsular contracture.1 The development of a fibrous capsule around a breast implant is a routine physiologic occurrence that occurs after breast augmentation. The capsule is an acellular collagenous sheath that aids with keeping the implant in place and prevents it from migrating to an unwanted position.2 The formation of this capsule occurs typically within 1 to 2 weeks after implant placement.3 This is considered a protective mechanism from foreign material and is carried out predominantly by myofibroblasts which are assisted by macrophages, leukocytes, lymphocytes, mast cells, and plasma cells.3 The formation of capsular contracture appears to be due to a prolonged inflammatory state within the breast capsule.3,4 It occurs with a rate which varies from 3% to 30% and some factors have been identified to increase the risk.1,5 These include a smooth texture and subglandular placement of the implant.1
Premise/Substantiating Data: When patients present with capsular contracture and elect for surgical management, it behooves the surgeon to consider strategies to reduce the potential for a recurrence. Recurrence rates have been reported in the range of 18% to 40%.5 Some factors that may impact the risk of recurrence include the surgical approach and the volume of the implant.5 Recurrence seems to be less with an anterior capsulectomy as opposed to total capsulectomy.5 Reducing the volume of the breast implant may also help reduce recurrence.5 Anterior capsulectomy limits scarring and reduces the risk of hematomas which are known risk factors for capsular contracture.5 Chemical capsulectomy can also be considered. The use of 90% trichloroacetic acid (TCA) for chemical capsulectomy was described by Blugerman et al6 for a variety of indications related to implant capsules. The premise being that there is a substantial amount of morbidity associated with capsulectomy and thus chemical capsulectomy serves to reduce this with similar results. The premise of the technique we are presenting is the combination of surgical capsulectomy along with chemical capsulectomy in an effort to minimize surgical risk, reduce postoperative morbidity, and further reduce the risk of recurrent capsular contracture. The use of TCA increases adherence of the flaps which reduces seroma and hematoma formation, thus reducing the risk of recurrence of capsular contracture. The TCA is perhaps best known for its use as a chemical peeling agent used in nonsurgical cosmetic treatments.7 The TCA coagulates surface proteins and dissolves keratin which leads to a frost appearance as the salts precipitate.7 When TCA is used as a chemical peel, concentrations typically range from 10% to 30% as this will provide a superficial epidermal peel. Concentrations above 50% produce a deeper peel which results in scarring.7
Treatment/Technique: We have used the following technique in 8 patients with capsular contracture in our surgical center to date. None of the patients have had a recurrence. Surgery begins with anterior capsulectomy. The site of residual capsule is then prepared for TCA application. The perimeter is protected with moistened gauze. The TCA is then applied carefully with a cotton tip applicator. A gray frost is noted immediately upon contact. We wait 2 minutes then irrigate the inside of the cavity with sterile 0.9% normal saline irrigation. The remainder of the procedure then proceeds in typical fashion.
Discussion: Despite best efforts, capsular contracture still presents as a challenging postoperative complication of breast augmentation surgery. There are ongoing efforts to address this complication and certainly to minimize its recurrence. It may be that combining techniques will prove to ultimately best reduce the risk of recurrence of this complication. Here we present the combination of surgical and chemical capsulectomy. This combined with other documented measures to reduce recurrence may pave the way to develop a protocol that can be tailored to the patient’s specific circumstances to reduce the recurrence of capsular contracture.
References
1. Headon H, Kasem A, Mokbel K. Capsular contracture after breast augmentation: an update for clinical practice. Arch Plast Surg. 2015;42:532-543.
2. Pittet B, Montandon D, Pittet D. Infection in breast implants. Lancet Infect Dis. 2005;5:94-106.
3. Steiert A, Boyce M, Sorg H. Capsular contracture by silicone breast implants: possible causes, biocompatibility, and prophylactic strategies. Med Devices. 2013;6:211-218.
4. Prantl L, Schreml S, Fichtner-Feigl S, et al. Clinical and morphological conditions in capsular contracture formed around silicone breast implants. Plast Reconstr Surg. 2007;120: 275-284.
5. Ganon S, Morinet S, Serror K, Mimoun M, Chaouat M, Boccara D. Epidemiology and prevention of breast prosthesis capsular contracture recurrence. Aesth Plast Surg. 2021;45: 15-23.
6. Blugerman GS, Schavelzon DE, Cáceres RR, Schavelzon VE, Mussi MA, Blugerman GA. Partial chemical capsulectomy and closing of the mammary capsule with anchoring flaps. In: Shiffman M, Low M, eds. Plastic and Thoracic Surgery, Orthopedics and Ophthalmology. Recent Clinical Techniques, Results, and Research in Wounds, vol. 4. Springer; 2018.
7. Nahai F and Nahai F. The Art of Aesthetic Surgery: Principles and Techniques. 3rd ed. Thieme Medical and Scientific Publishers; 2005.
Take-Home Message: A technique to treat capsular contracture is presented using a combination of surgical capsulectomy along with chemical capsulectomy with 80% trichloroacetic acid (TCA). This is done in an effort to minimize surgical risk, reduce postoperative morbidity and further reduce the risk of recurrent capsular contracture.
My Evolution to the Safest, Simplest, and Sexiest BBL
Scott Blyer, MD, FAACS
Disclosures: Nothing to disclose.
Category: Body Contouring
Over the past decade, I personally have safely performed well more than 1000 Brazilian butt lifts. There is no substitute for experience and over the years I have modified my BBL technique to avoid some of the pitfalls I encountered and potential dangers that have come to light and have now reached a point where I believe I can perform and teach this procedure in a such a way that is easy, predictable, safe, and get outstanding results.
Take-Home Message: Inform and educate my colleagues how I perform the BBL in a safe manner to avoid some of the potential problems I have encountered and those I have avoided so they can perfect and refine their techniques.
Foreign Body Granuloma to Dermal Filler Presenting as an Orbital Mass: A Case Report
Karen R. Brown, MD, Makayla McCoskey, MD, and Tanuj Nakra, MD, FACS
Disclosures: Nothing to disclose.
Category: Face
Introduction: Foreign body granuloma is a known potential complication of dermal filler. Delayed granulomatous reaction can occur months or even years after filler placement, with an estimated incidence of 0.1% to 1.0% in a 1-year follow-up period. Recent literature has described very delayed onset granulomatous formation in response to filler, occurring up to 17 years after filler treatment. Here we report a patient who presented with an inferior orbital rim mass, treated with excisional biopsy, with histopathology consistent with foreign body granuloma approximately 5 years after filler treatment. This case supports the existing literature regarding the possibility of very delayed onset granulomatous formation after hyaluronic acid–based fillers.
Case: A 71-year-old white female was referred for evaluation of an infraorbital mass, present for 5 months and subjectively stable since onset. She denied associated pain, vision change, or diplopia. On examination, there was a palpable firm, nontender, mobile mass along the inferior orbital rim. The patient underwent excisional biopsy via transconjunctival approach, with the mass noted to be in the orbicularis oris plane. The mass was sharply dissected with Westcott scissors and submitted in formalin for histopathologic analysis, which demonstrated foreign material deposition with chronic inflammation and multinucleated histiocytic reaction, consistent with foreign body granuloma. On further history, the patient noted hyaluronic acid–based filler injection to the tear trough region approximately 5 years prior. At 3 months follow-up, the surgical site was well healed with no recurrent or further palpable mass present. Of note, she also underwent simultaneous excision of bilateral palpable nodules in the nasolabial fold at the time of the infraorbital mass excision. Histopathology demonstrated similar findings consistent with foreign body granuloma, in the setting of previous filler the nasolabial fold region.
Discussion: Foreign body granuloma describes a chronic inflammatory process of predominantly multinucleated giant cells in response to nonself material. Foreign body granuloma is a known complication of dermal filler placement and can occur in association with high-volume administration, impurities in fillers, or cross-reactivity after infection. While there are reports of periorbital foreign body granuloma formation after filler,3,6 there is only one reported case of orbital granuloma which occurred 8 months after filler injection.7 This case demonstrates a very late-onset granulomatous reaction to hyaluronic acid–based filler with the granuloma located in the orbit along the orbital rim. Of note, she was found to have similar foreign body granulomas in the nasolabial fold region. This supports the concept of granulomatous reaction in response to a cross-reactive immune process, rather than volume of filler injected. The present case further supports the importance of counseling patients on the potential late complications of dermal filler and maintaining foreign body granulomatous reaction in the differential diagnosis for patients presenting with similar findings.
Take-Home Message: This case of very late-onset orbital foreign body granuloma in response to dermal filler highlights the importance of counseling patients on the potential late complications of dermal filler and maintaining foreign body granuloma in the differential diagnosis for patients presenting with similar findings.
Pain Relief Post Abdominoplasty: A Single Surgeon’s Experience in Minimizing Patient Discomfort and Narcotic Use
H. Christopher Coley, MD
Disclosures: 1. Heron Pharmaceuticals: Clinical Trial Investigator; 2. Heron Pharmaceuticals: Grant Recipient.
Category: Body Contouring
Abdominoplasty is one of the most common aesthetic surgical procedures worldwide. Because of the extensive dissection and rectus plication, it is also one of the most uncomfortable procedures performed and has one of the longest recover periods.
Adequate pain management is a primary goal of the surgeon and team to provide the patient with a more satisfying recovery.
Unfortunately, narcotic pain medication both intraoperatively and postoperatively has some challenges such as nausea, decreased bowel function which results in constipation, and even addiction.
ZYNRELEF (HTX-011) is an extended-release, dual-acting local anesthetic (DALA) formulation comprising bupivacaine and low-dose meloxicam in a controlled-diffusion polymer that allows for controlled delivery of active ingredients over 72 hours.
HTX-011 was approved in the European Union on September 24, 2020, and was approved in the United States on May 12, 2021.
The NSAID meloxicam in HTX-011 reduces surgery-related inflammation, thereby normalizing the local pH, which enhances penetration of bupivacaine into the nerve cell and potentiates its analgesic effect.
Neither the low dose of meloxicam contained in HTX-011 nor the addition of NSAID-containing multimodal analgesia have been shown to increase NSAID-related adverse events.
Take-Home Message: Another option for postoperative pain control in the abdominoplasty patient.
“Funnels” and Other Implant Placement Devices. Do They Truly Have Clinical Benefit or Are They an Advertising Gimmick? A Thorough Literature Review
Chad Deal, MD
Disclosures: Nothing to disclose.
Category: Breast
Over the last decade, novel implant placement devices known as “funnels” have been used with increasing popularity for breast augmentations with or without lift. They have been heavily marketed as the “no touch technique” and for decreasing the rates of infection. This podium presentation is a thorough literature review to see whether there is any supporting evidence for the claims.
Take-Home Message: After a thorough literature review, the authors find no significant supporting data to come to the conclusion that implant placement assisting devices are decreasing infection. In fact, we find out the claim “no touch” is a complete fallacy as the implant must be touched immediately following placement to confirm unfurling and valve placement. There is some early signs of benefit to be discussed but overall the main advertised claims are unfounded.
In Search of the Perfect MedSpa Treatment: Maximizing Powerful Outcomes Without Surgery and Little to No Complications
Chad Deal, MD
Disclosures: Nothing to disclose.
Category: Face
The trend or noninvasive aesthetic treatments has continued over the last several years. Finally, more powerful options are existing where mid-level providers can offer significant results with little to no downtime. Advancements in technology and techniques have allowed medical spas to offer breakthrough nonsurgical results to a much larger percentage of the population. However, there is a delicate balance between the power and consistency of the results with the complications and level of skill and training of the provider. The author in this presentation attempts to educate cosmetic practitioners as to that delicate balance, maximizing results, while minimizing complications.
Take-Home Message: The author feels that we truly are on the cusp of surgical-like results coming out of medical spas being offered by mid-level providers. With the right training and technology, these cosmetic outcomes can be offered with more confidence while maintaining great safety. A thorough review of the most current technology, medicines, and techniques is summarized to help the aesthetic practitioners make better and safer decisions for their medical spas.
Social Media and Cosmetic Surgery: Pearls on Patient Safety, Compliance, and Legality
Chad Deal, MD
Disclosures: Nothing to disclose.
Category: Practice Management
The rise on social media to market one’s practice in cosmetic surgery has skyrocketed over the last decade. However, there are many concerns about professionalism, legality, HIPAA violations, and safety. There has been no consensus on a standard of care approach to adding Social Media to a medical practice. Based on 3 years of personal experience, and managing 19 accounts with more than 2 million collective followers, the author attempts to create professional guidelines to assist the cosmetic practitioner who wishes to use social media to advertise.
Take-Home Message: Guidelines for use of social media in a cosmetic practice are desperately needed for practitioners to safely navigate this new form of advertising. The author feels that this can be professionally done as long as these particular tenants are followed.
Building a Facelift Practice: Getting Started Safely
J. Kevin Duplechain, MD, FAACS, FACS
Disclosures: Lumenis: Honorarium.
Category: Face
Interest in deep plane facelift has exploded in the last 5 years. Although considered the standard of facial rejuvenation surgery, years of training and experience are required to master this procedure. For surgeons who are beginning a career in facelift surgery, this procedure can be challenging at times even for the most experienced facelift surgeon. Approaching this technique with an integrative concept, ie, advancing to a deep plane facelift as experience is obtained, is a safe and savvy approach to safe facelift surgery. This discussion will highlight an effective stepwise approach to the deep plane facelift with progression to a complete deep plane dissection as experience allows. It will provide for the surgeon early in a career with safe and effective steps to becoming a master deep plane surgeon.
Take-Home Message: A complete understanding of the anatomic considerations of a deep plane facelift is paramount to a successful operation. Recognizing these anatomic landmarks is accompanied by sense of confidence in performing this operation. A stepwise approach leading to deep plane dissection is a safe journey for any surgeon wishing to understand and perform this complex operation.
Why the CO2 Laser Is the Single Best Resurfacing Tool
J. Kevin Duplechain, MD, FAACS, FACS
Disclosures: Lumenis: Honorarium.
Category: Skin Rejuvenation
Carbon dioxide skin resurfacing has evolved through the last 27 years to become a highly controllable, effective skin rejuvenation procedure. Many of the concerns of CO2 resurfacing have been mostly eliminated through better technology and a clear understanding of why complications occur. The current “gold standard” of skin resurfacing remains CO2 skin resurfacing because of its safe, predictable, and easy to manage postop course. Complications are most often related to overtreatment which can be avoided if the anatomy of the skin being resurfaced is considered. This presentation will provide any CO2 user the details of how to treat the skin, on and off the face, with a high safety profile.
Take-Home Message: Skin resurfacing is a safe and reliable treatment for skin rejuvenation. The proper use of this device is primarily dependent on the user’s knowledge of the skin and the energy characteristics of the device.
The Key Elements of Accreditation and Physical Space Requirements
Marzi Emami Ghoreishi, AIA, NCARB
Disclosures: Nothing to disclose.
Category: Practice Management
As a young surgeon or a surgeon with many years experience, depending on what kind of surgery you perform and what kind of accreditation you would like to obtain, there will be physical space and infrastructure requirements as part of the process beyond a building permit. Before planning on opening of a new practice, accreditation is the first step to be considered.
This presentation provides a summary of the requirements for physical space and the architectural aspect of them by providing several case studies in different scenarios.
To be able to assess your next step, buying space, buying land, or leasing an office, knowing these requirements is the key factor in making right decision. This presentation will review some of the key requirements of the physical space based on ASC, AAAASF, AAAHC, and Joint commission.
Take-Home Message: This presentation provides fundamental and brief knowledge about accreditation and physical space requirements.
Introduction to Cybersecurity—How Not to Lose Your Practice
Mark D. Epstein, MD, FACS
Disclosures: 1. Accurate surgical and Scientific: Royalties; 2. Crytica Security: Advisory Board; 3. Crytica Security: Stock Holder; 4. Establishment labs: Stock Holder.
Category: Practice Management
As the internet grew and bandwidth increased, so did malware threats. The complexity of the threats has increased significantly over the past several years, along with the severity of the attacks. Most attacks result in exfiltration of data to the threat actor followed by encryption preventing the victim to access their data without paying a ransom to regain access to their data and prevent the threat actor from selling the data on the dark web. Recent attacks have become more brazen with some threat actors (BlackCat) making the data available to anyone in the public to view on the clear web to further place pressure on the victim to pay a ransom.
Despite full implementation of the most current technology, such attacks are still occurring with no sign of the problem resolving anytime soon.
Plastic surgeons have become a target for threat actors as their data (photographs) are highly sought for ransom. The costs of mitigation of the attack, ransom for data recovery and preventing dissemination of exfiltrated data, notification of affected individuals, loss of business due to loss of confidence among the community, legal and forensic costs can destroy an unprotected and unprepared practice.
While there is little that can be done to eliminate the probability of an attack, there is much that can be done to prepare your practice financially and technologically to protect your data, ensure valid backups in the case of encryption, and hide critical data from threat actors, as well as reduce the risk of an attack.
Via case study, the author will review the current data on cost of an attack, what data are targeted, how the threats operate, and what steps should be taken to reduce the likelihood of an attack and what to do if attacked. Technological, legal, forensic, insurance, and social engineering will be discussed.
It is anticipated that nearly everyone who participates will be able to take home several new ideas to enhance the security of their data.
Take-Home Message: Everyone is one click away from losing their practice. Learn how to protect it and prevent financial devastation.
Prevention of and Salvage of Infection in the Breast Implant Patient
Mark D. Epstein, MD, FACS
Disclosures: 1. Accurate Surgical and Scientific: Royalties; 2. Crytica Security: Advisory Board; 3. Crytica Security: Stock Holder; 4. Establishment Labs: Stock Holder.
Category: Breast
Infection following breast augmentation with implants is an infrequent occurrence. When infection occurs, the results can be disheartening for both the patient and surgeon. Management of a patient with an infected implant can range from removal of the implant with replacement of the implant later to attempted salvage of the implant.
This presentation will discuss one surgeon’s 30-year evolution in the prevention of, identification of early infection and salvage of same.
A detailed description of the current preoperative, intraoperative, and postoperative management to prevent infection will be described. Earliest warning signs of infection will be discussed. It is essential that the entire clinical staff is also aware of these. An algorithm for evaluation and management of infection will be described. Last, surgical management of the infected implant will be detailed.
The goal is to reduce the surgeon’s infection rate with breast implant surgery while identifying infection early to improve the rate of salvage and prevent the need for explanation of the implant without immediate replacement.
Take-Home Message: Learn how to reduce the risk for post surgical infection following breast augmentation with implants, how to detect an infection at its earliest stage, and how to salvage the implant and avoid explantation whenever possible.
Abdominoplasty “Strong Convictions Loosely Held” Personal 19-Year Evolution Technique
Babak Farzaneh, MD, FACS
Disclosures: Nothing to disclose.
Category: Body Contouring
Understanding the difficulty in elective surgery research and value in keeping an open mind.
Discuss a few controversies in abdominoplasty.
Discuss a few key points in patient selection.
Discuss a few key preoperative, operative, and postoperative approach.
Take-Home Message: Having intellectual humility, understanding the difficulty in performing well-controlled studies in cosmetic surgery, discussing a few controversies in approach to abdominoplasty.
Complications of Nonsurgical Rhinoplasty “Sometimes Thin Zebras”
Babak Farzaneh, MD, FACS
Disclosures: Nothing to disclose.
Category: Complications
Review general complications of nonsurgical rhinoplasty, focusing on less common complications that may be confused with vascular occlusion and their management.
Take-Home Message: Consider other possibilities such as hematoma or Herpes simplex virus (HSV) infections when presented with what appears to look at first glance as vascular occlusion.
MLD and Properly Sequenced Postsurgical Care: Reducing Risks of Future Complications
Brandy Fenwick, PTA, LMT
Disclosures: Nothing to disclose.
Category: Preop and Postoperative Care
Introduction: Manual lymphatic drainage (MLD) is a light skin stretch stroke, manual application to mimic the lymphatic system. The therapist acts not only to mimic but also to increase the lymphagiomotoricity from approximately 12 pulses per minute to 20 pulses per minute (maximum is 60 pulses per minute). A patient’s lymph volume increases due to tumescent, bleeding, and the natural acute inflammatory process, thus requiring the safety factor to activate and MLD utilization to aid in the return to homeostasis. Sequenced applications during the recovery process require knowledge of the stages of healing and how it correlates with the treatment. Incorporating superficial and deep lymphatic work coupled with the application of soft tissue mobilization to address indurated or fibrotic tissues, scar work and adhesion release, KT or Kinesio taping (dermis), manual sculpting, and self-care programs all lead to quality outcomes. Improper or lack of postsurgical aftercare, combined with patients’ healing properties, comorbidities, and poor self-care, may result in future complications.
Method: This presenter and author has a 27-year background in physical therapy, wound care, complete decongestive therapies with lymphedema and lipedema patients, manual lymphatic drainage, compression fitting, and massage therapy. The presentation is a comprehensive approach to postsurgical care. This will address recovery benefits and reducing risks of future complications. The presentation consists of a lecture via PowerPoint and a practical application with a patient demo.
Premise: Improper or lack of postsurgical aftercare combined with patients’ healing properties, comorbidities, and poor self-care may result in future complications. Secondary facial, truncal, upper extremity, lower extremity lymphedema, or further contributing to existing lipedema.
Substantiating Data: Mimicking the lymphatic system at an increased rate of lymphagiomotoricity to direct/redirect lymphatic fluids to the proper regional lymph bundles is a mechanism to promote homeostasis of the lymphatic load and volume. MLD encourages lymphagiogensis (macrophages secrete VEGF A&C to stimulate Lymphatic endothelial cells (LECs)). It promotes a more fluid pattern of the collagen matrix or scar tissue, allowing superficial lymphatic vessels to reestablish a through passageway within each quadrant (lymphatome). Rerouting or redirecting occurs with multiple superficial anastomosis and the deep lymphatic system. Most lymphedema cases involve only the superficial lymphatic system.
Discussion: The superficial lymphatic system has multiple quadrants, separated by watersheds (theoretical boarders). The application of MLD, postsurgical treatments, and patient education have a direct link to quality patient outcomes. Surgery, ie, cosmetic procedures, creates dynamic lymphatic insufficiencies. The intensity of a cosmetic procedure as it relates to location or a combined procedure, such as a “mommy make over.” Patients’ lack of self-care, among other contributing factors, may introduce a higher risk for future complications, ultimately transforming a dynamic insufficiency to mechanical irreversible insufficiency.
Objectives:
Discussing the main purpose and benefits in MLD;
Discussing how managing diffusion distance will aid in the recovery process;
Discussing the multiple roles of compression in postsurgical care;
Reviewing both superficial and deep lymphatic systems and the roles they play;
Reviewing critical thinking applied with postsurgical MLD and sequential postsurgical care;
Discussing dynamic and mechanical insufficiency of the lymphatic system.
Take-Home Message: The positive impact aftercare has on our patients recovery journey.
The Simple Use of the Autospreader Graft to Help Prevent Nasal Obstruction
Sara Fiene, MD
Disclosures: Nothing to disclose.
Category: Rhinoplasty
The spreader graft has been the gold standard technique for the reconstruction of the nasal mid-vault. The autospreader flap technique offers an alternative approach to the traditional spreader graft for reconstruction of the nasal mid-vault. It was first described by Fomon in 1950, but it became repopularized in the 1990s when Berkowitz used the term “spreader flap.” The autospreader flap uses the upper lateral cartilage as a donor site flap to improve the effects of nasal obstruction after mid-vault surgery and dorsal hump reduction. It requires less dissection than a traditional graft and minimizes the risk for graft slippage while having the potential for decreased operative time.
At our institution, we frequently use the autospreader flap to prevent mid-vault obstruction to the internal nasal valve. It has been our experience that the autospreader flap takes less time in the operating room and has found to be just as, if not more, effective than the spreader graft. Over 90% of our autospreader flap rhinoplasty patients have shown improvement in nasal valve function postoperatively. In this talk, the pertinent anatomy, indications, contraindications, and surgical technique will be reviewed.
Take-Home Message: The autospreader flap offers a great alternative to the traditional spreader graft in mid-vault reconstruction of the internal nasal valve to improve function after dorsal hump reduction.
How to Get More Google 3-Pack Map Listings
Bill Fukui
Disclosures: Nothing to disclose.
Category: Practice Management
Overview: Google’s map listings have become the most important real estate in search results. Google 3-Pack Map Listings can capture as much as 50% or more of all clicks on key search results. And when combined with traditional search listings, practices can secure multiple organic listings on their most important search results to attract more high-quality visitors, boost credibility, and generate more leads. This course provides an easy-to-understand tutorial on Google Maps and Google Business Profile optimization and strategies to expand your “Local” exposure. Many of these strategies are ones that practices can implement themselves. The course leverages actual profile examples, competitor research strategies, and results tracking.
Learning Objectives:
Understand how Google Maps works and why it needs to be core to your SEO strategy.
Get “best practice” tips your practice can implement to boost your search results (beyond getting more reviews).
Master Google’s Vicinity Update and how it can actually expand your opportunities.
Learn tactics to AVOID that can lower your results and even suspend your profile.
Course Outline:
Why and how to conduct competitive research.
Understanding Google Reviews
a. Why do practices with fewer reviews outrank me?
b. Review tips for success!
Leverage GBP features
a. Google’s social media platform
b. Strategies for Update posts
c. Targeting Areas Served
d. Develop Optimized Products, and Services
How does my website impact my Google local maps results?
Tactics to avoid that can undermine results and penalize your profile.
What’s coming for “Local” advertisers—Google’s screened local providers and pay-per-lead advertising has expanded to medical industries.
Take-Home Message: At the end of this presentation, the audience will have a strong understanding of how to improve their rankings in Google’s 3-Pack Map Listings. The audience will leave the presentation knowing how to leverage Google local tools and map listings to bring in higher quality leads that convert to loyal patients.
Maximize Google Local Service Ads to Boost Your ROI
Bill Fukui
Disclosures: Nothing to disclose.
Category: Practice Management
This educational workshop will provide attendees with a detailed understanding of Google’s pay-per-lead platform, Local Service Ads (LSAs). Launched in 2015, the platform was only made available to medical practitioners in 2023. This workshop will showcase what LSAs are, how they are different from traditional Google PPC ads, how they have performed in other industries, and why they are tailor-made for cosmetic dentistry. This is a timely course for practices looking for immediate Google exposure that projects more credibility, instills greater consumer trust, and generates a higher ROI.
Three learning objectives:
Learn fundamentals of Google’s Local Service Ads platform;
How to get Google screened;
Factors to get your LSAs ranked.
Course Subject matter:
In 2015, Google began beta testing its pay-per-lead platform, now known as Local Service Ads, or LSAs. Industries and markets selected to participate—namely, lawyers and home services companies—have leveraged the ads to increase the volume and quality of leads entering their sales pipeline. Because of the “pay-per-lead” structure of LSAs, these businesses accomplish both goals and even diminish their costs; companies only pay when the ad generates an actual lead.
Following the success of LSAs in improving ROI for businesses as well as advancing consumers’ ability to easily access trustworthy and expert companies, Google opened the ads to dentists and other health care providers in 2023. In addition to only paying for leads, LSAs differ from traditional Google PPC ads in that they position the ads higher on Google’s search results, combine local targeting, and add a trust-building screening process with a certified badge.
Although pay-per-lead ads have been available for other industries, such as home services and lawyers, there are unique differences in dentistry due to HIPAA and other regulatory restrictions. The LSAs are not the same across all industries. This course will address those differences and give attendees a good understanding of how to incorporate LSAs into their digital marketing mix.
Take-Home Message: At the end of this presentation, the audience will understand how to leverage LSAs to bring in higher quality leads while generating a higher ROI. Specifically, the audience will understand the differences and benefits of pay-per-lead compared with pay-per-click ads as well as the drawbacks to pay-per-lead ads and efficient techniques to overcome these drawbacks. Audience members will feel confident in designing and launching their own LSA campaigns at the end of the presentation.
Blueprint for Success
Mohsen Ghoreishi, MA
Disclosures: Nothing to disclose.
Category: Practice Management
This course will provide participants with evidence base numbers and analysis presenting important information and steps to overall physical environment layout, road map to juxtaposition of spaces and clinical services provided, volumetric essence and the feeling desired, coupled with importance of clinical skills, integration of streamlined operations and its impact which can make or break financial stability and growth of the practice.
Although it may not be customary to think a beautifully designed physical environment can be a marketing tool as much as the ability and competency of your clinical skills in the way in which the practice is introduced; however, it is proven by example, practice growth and financial improvement are directly related to patient experience by way of design.
Take-Home Message: Physical office design and clinical skills are equally important marketing tools to enhance patient experience, business growth, and prosperity.
Relationship Between Liposuction Surgery and Injectable Semaglutide Treatment for Body Contouring
Neil C. Goodman, MD
Disclosures: Nothing to disclose.
Category: Body Contouring
I have performed between 8000 and 9000 liposuction procedures over the past 20 years, all in my offices under local anesthesia. During this time, I have photographed every preoperative and postoperative visit for each patient and obtained a body weight on each visit as well. I have previously lectured at American Academy of Cosmetic Surgery (AACS) in 2017 on the profound effect of weight gain (or loss) on liposuction outcomes. With the introduction of the newer injectable medications for weight loss, I am seeing many more patients with significant weight loss preoperatively. In addition, many of my liposuction patients are requesting semaglutide treatment postoperatively for additional weight loss, but this adjunct has both positive and negative conseqences, which I would like to discuss.
The 2 procedures, liposuction and semaglutide weight loss, are markedly different in their mechanisms. Liposuction is a surgical procedure which removes fat and fat cells resulting in permanent volume reduction of the subcutaneous space in cosmetically unfavorable areas, along with subsequent skin retraction which occurs during the healing process. Both of these changes take place only in the area of treatment. Even loosened skin following previous large weight loss due to dieting or bariatric procedures will be followed by significant skin retraction after a liposuction procedure.
The newer weight loss drugs, such as semaglutide, are very effective in curbing the patient’s appetite resulting in large weight loss quickly over a number of weeks to months, which results in subcutaneous volume reduction in all areas of fat storage over the entire body. However, while the removal of fat from fat cells is occurring, the overlying skin becomes significantly loosened, which is the direct OPPOSITE effect obtained by a liposuction procedure. In addition, the removal of fat from cells throughout the body is disadvantageous for total body contouring, as buttocks lose volume and breasts lose volume and hang more as weight is lost. While clothing may hide these changes, facial volume loss leads to a more aged appearance, which cannot be hidden so easily. Finally, the weight loss drugs do not result in permanent changes so many patients return to their starting weight and appearance over time, when the drugs are discontinued. My basic recommendations are as follows. For patients planning a liposuction procedure, who have previously undergone significant weight loss by medical and or surgical means, I recommend 1 or 2 liposuction procedures for selective removal of additional fat storage areas, as well as for significant skin retraction. Fat transfer may be used during the same procedure to make up volume loss in buttocks, breasts, face, and hands. Additional weight loss by medical agents is inappropriate because it will further loosen skin. For patients planning a liposuction procedure who have not lost significant body weight preoperatively, the best strategy depends on the age, weight, size, and skin texture of the patient. For heavy patients who have moderate or tight skin, I recommend a maximal liposuction procedure initially for contouring, with a weight loss of an additional amount of 10% of body weight at most. This produces the best overall outcome for the torso and other areas, with minimal negative effects. A larger weight loss produces additional skin laxity, which results in a lesser cosmetic outcome, even in patients with tight skin or with previous tummy tuck procedures. Finally, in elderly and relatively thin patients who have loose skin, significant facial wrinkles, or hanging breasts, I recommend a liposuction procedure, along with selective fat transfer to the cosmetically unfavorable areas. I often recommend weight regain following the liposuction and fat transfer procedure as well. I will present sequential photographs to demonstrate each of these different treatment modalities and outcomes.
Take-Home Message: The proper usage of liposuction surgery in combination with semaglutide weight reduction can lead to outstanding results; however, there are limitations that must be considered, depending on the age, weight, height, and skin texture of the patient.
Eyes Plasma Gel 3D Method: An Innovative Regenerative Medicine in Periocular Rejuvenation
Enrico Guarino, MD
Disclosures: 1. Evoskin: Advisory Board; 2. Evoskin: Clinical Trial Investigator.
Category: Eyes
Introduction: The periocular area undergoes significant changes during the aging process, including volumetric loss, thinning of the skin, reduced collagen and elastin synthesis, and under-eye dark circles due to visible blood vessels, pigmentation irregularities, and melanin accumulation. Skin laxity and wrinkles further contribute to the aged appearance. Various minimally invasive techniques have been employed to address these concerns, such as dermal fillers, chemical peels, laser resurfacing, platelet-rich plasma therapy, radiofrequency therapy, thread lifts, and microneedling. However, the efficacy of these techniques may vary. In this study, a combination therapy approach is proposed to enhance the appearance and rejuvenation of the periocular area. This protocol uses plasma and platelet-derived growth factors and a gel derived from the patient’s plasma to achieve regenerative and filling effects. In addition, a fractionated erbium laser is used for skin resurfacing, specifically targeting the eyelid and periocular region. This combined approach aims to optimize outcomes and provide a comprehensive solution for addressing the aging signs in the periocular area.
Materials and Methods: Adult patients with dark circles, empty tear troughs, various degrees of wrinkles, and lines in the periocular area were included in the study. In total, 30 patients (8 males and 22 females) between 33 and 73 years of age were enrolled in the study. The exclusion criteria were any injectable treatment within the past year in the periorbital region and tear trough, oculoplastic surgery within the past 2 years, or any topical treatment of the periorbital area other than the prescribed topical creams. All patients underwent photographic evaluation with a QuantifiCare camera before and immediately after treatment and at follow-ups after 15 days, 1 month, 3 months, and 6 months. Before starting the laser procedure, 18 mL of blood was collected and processed to create a liquid version of plasma rich in growth factors and a gel version rich in plasma and platelet-derived growth factors. After cleaning and disinfection, patients underwent erbium fractionated laser treatment (Xlase Plus; Biotec Italia, Dueville, Italy) of the periorbital area and upper and lower eyelids. One milliliter of plasma gel was administered into the tear trough, while another 1 mL was directed to the cheekbone region using a 25G cannula. The remaining 1 mL of plasma gel was injected subcutaneously, targeting the periorbital area, specifically addressing the crow’s feet and forehead wrinkles, using a 27G needle.
Results: All patients followed the protocol and attended their scheduled follow-up appointments No major complications were observed. The swelling was observed for 3 days in the tear troughs of 7 patients, while 6 patients experienced small hematomas in the cannula area insertion or the crow’s feet areas. No cases of hyperpigmentation or long-term side effects were observed. In 10 patients, we did a gel retouch after 3 months, and in 6 cases, we combined it with a second laser treatment. Of the 20 patients, 18 patients who had only 1 treatment were still satisfied with the results at the 6-month follow-up; 10 patients who had the retouch were still satisfied at a follow-up after 9 months after the first treatment.
Conclusion: The utilization of platelet-derived growth factors in aesthetic regenerative medicine has been well-documented in various publications. In this protocol, we have highlighted the advantageous outcomes achieved by combining these growth factors with the filling properties of the gel and the precision of fractionated laser resurfacing, resulting in a durable and sustainable rejuvenation of the periorbital region. Based on our evaluation of the initial outcomes, we consider incorporating a touch-up treatment as a standard step to ensure a lasting impact exceeding 9 months.
Take-Home Message: The Plasma Gel, enriched with growth factors, is a natural and safe treatment combined with an erbium laser for skin rejuvenation. The Erbium laser provides controlled exfoliation and collagen stimulation, while the growth factors in Endoret Plasma Gel enhance tissue repair and regeneration. Furthermore, using the plasma gel like an organic regenerative filler is safe in the tear trough treatment. This powerful duo can help reduce wrinkles, improve skin texture, and achieve a youthful appearance.
Face Plasma Gel 3D: An Innovative Use of Autologous Protein Gel for Soft Tissue Augmentation and Regeneration
Enrico Guarino, MD
Disclosures: 1. Evoskin: Advisory Board; 2. Evoskin: Clinical Trial Investigator.
Category: Face
Introduction: Platelet-rich plasma (PRP) is a natural and effective procedure for slowing aging. However, its limitations include a long time to see the results and difficulty achieving significant volume recovery, often a patient’s primary concern. Various procedures have been proposed to address this, such as the Vampire facelift and platelet-rich fibrin (PRF) techniques, to preserve growth factor regenerative capacity and improve volume. The Vampire facelift combines PRP with hyaluronic acid (HA) fillers, while PRF uses plasma fibers as a scaffold to create container platelets from cooked plasma. However, PRF has been shown to have limited volume longevity and questionable platelet quality and effectiveness. Recently, a new system has been introduced that guarantees the creation of a plasma gel rich in growth factors. This autologous gel formulation has optimal biomechanical and bioactive properties for soft tissue restoration and slow growth factor release.
Materials and Methods: Patients with aged and dropped skin symptoms and empty deep fat bags were treated with a uniform dose of plasma gel via standard injections to achieve a facial lifting effect. Blood samples were collected from each patient, and 18 milliliters of blood were processed in 9 mL tubes containing 3.8% sodium citrate as an anticoagulant. After centrifugation to separate the platelet-rich plasma, the gel was prepared. After preparation, the gel was mixed and emulsified with activated liquid plasma rich in growth factors, following a standardized ratio. Once ready, the plasma gel was injected deep into the subcutaneous fat pads to support the zygomaticus major muscle, producing a lifting effect at the jawline and pre-jowl sulcus. In addition, it was injected to replace lost volume and augment nasolabial folds and cheeks by injecting the deep/superficial subcutaneous layers in a linear retrograde mode. A 25G cannula was used to fill all the empty bags of fat, and a 30G needle was used to fill wrinkle lines by placing serial micro-droplets at the dermal level. Patients were followed up at 1, 3, 6, and 9 months with standardized photographs taken using a QuantifiCare camera and clinical evaluation. Patient surveys were conducted using Likert scales to evaluate the clinical performance of the treatment.
Results: Between June 2022 and March 2023, 50 patients (42 female, 8 male) with a median age of 52 years (ranging from 25 to 72 years) were treated with Plasma Gel 3D. All patients completed the follow-up period, including photographic and clinical evaluations and satisfaction tests. Clinical evaluations of pretreatment and posttreatment photographs showed a gain of 2.5 to 3 points. Three months posttreatment, the treated areas exhibited a significant volumetric increase with an average reduction of 20% in total volume. After 6 months, an additional average loss of 30% was observed. At the 9-month follow-up, approximately 10% of the initially injected product remained. The treatment profoundly impacted skin texture quality, improving elasticity and compactness. Even small wrinkles showed a permanent reduction in depth that persisted even after 9 months. Most patients (36 of 40) reported high satisfaction with the treatment, meeting their initial expectations regarding fine-line improvement, wrinkle reduction, and sagging improvement. The treatment resulted in noticeable facial rejuvenation and attributed to the soft tissue augmentation effect, resulting in improved surface texture and tone. Regarding volume persistence at the 3-month follow-up, 70% of patients expressed high satisfaction, 20% were moderately satisfied, and 10% desired an immediate second treatment. At the 6-month follow-up, 55% remained highly satisfied, 10% somewhat satisfied, and 25% expressed satisfaction but would consider a touch-up treatment. After the 9-month check-up, all participants reported high satisfaction with the treatment’s ability to enhance skin quality and reduce wrinkle appearance. Eighty percent of the participants were willing to undergo the procedure again immediately.
Conclusion: Although more randomized clinical trials are necessary, our preliminary clinical findings indicate that Plasma Gel 3D shows excellent potential as a procedure that can combine facial volume restoration with regenerative abilities. Due to its organic filler that can be extracted from just 18 mL of blood at a low cost and its natural protocol, we suggest a second treatment after 3 to 6 months to attain volume persistence for up to 12 months.
Take-Home Message: The Plasma Gel 3D is a natural and safe treatment that offers exciting facial reshaping and rejuvenation possibilities. By harnessing growth factors and bioactive substances, the gel stimulates collagen production, tightens skin, and enhances volume naturally.
Mastectomy Recommendations for Female-to-Male Transgender Patients and a Discussion of Gender-Affirming Care for Gender-Dysphoric Adolescents
Aneesh Gupta, MD, MPH and Jeffrey B. Marvel, MD
Disclosures: Nothing to disclose.
Category: Breast
Subcutaneous mastectomy (top surgery) in female-to-male patients is one of the most common procedures gender-dysphoric patients will undergo to live as their desired gender. By consistently using the technique described in this article, surgeons can achieve consistent and aesthetically pleasing results.
One of the more common topics being addressed is what to do in patients seeking care that are below the age of 18. Multiple states in the United States are seeking to ban this type of care, and are even attempting to restrict health care for adults. These bans are being enacted despite carefully researched and written guidelines from major international organizations. By following these guidelines, physicians can provide safe and evidence-based care to adolescents. Most importantly, the evidence conclusively demonstrates that providing gender-affirming care to patients of all ages improves their mental health, reduces rates of depression, and decreases the risk of suicide.
Take-Home Message: By using safe and consistent technique, top surgery on female-to-male transgender patients can produce excellent aesthetic results. In addition, gender-affirming care saves lives by improving the mental health of transgender patients, specifically by reducing the incidence of depression and suicidal ideation.
Proper Diagnosis and Management of Iatrogenic Festoons
Lopa Y. Gupta, MD
Disclosures: Nothing to disclose.
Category: Face
Introduction: Hyaluronic acid (HA) fillers are a leading cause of iatrogenic festoons. Festoons can affect patients’ well-being on multiple levels. First, they can cause an undesirable cosmetic appearance that is not easily remedied by over-the-counter treatments such as creams and lotions. On the psychological front, they can result in anxiety or depression, which can lead to poor self-image and low self-esteem. This prompts them to see specialists to evaluate and treat this condition. In our experience, many patients do not even have insight into the cause of their condition, let alone know its name. Unfortunately, most cosmetic specialists shy away from festoons because of the lack of accepted and verifiably successful treatment strategies, often further stranding the patient psychologically. Our practice has a large volume festoon patient population and herein we describe our experience with this common conundrum.
Background: Hyaluronic acid fillers are hydrophilic materials that are injected subcutaneously to “fill” hollow areas or to provide “plumpness” to either regain or maintain a youthful appearance. Contrary to initial studies on reabsorption and dissolution, there is evidence that they can persist for years. In fact, smaller HA particles introduce more water binding regions, thereby inviting more edema along with their known angiogenic and inflammatory diatheses. This potpourri of filler, fluid, hypervascularity, and inflammatory mediators often segues to festoon formation in the prezygomatic space or PZS. With a leaky orbicularis retaining ligament at the superior border of the PZS and a robust, nonpermeable zygomaticocutaneous ligament at the inferior border, the PZS provides the perfect milieu for fluid accumulation. The PZS is also a sponge with potential space throughout, further adding to the saturation. When filler is injected is directly into the PZS or migrates from the lower lid or high cheek, it can become trapped or encapsulated, acting as a water magnet. If there is significant posttreatment edema, the patient is prompted to return to the office for prompt help with hyaluronidase to dissolve some or all of the filler. The problem, however, is that this acute postinjection edema may subside enough for most patients, allowing the filler to get settled in, get partially metabolized, and likely get encapsulated rendering it impermeable to enzyme reversal. After serial treatments with HA fillers, the amount retained accumulates, often leading to chronic swelling sequelae further exacerbated by other triggers such as salt, alcohol, allergies, or low atmospheric pressure to name a few. The author, however, has had numerous patients with festoons after a single injection of HA filler done 10 to 15 years prior. Without a priori knowledge of this possibility, the direct correlation between HA fillers and festoons may be missed by the doctor and patient alike. Festoons are thus underdiagnosed, misdiagnosed, undertreated, and inadequately treated. Existing festoon management methods include painful doxycycline injections, long incisions, aggressive laser resurfacing, or deep dissections with ligament releases and tissue redraping under general anesthesia. Despite these measures, however, recurrence rates are high.
Experience/Data: In 2007, the author created and in 2022, published, a minimally invasive festoon to treat all festoons, regardless of etiology, with documented long-term success and low recurrence rate. The purpose of this presentation is to describe the etiology and best treatment strategy for iatrogenic festoons. The author’s published technique, aptly called MIDFACE, is an acronym for mini-incision direct festoon access cauterization, and excision has withstood the test of time. The procedure is performed under local anesthesia in the office with radiosurgery using the Ellman Dual Surgitron apparatus. After the skin is cleansed and prior to the local injection, the area of the festoon is delineated with a surgical marking pen. Next, a 1-cm line is marked along an orbicularis rhytid at the inferior margin of the lower lid and just above the festoon. If a lower lid blepharoplasty is performed simultaneously, the herniated orbital fat pads and any extension of the festoon into the eyelid are marked as well. Using a cannula method and at multiple levels, hyaluronidase is injected into the festoon and, if indicated, the lower eyelid. After 30 minutes, the surgical area is injected with 2% lidocaine with epinephrine 1:100 000 parts. After another 30 minutes, a conventional transcutaneous lower lid blepharoplasty is performed, including skin and herniated orbital fat excision. Attention is then directed to the festoon, whereby the premarked line is incised. An ellipse of skin is excised above and below the incision to preempt skin burn at the entry site. Using the empire needle on hemo mode, dissection is carried down to the pre-periosteal level. A toothed forceps is introduced through this opening and burrowed horizontally to grasp the suborbicularis oculi fat (SOOF) from underneath the festoon. The grasped SOOF is then pulled toward the opening so that metal to metal contact is made between the forceps and the empire needle tip. Radiowave energy is transmitted to cauterize the SOOF with the empire needle on the hemo mode. This maneuver is performed circumferentially at a deep level from the entry point. Passive transfer of energy to the superficial levels along with direct deep energy results in visible effacement of the festoon after multiple passes are undertaken. Radiofrequency energy thus dessicates and tightens different levels of the PZS, including the potential space. It also destroys any enzyme-resistant or trapped filler in the PZS. The incision is then closed with a deep absorbable suture as well as skin apposition suture for the festoon site and if indicated, the subciliary incision.
Discussion/Results: Proper management of festoons, nonetheless, is predicated on accurate diagnosis. Thorough history-taking regarding previous HA fillers is paramount. Examination with good lighting and magnification often reveals telltale signs of HA filler–induced festoons, including Tyndall effect, hypervascularity, and pitting edema extending from the nose to the lateral cheek. High-frequency ultrasound is also helpful in detecting filler if the clinical examination is inconclusive. Once an accurate diagnosis is made, the patient must be advised of all surgical and nonsurgical options and of the need to abstain from future HA fillers in the lids and cheeks. A survey was sent to 75 patients who underwent festoon treatment in our practice with the MIDFACE technique. The response rate was 49%. A history of HA injection preceding festoon occurrence was present in 54% of patients. An additional 12% of patients had a history of injection with another filler (fat, Radiesse, Sculptra). Residual festoons were present in 8.1%. Most of these were minor and required no further surgical treatment. One patient (2.7%) with a late recurrence at 8 years postoperative underwent revisional surgery with successful resolution.
Conclusion: The HA fillers accumulate over time and in thin-skinned areas like the eyelids and ligament-bound areas like the PZS, the hydrophilic nature of HA fillers can result in unsightly eyelid swelling and festoon formation weeks or even years after injection. The onus is on us, as cosmetic practitioners, to think twice before serial and/or overzealous HA filler injections are performed in the lower lids, midface, and cheeks. In our practice, we avoid HA fillers in these regions altogether. We also need to educate our patients on the risk of festoon formation after HA fillers and to make them realize that instant gratification may lead to devastating consequences in these areas. Surgical correction with the MIDFACE technique is feasible and when done in concert with lower lid blepharoplasty has a high success rate, durable results, and excellent aesthetic restoration of the lid-cheek junction.
Take-Home Message: Hyaluronic acid fillers in the lower lids, midface, and cheeks can segue into festoon formation acutely or years after injection. From their unsightly appearance to the lack of successful treatment options, patients feel stuck and often spiral into anxiety, depression, and social isolation. It is time for doctors and patients alike to be equipped with knowledge on the proper diagnosis and management of festoons. The author’s published MIDFACE technique, especially when combined with transcutaneous lower lid blepharoplasty, has proven to be a viable option for the surgical management of HA filler–induced festoons with an excellent long-term success rate and a low recurrence rate.
After 30 Years of Performing Facelifts, Why I Have Evolved to the Extended Deep Plane Technique?
Wilbur Hah, MD
Disclosures: Nothing to disclose.
Category: Face
Facelifts continue to one of my favorite procedures to perform. I will share my 30-year journey from SMAS plication, SMASectomy, to Deep Plane, and then to Extended Deep Plane technique. Techniques on how to safely enter into the deep plane and release the osteocutaneous retaining ligaments will be demonstrated. By releasing these ligaments, a significantly better lift of the midface and area around the mouth can be achieved. The Extended Deep Plane technique incorporates a platysma flap to provide a “hammock” to support/elevate the submandiublar glands as well as providing a better gonial angle contour.
Take-Home Message: The Extended Deep Plane technique is a safe and powerful technique for performing natural-appearing facelifts.
A Comprehensive Approach to Facial Rejuvenation: Component Deep Plane Face Lift and Adjunctive Techniques
Daria Hamrah, DMD, FAACS
Disclosures: InMode Aesthetics: Honorarium.
Category: In this presentation, I will discuss the efficacy and integration of the Component Deep Plane Face Lift with other rejuvenation techniques including blepharoplasty, brow lift, laser resurfacing, and fractionated radiofrequency. My focus is on the application of a comprehensive, multidimensional approach to address patient-specific needs and achieve optimized aesthetic outcomes. I will delve into the anatomical and procedural specifics of each component, demonstrating how their combination offers more comprehensive and natural results. Practical case studies will be shared to provide a clear understanding of the potential benefits and drawbacks of this integrated approach. This concise presentation aims to illustrate how the individualized and comprehensive treatment plans within the field of cosmetic surgery can cater to evolving patient needs and enhance overall patient satisfaction.
Take-Home Message: The Component Deep Plane Face Lift, when combined with adjunctive facial rejuvenation techniques such as blepharoplasty, brow lift, laser resurfacing, and fractionated radiofrequency, allows for a more comprehensive, individualized approach to cosmetic surgery. This integrated methodology not only caters to the patient-specific aesthetic goals but also significantly enhances overall satisfaction by delivering more natural and enduring results. As practitioners, it is imperative that we remain adaptable and continue to evolve our techniques in line with patient needs and emerging technologies.
Redefining Nasal Aesthetics: The Supratip as a Pivotal Landmark in Cosmetic Rhinoplasty
Daria Hamrah, DMD, FAACS
Disclosures: InMode Aesthetics: Honorarium.
Category: Rhinoplasty
In the intricate artistry of rhinoplasty, the precision of aesthetic landmarks contributes significantly to the successful outcomes. This presentation will shine a spotlight on one of these critical, yet often overlooked landmarks: the supratip. Despite its defining role in creating a distinctly outlined nasal tip, it is frequently misapprehended or disregarded in rhinoplasty procedures. This presentation will argue for its cardinal role in enhancing the overall aesthetic appeal of the nose, emphasizing that a well-defined supratip can dramatically influence the perception of nasal tip refinement and definition. We will explore the precise anatomical understanding of the supratip, its clinical implications in rhinoplasty, and propose specific surgical techniques to achieve an optimal supratip delineation. This includes the technical nuances required in sculpting this aesthetic landmark, focusing on the pitfalls of supratip mismanagement and the significant improvement in postoperative results when the supratip is appropriately addressed. Through a series of case studies, we will demonstrate the transformative power of the supratip in overall nasal aesthetics, providing tangible evidence of how a well-defined supratip enhances the nasal tip and lends harmony to the facial profile. The ultimate objective is to augment the average rhinoplasty surgeon’s understanding and skill set in crafting the supratip to refine surgical outcomes and patient satisfaction. My intent with this presentation is to stimulate a new level of discourse in the field of rhinoplasty, pushing the boundaries of aesthetic excellence by advocating for a more nuanced approach to the often overlooked supratip. Together, we can elevate the field of rhinoplasty, advancing our shared objective of aesthetic enhancement and patient satisfaction.
Take-Home Message: This presentation underscores the importance of the often overlooked supratip in rhinoplasty. A well-defined supratip can significantly improve the aesthetics of the nose and the overall facial harmony. Comprehensive understanding of supratip anatomy and proper surgical techniques can dramatically elevate postoperative outcomes and patient satisfaction. Hence, I advocate for a stronger focus on the supratip to achieve superior results in rhinoplasty. This message encourages rhinoplasty surgeons to elevate their technical prowess by recognizing and addressing the supratip effectively, thus promoting a holistic and nuanced approach in this field of cosmetic surgery. The supratip is not just a detail; it is an essential factor in the artistry of rhinoplasty. Recognizing its impact could be the differentiating factor that takes a good outcome to an excellent one, setting a new standard in the realm of aesthetic surgery.
Upper Eyelid Blepharoplasty Closure With Running Subcuticular 6-0 Plain Gut Suture—A Novel Technique and Report of a Case
David J. Haralson, MD, DMD
Disclosures: Nothing to disclose.
Category: Eyes
In this abstract, we report on the outcome of an upper blepharoplasty (UB) case performed on a 27-year-old woman where a running 6-0 plain gut subcuticular suture technique was used, along with three to four 6-0 plain gut interrupted support sutures for closure of the incisions bilaterally. Blepharoplasty remains one of the most commonly requested facial cosmetic procedures. Cosmetic surgeons are continually seeking ways to reduce the unwanted postsurgical sequelae for their patients and optimize healing. Eyelids remain an opportunity for surgeons not only to showcase their ultimate postsurgical cosmetic results, but also to demonstrate their efforts to minimize ecchymosis, edema and erythema, scarring, dehiscence, and/or milia formation—all during the recovery period, thereby returning the patient to normal functioning as efficiently as possible. A number of suture techniques and suture materials have been used for closure of the UB incision. Techniques include running cuticular suturing, running subcuticular suturing (pullout or permanent), and interupted suturing. Due to the thinness of the eyelid skin, popular sutures are typically a 6-0 or smaller variant of polypropylene, nylon, vicryl, or fast-absorbing gut. Tissue adhesives such as ethyl cyanoacrylate and tissue taping have also been studied. A recent article by Aydemir et al1 showed evidence that interrupted suturing appears to lead to less edema, ecchymosis, and scarring than running cuticular suture regardless of whether 6-0 polypropylene or 6-0 vicryl was used. Another study by Joshi et al2 favored running cuticular 6-0 fast-absorbing gut stabilized with 2 interrupted 6-0 polypropylene sutures. To date, the use of 6-0 plain gut as a subcuticular suture in the closure of UB incisions has not been reported. Concerns over inflammatory reactions with gut suture and premature suture breakdown are the likely reason this technique has not previously been considered. Indeed, gut suture (being mostly collagen) is dissolved by proteolytic enzymes during the inflammatory process. It is thought that gut suture loses a substantial amount of its tensile strength within 7 to 10 days. This should not be a downside as most blepharoplasty sutures are moved around 1 week postop. Removable sutures, whether polypropylene or nylon, gut or vicryl, interrupted, running, cuticular, or subcuticular, are commonly removed around the 7-day mark to prevent excessive irritation and scarring in hopes that wound dehiscence will not occur. Eyelid incision healing is therefore a delicate balance of bringing the wound edges together to promote healing and prevent dehiscence but minimize excess inflammation that detracts from the healing process.3
Our patient is a 27-year white woman who is otherwise healthy (ASA I). She complained of redundant upper eyelid skin and lack of an eyelid “shelf” for application of eyeshadow. On further questioning, it was noted that this is a family trait. We discussed the risks, benefits, and alternatives to UB and preoperative photographs were taken. She agreed to schedule the procedure under outpatient intravenous sedation in our clinic operating room.
Technique: The patient arrived Nothing by mouth (NPO) for her appointment with the exception of 2 tablets of tranexamic acid 650 mg and 4 tablets of 500 mg Keflex which she had taken 2 hours before with a small sip of water. Skin markings were completed in the consultation room as were additional photographs. Ice packs were held over her eyelids preoperatively. She was then taken to the operating room, where IV sedation was introduced and she was prepped and draped in the customary sterile fashion for a facial cosmetic procedure.
Appropriate local anesthetic was instilled into each upper eyelid (2% lidocaine 1:100 000 epi), approximately 1.7 mL per lid, and 10 minutes were allowed to elapse prior to incision. A #15 blade was used to outline the elliptical upper eyelid skin incision. The excision of skin and orbicularis muscle was then accomplished with the same #15 blade. Bipolar cautery was used to control small bleeders. An iris scissor was used to removed a strip of orbital septum overlying her medial and middle fat pads. Blunt dissection here exposed a significant amount of palpebral fat which was clamped with a mosquito hemostat and cauterized and excised with bipolar cautery and iris scissors. After the skin, muscle, and fat removal was performed, a 6-0 plain gut suture on a CP1 conventional 3/8 circle 11-mm cutting needle was passed through the skin using a Castroviejo Needle Holder and Bishop skin forcep starting at the medial portion of the wound and was then used in a subcuticular fashion to close the upper and lower edges of the skin excision continuing through the lateral portion of the wound, and then exiting the skin surface at the temporal aspect. No knots were tied on the 6-0 plain gut subcuticular suture. Rather, about 5 mm of the suture tail was left medially and laterally at the entrance and exit points. The same 6-0 plain gut suture was then used to place 3-4 supporting interrupted sutures along the incision line. Bacitracin was placed, and then ice packs were again introduced. The patient was allowed to recover appropriately and be discharged home with appropriate postop instructions. The patient kept us apprised of her progress with frequent selfies sent to the author via text. These are included with this abstract. The patient was seen 7 days postoperatively for removal of the interrupted supporting sutures and again at 14 days for removal of the right-running subcuticular suture. The ends of the left-running subcuticular suture were no longer visible at this time. The patient started wearing hypoallergenic makeup at 2 weeks postop. At the end of postop week 3, the patient noticed what may have been a couple of milia forming on the left UB incision line, but was unable to come in for observation. This concern resolved on its own over the next couple of days. By 1 month, the patient’s incisions appear well healed with no inflammation and minimal scar formation. She is extremely pleased with her outcome. Balancing patient demands for minimal postprocedure downtime and exceptional cosmetic results with the available techniques and materials is the constant task of the cosmetic surgeon. In this case, we demonstrate a new suture technique using running subcuticular 6-0 plain gut with 3-4 supporting 6-0 plain gut interrupted sutures for closure of UB incisions. Running subcuticular suturing has the advantage of well approximated wound edges when performed with precision. Running cuticular sutures have the disadvantage of gathering and bunching the tissue once inflammation sets in. This can lead to unsightly wound edges that require a significant amount of time for the erythema and edema to resolve. In addition, there is the question of whether the wound edges will remain approximated when sutures are removed around day 7. This is a concern for cuticular interrupted or running sutures (whether resorbable or nonresorbable) as well as subcuticular pullout sutures. There is also that tense moment when removing a polypropylene subcuticular pullout suture where it is uncomfortable for the patient or does not easily “pull out.” Plain gut sutures have not traditionally been used in a subcuticular fashion because of perceived inflammation. However, we have shown in this case that 6-0 plain gut in the appropriately selected patient could be used in a running subcutaneous fashion with stabilizing interrupted 6-0 plain gut sutures to achieve an excellent cosmetic closure and result. The resorbable gut suture can be treated as a permanent suture (although it will degrade through proteolytic enzymes) or it can be used as a pullout suture. The interrupted stabilization sutures can be removed at days 5 to 7 and the subcuticular left in place longer for more initial wound strength. It is believed that the biologic burden of the small caliber of 6-0 plain gut is not too great for the body’s healing mechanism to tolerate and degrade. The potential downsides for employing this technique could be extremely thin eyelid skin which may not lend itself to any subcuticular running suture or known sensitivity to the animal products (collagen) from which these sutures are made. Loupes were not necessary for this procedure despite the delicate nature of the closure. Consideration should be given to the surgeon’s judgment and expertise when customizing care for each patient.
References
1. Aydemir E, Kiziltoprak H, Aydemir GA. Comparison of clinical outcomes of upper eyelid blepharoplasty using two different suture techniques. Beyoglu Eye J. 2022;7(1):18-24.
2. Joshi AS, Janjanin S, Tanna N, Geist C, Lindsey WH. Does suture material and technique really matter? lessons learned from 800 consecutive blepharoplasties. Laryngoscope. 2007; 117(6):981-984.
3. Alawadh IH, Alshehri WM, Alshehri NA, et al. Closure techniques and suture materials for upper blepharoplasty: an extensive narrative litrature review. J Orthop Surg Res. 2022; 5(2):202-211.
Take-Home Message: It is possible to have excellent cosmetic results and minimal surgical morbidity from upper eyelid blepharoplasty. Using 6-0 plain gut suture in a running subcuticular fashion on appropriately selected patients is a novel technique which may prove valuable. This case report highlights our technique and patient experience.
Capsular Contracture: A Reproducible Regimen to Prevent and Treat Capsular Contracture in Aesthetic Breast Surgery
David Henry, DO, Dennis Idowu, MD, and Jacob Haiavy, MD, DDS
Disclosures: Nothing to disclose.
Category: Breast
Introduction: Capsular contracture in cosmetic, as well as reconstructive; breast surgery has been a consistent burden for patients and surgeons alike since the advent of the breast prosthesis more than 40 years ago. Many studies have attempted to identify the etiology of capsular contracture. These studies have examined factors such as bacterial loads and sterility at augmentation, differing surgical approaches and planes, assessing characteristics of the prosthesis itself and postsurgical complications such as hematoma formation. Previously described nonsurgical treatments have included diclofenac patches, pirfenidone, intracapsular triamcinolone injections, leukotriene inhibitors, ultrasound treatments, and laser treatments. A summary review of the literature on this topic ultimately reveals these treatments to have varying levels of efficacy. At this time, the gold standard for treatment is capsulectomy, implant exchange, and conversion of the pocket. Acellular dermal matrix may also be a useful adjunct but requires more long-term data. This study aims to propose a new nonsurgical treatment and postsurgical prophylaxis regimen for capsular contracture. In addition, we hope it will serve as a starting point for further collaborative multicenter studies. This will facilitate in the recruitment of patients to significantly increase the power of this study to establish this regimen as the new gold standard.
Materials and Methods: This was an institutional review board–approved study looking at all of the patients diagnosed and treated for capsular contracture at our facility from 2016 to 2023. Patients with Baker scores II-IV capsular contracture were included in our study. The patients were categorized after being examined by a senior surgeon on staff. Collectively, the 2 senior surgeons have more than 30 years of experience treating capsular contracture and performing aesthetic breast surgery. Patients recruited into the study were established patients, new patients, and patients who had undergone capsulectomy with re-augmentation. The mainstay of treatment was Celluma light therapy. This was performed in 30-minute sessions on the red/infrared light setting. We combined low-level light therapy with daily breast exercises and enzyme supplementation with milk thistle 1000 mg twice daily.
Results: In total, 205 patients were identified with capsular contracture. In all, 58 patients were removed from the study, based on our exclusion criteria; 85 patients were placed into the treatment arm; and 62 patients were placed into the prophylactic arm. In the multimodal medical treatment arm, 79% (67/85) of patients had a reduction of at least 1 Baker grade. Also in the medical treatment arm of our study, 20% of patients (17/85) improved from a Baker grade III to a Baker grade I and 5% of patients (4/85) improved from a Baker grade IV to a Baker grade I. Average follow-up was 13.44 months. In the prophylactic arm, 85% (53/62) did not have evidence of re-encapsulation and remained as Baker 1 with an average follow-up of 16.6 months.
Conclusion: Capsular contracture will continue to be a prominent source of concern as long as breast augmentations are being performed. Attempts at controlling etiologies and modifying surgical techniques have not been sufficiently effective. The rates of capsular contracture after primary augmentation range from 0.6% to 17.4%.Unfortunately, the rates of contracture after reoperation increase significantly. Our multimodal regimen of Celluma light therapy, milk thistle, and breast exercises is simple to adhere to and, in our experience, is highly efficacious. To our knowledge, no other medical treatment modality has been as effective in treating Baker grade III and IV capsular contracture or in the prevention of recurrent capsular contracture after surgical correction. Improvement of Baker grade II to grade I capsular contracture was the largest group of change in the medical treatment arm of our study. It is the opinion of the authors of this study that if capsular contracture intervention is to be undertaken, it should be done early to ensure the highest rate of success. Furthermore, if surgical correction of capsular contracture is intended, breast implants should be replaced, pocket conversion should be performed if applicable, and our postoperative prophylaxis protocol should be employed to dramatically reduce the risk of recurrence. The existing literature on the treatment and prevention of capsular contracture is heterogeneous and inconsistent in nature. Based on our results and the success, we have had in our office we believe initial efforts to treat capsular contracture should refocus on the proposed multimodal medical treatment regimen and that the same treatment regimen should be used prophylactically following surgical correction of capsular contracture.
Take-Home Message: Capsular contracture can be successfully and reliably treated with simple easy to adhere to nonsurgical interventions regardless of severity. When surgical intervention is warranted, the same simple adjunct protocols can greatly reduce the risk of recurrent capsular contracture.
Five Tips of Exponential MedSpa and Nonsurgical Growth
Jon Hoffenberg
Disclosures: Sientra: Honorarium.
Category: Practice Management
Unlock the secrets to achieving exponential growth in your MedSpa and nonsurgical cosmetic services with these 5 invaluable tips. This session will provide attendees with practical strategies and actionable insights to propel their nonsurgical practices to new heights.
Objectives:
Learn proven sales techniques helping achieve million dollar annual nonsurgical growth.
Obtain effective marketing strategies maximizing visibility and patient engagement.
Explore innovative approaches to enhance patient experience and satisfaction, leading to increased referrals and loyalty.
Gain insights into operational efficiencies and scheduling techniques to drive productivity and profitability in MedSpa services.
Implement actionable steps to differentiate your practice in the competitive landscape, positioning it as a leader in MedSpa and nonsurgical aesthetic treatments.
Attendees will unlock their practice’s true potential and pave the way for unparalleled success in their nonsurgical business.
Take-Home Message: Attendees will learn 5 tips for nonsurgical and MedSpa growth maximizes a stream of revenue for while the surgeon is away or to build a MedSpa.
Anatomy of a Successful Digital Marketing Strategy
Jon Hoffenberg
Disclosures: Sientra: Honorarium.
Category: Practice Management
Websites, pay-per-click, social media, and influencer marketing, oh my! Are you a plastic surgery practice struggling to determine the most effective marketing strategy amid the plethora of options available? This course will guide you through the process of budgeting your marketing dollars for maximum exposure and growth. Our expert team will discuss the optimal order of marketing steps, taking into account the size and scope of your practice, to ensure minimal risk and maximum success. From site building to organic SEO, pay-per-click to social media, and ratings and reviews, we will provide valuable insights and a proven accountability structure to help you build a successful marketing program. Do not miss this opportunity to learn how to maximize your marketing budget and grow your plastic surgery practice in 2023 and beyond.
Take-Home Message: Attendees will learn the specific order and budgets based on practice size and scope in which to craft their own digital marketing strategy to increase exposure, brand awareness, and gaining true market share in 2023 and beyond.
The Most Costly Mistakes Practices Make in Business—Cost Versus Profit Centers
Jon Hoffenberg
Disclosures: Sientra: Honorarium.
Category: Practice Management
Uncover the most common and detrimental mistakes made by aesthetic practices when it comes to managing their finances. This presentation will focus on the crucial concept of differentiating cost centers from profit centers and how it impacts the overall financial health of a practice. Course will help attendees:
Identify the key differences between cost centers and profit centers within a plastic surgery practice and understand the financial implications and consequences of misclassifying expenses and revenue streams.
Learn practical strategies and best practices for optimizing cost centers and maximizing profit centers.
Discover effective financial management techniques to enhance practice profitability and sustainability.
Develop a clear action plan to avoid costly mistakes and improve overall business performance in the plastic surgery industry.
Do not miss this opportunity to gain a comprehensive understanding of the financial pitfalls that can hinder your practice’s success and learn invaluable strategies for achieving long-term financial prosperity.
Take-Home Message: Attendees will gain a comprehensive understanding of the financial pitfalls that can hinder a practice’s success and learn invaluable strategies for achieving long-term financial prosperity.
Conscious Sedation Anesthesia for Deep Plane Facelifts
Steven B. Hopping, MD, FACS
Disclosures: Nothing to disclose.
Category: Face
Introduction: Conscious sedation is increasing being requested and utilized in nearly all cosmetic procedures for both touch-up and primary procedures. Given the option, many patients prefer conscious sedation to general anesthesia particularly if they have had past complications with general anesthesia such as nausea, vomiting, and prolonged recovery.
Methods: Principals and techniques that can provide optimal surgical results with conscious anesthesia while meeting many patient’s expectations are discussed. Results and important criteria for safe implementation of conscious sedation in an outpatient setting are discussed. Patient satisfaction evaluations of these methods are reviewed.
Discussion: The advantages and disadvantages of using conscious sedation anesthesia for deep plane approaches to facelifting are critically evaluated. Recommended criteria for patient selection and key elements for maximum safety are reviewed.
Summary: Patients are increasingly interested in avoiding general anesthesia for elective procedures. Increasingly conscious sedation is selected by patients when given the choice as an alternative to general anesthesia. Safe and effective utilization of these techniques can be performed in outpatient settings with Accreditation Association for Ambulatory Health Care (AAAHC), American Academy of Anesthesiologist Assistants (AAAA), or equivalent certifications.
Take-Home Message: Patients are increasingly concerned about anesthesia complications especially for elective cosmetic procedures. Safe outpatient cosmetic surgical procedures should be ideally performed in a AAAHC, AAAA, or equivalently certified setting. It behooves all cosmetic surgeons to have knowledge and experience in conscious sedation anesthesia techniques as an option particularly for patients requesting such procedures.
Intraoperative Ultrasound in Cosmetic Surgery—Guided Gluteal Fat Grafting and Using Regional/Local Nerve Blocks in Breast and Abdominal Surgery
Alton Ingram, MD, FAACS
Disclosures: Nothing to disclose.
Category: Other
The use of ultrasound-guided fat grafting has grown exponentially as it was mandated in autologous fat grafting to the buttocks (BBL) by the Florida Board of Medicine in 2022, and the TAP (transversus abdominis plane) block has been used in abdominal cosmetic surgery since the early 2000s. Many more cosmetic surgeons have access to handheld ultrasound devices, which can be very useful in cosmetic surgery of the breast and abdomen. Furthermore, regional anesthesia plays an increasingly significant role in perioperative care for patients undergoing breast and abdominal surgery, providing several advantages such as improved patient comfort and decreased dependence on opioid medications. This presentation will focus on the use of regional anesthetic blocks with and without ultrasound guidance cosmetic surgery of the breast and abdomen, highlighting 4 specific blocks: PECS I, PECS II, Serratus Anterior Plane (SAP), and TAP, as well as ultrasound-guided fat injection during BBL surgery.
Take-Home Message: Intraoperative ultrasound is an inexpensive and easily learned imaging modality that can increase patient comfort and safety. Regional and local nerve blocks can be used safely and effectively either with or without ultrasound. Ultrasound-assisted fat injection is already required in at least one US state and may already be the standard of care for BBL surgery.
Patient Safety in Brazilian Butt Lift: Best Practices, Standard of Care, and Regulatory Update
Alton Ingram, MD, FAACS
Disclosures: Nothing to disclose.
Category: Body Contouring
Brazilian butt lift is a safe and effective cosmetic procedure when performed properly. Nevertheless, sensationalized reporting and high-profile deaths continue to surround this operation with a whiff of scandal in the eye of both the public and regulatory bodies. This lecture will focus on patient safety in BBL surgery, with a specific emphasis on the evolution of the standard of care in the last 5 years—specifically the use of subcutaneous-only injection and intraoperative ultrasound—and will provide an update on recent changes to the regulatory environment at both the legislative and board of medicine levels.
Take-Home Message: The BBL is safe and effective when performed in the subcutaneous plane. Ultrasound guidance of fat injection can help verify that the surgeon is injecting in a safe plane. Each state in the US is subject to potentially differing regulatory requirements when performing BBL surgery, and all cosmetic surgeons performing this procedure must stay apprised of their states’ desiderata.
Can You Handle The Truth?! Semaglutide Versus Tirzepatide, Head-to-Head Comparison in Our Practice
Jonathan Kaplan, MD, MPH
Disclosures: KP Innovations LLC: Ownership Interest (Ownership interest of an ineligible company).
Category: Practice Management
With Ozempic, Wegovy, and Mounjaro on the FDA shortage list, Federal law allows compounding pharmacies to make duplicates of commercially available drugs without risk of patent infringement. We have built a large weight management program in our practice using semaglutide (active ingredient in Ozempic and Wegovy) and tirzepatide (active ingredient in Mounjaro) so we were able to compare the weight loss results and side effects between the 2 medications. Before now, the only head-to-head comparison of the medications was financed by Eli Lilly, the developer of Mounjaro. We will present our findings.
Take-Home Message: Which is better for weight loss and fewer side effects? Semaglutide or tirzepatide? By the end of the presentation, the audience will know our practice’s experience.
A Contiguous Series Retrospective Review of Patient Charts Where Renuvion Was Used for Body Contouring Compared With the InMode RF System
Michael S. Kluska, DO, FAACS, FACOS, Chad Deal, MD, Kyle Summers, DO, and Steven Chang, MD
Disclosures: 1. Apyx Medical: Advisory Board; 2. Apyx Medical: Honorarium.
Category: Body Contouring
Title: A Contiguous Series Retrospective Review of Patient Charts where Renuvion was used following Liposuction or Body Contouring Compared to the InMode RF System used in Conjunction with Liposuction or Body Contouring.
Purpose: The purpose of this study is to collect and compare retrospective procedure and safety data of patients where Renuvion was used following liposuction or body contouring compared with the InMode RF System used in conjunction with liposuction or body contouring.
Design: A contiguous series of subject charts from 2018 to 2022 at a single site who were treated with Renuvion, InMode RF, or both (split body) were reviewed retrospectively for demographic, procedure data, and safety data. Outcome measures were analysis of adverse events recorded by the body area during or postprocedure by group and analysis of procedure information by group. Additional analyses within each group may be done if different liposuction or body contouring devices were used within the group or if Morpheus or other microneedling device was added as treatment to the same body area.
Findings: Retrospective data have been collected on more than 400 subjects who were treated with Renuvion (45%), InMode (51%), or both devices (split body) (4%) between January 2018 and December 2022. Data analysis is currently underway at the time of the abstract submission. The complete data analysis will be presented at AACS 2024 to include comparisons of procedure data including procedure times and adverse events by group as well as any additional subanalyses completed.
Conclusion: This is an important, first of its kind, study analyzing a large contiguous series data set of procedural and safety data from a single site where both Renuvion and InMode systems were used in conjunction with Liposuction or Body Contouring.
Take-Home Message: Patient safety is a key issue when deciding on new technologies.
BIA-ALCL Epidemiology in a Cosmetic Breast Augmentation Patients
Jerzy Kolasinski, MD, PhD, Malgorzata Kolenda, MD, PhD, Fabio Santanelli di Pompeo, MD, PhD, and Michail Sorotos, MD
Disclosures: Nothing to disclose.
Category: Breast
Background: Previous studies based on breast reconstruction populations have assessed the risk of breast implant–associated anaplastic large-cell lymphoma (BIA-ALCL) between 1:300 and 1:30 000. However, there is a lack of data regarding breast augmentations used for cosmetic purpose.
Objectives: The objective of this study was to investigate the epidemiology of BIA-ALCL in a cohort of patients who underwent breast augmentation with textured implants for cosmetic indications.
Materials and Methods: A prospective cohort observational study was conducted on 1501 patients who underwent cosmetic breast augmentation between 2006 and 2016. The patients were closely monitored for any implant-related complications, including BIA-ALCL. Data from clinical, pathology, and external records were cross-checked to identify cases. Prevalence, implant-specific prevalence (I-SP), incidence rate (IR), event-free time (EFT), and Kaplan-Meier survival estimates were calculated.
Results: The vast majority of patients (all but 2) received macrotextured or microtextured devices bilaterally. The average follow-up period was 3.2 years, ranging from 1 month to 16.4 years. The study identified 5 cases of BIA-ALCL, resulting in a prevalence of 1:300 patients. The I-SP for Allergan Biocell devices was 6.9 cases per 1000 individuals, while for Mentor Siltex devices, it was 1.3 cases per 1000 individuals. The IR was calculated to be 1.07 cases per 1000 females per year, and the mean EFT was 9.2 years.
Conclusion: These findings suggest that the occurrence of BIA-ALCL is higher in cosmetic patients compared with previous reports, particularly in those with macrotextured devices. Similar incidence rates in reconstructive and cosmetic cohorts may be due to underreporting, potentially caused by poorer follow-up and lower awareness in the latter group. Genetic predisposition in the oncologic cohort may play a role in early onset cases. The study emphasizes the importance of accurate follow-up and advocates for stratification risks analysis to aid surgeons in counseling patients on the decision for prophylactic explantation.
Take-Home Message: The occurrence of BIA-ALCL is higher in cosmetic patients compared with previous reports, particularly in those with macrotextured devices.
New Biostimulatory Filler Using Poly-l-Lactic Acid (PLLA), Hyaluronic Acid (HA), and Polydeoxyribonucleotides (PDRNs)
Quita Lopez, MD
Disclosures: Nothing to disclose.
Category: Injectables
Introduction: Poly-l-lactic acid (PLLA) is a traditonal filler used for biostimulation. The PLLA is mixed with an HA (hyaulronic acid) and polydoxyribonucleotides (PDRNs). This combination when injection is a very effective biostimualtory agent requring 2 sessions for signifcant long-acting collagen stimulation. Mechanism of action of the different components is presented along with a video showing injection techniques and before and afters.
Objective: To show the above components in a combination coctail is safe and effective and very effacious in providing long-term collagen and elastin formation with 2 treatments that last 16 to 24 months or longer. Very little complications have been noted in the last 2 years of treatments.
Materials and Methods: Patients injected with the combination trio of products presented. Videos showcasing injection techniques using a cannula and feeling in the deep fat layers are presented. Good quality before and afters are presented. Complications are also presented.
Discussion: The PDRNs are bind receptors in the dermal and subcutaneous levels. They stimulated the production of collagen 1 and also stimulated myofibrolast production to increase the lifting capacity. At the subcutanous level, they prevent lipid degradaton and hence enhance fat survival in the deep fat pads. Glutathione is also present, which has a strong antioxidant property. This product is combined with PLLA and an HA. The collagen stimulation of PLLAs has been well documented. The HA in the product provides immediate volume, so the patients are less disappointed with volume loss as occurs with PLLA treatments. The treatments are repeated every month and most patients just need 2 treatments for long-term collagen and elastin formation. The treatments also improve the quality of the skin.
Conclusion: The PLLA, HA, and PDRNs in combination are powerful biostimualtory agents that are well tolerated with minial complicatons.
Take-Home Message: This is a powerful cost-effective treatment for long -term collagen and elastin stimulation. It well tolerated with minimal side effects.
Reprocessing Capabilities of Newly Approved Devices for Use in Minimally Invasive Aesthetic Procedures
Andrew J. Malek, BS, Kala T. Pham, BS, Colby J. Hyland, MD, and Justin M. Broyles, MD, MPH
Disclosures: Nothing to disclose.
Category: Practice Management
Introduction: Single-use medical devices are commonly used in aesthetic procedures, contributing to medical waste and the potential for increased costs and environmental impact. Reprocessing of medical devices, instead, may reduce both cost and environmental impact. However, the landscape of new devices approved for reprocessing in aesthetic surgery is less known.
Objective: To comprehensively identify FDA-approved reprocessing capabilities of devices used in minimally invasive aesthetic procedures and evaluate gaps and recommendations for potential reprocessing innovation.
Methods: Aesthetic medical devices and their design features were identified using the publicly available FDA Releasable 510(k) Database from January 2018 to April 2023 using the product codes GEI, GEX, and OLI. Only devices indicated as posing a high risk for infection in the FDA’s Reprocessing Final Guidance Appendix E were required to include reprocessing validation information in their submissions. Laser devices are not included in Appendix E, and thus do not require submission of reprocessing validation information. Reprocessing capability was defined as inclusion of approved reprocessing procedures in device summaries. Single-use devices were those that included any single-use components and cannot be reprocessed. Costs were obtained from medical device company websites.
Results: There were 334 510(k) premarket applications for aesthetic devices between 2018 and 2023, representing 2% (334/16 723) of total applications. Of these, 82 (24.6%) applications were high-infection-risk devices and represented 5 device categories: skin tightening, skin resurfacing, cellulite treatment, full body systems, and noninvasive lipolysis. Cellulite treatment and noninvasive fat lipolysis devices represented the lowest proportion of single-use devices, with 81.8% (9/11) and 100% (5/5) of devices having reprocessing capabilities, respectively. Conversely, 2.5% (1/40) of skin tightening devices, 5% (1/20) of skin resurfacing devices, and 33.3% (2/6) of full body systems had reprocessing capabilities. The average cost of single-use skin tightening devices ($34 395) was similar to that of their reprocessed counterpart ($35 750). Comparatively, a much greater difference was found between the average cost of single-use ($38 211) and reprocessed ($89 995) skin resurfacing devices. However, for full body systems, the average cost of reprocessed systems ($20 000) was lower than systems with single-use components ($48 292). There were 252 (75.4%) laser device submissions. Of these, 21% (53/252) had reprocessing information available: 100% of hair removal devices (9/9), UV phototherapy systems (1/1), noninvasive lipolysis systems (1/1), and vascular lesion treatments (1/1); 50% of skin resurfacing devices (7/14) and tattoo removal devices (2/4); and 30% of combination systems (3/10). None of the laser accessories (0/11) or vein treatment devices (0/2) could be reprocessed.
Conclusion: There is heterogeneity in reprocessing capabilities for newly approved high-infection-risk devices in aesthetic surgery. New skin resurfacing and tightening devices have the least reprocessing potential, which may be contributing to the higher costs of devices with reprocessing capability in this category. Investigation is needed into the cost of purchasing devices with reprocessing potential, coupled with the cost of reprocessing itself, versus the cost of using single-use alternatives. Plastic surgeons should consider the reprocessing capabilities of devices used within their practice, and device manufacturers should consider ongoing design initiatives to enhance reprocessing capabilities in future device design.
Take-Home Message: Developing surgical devices with reprocessing capabilities can serve as a solution to the medical waste, increased costs, and negative environmental impact generated by single-use devices within the realm of cosmetic surgery.
Drop the Drama of Staff Turnover
Catherine Maley, MBA
Disclosures: Nothing to disclose.
Category: Practice Management
The first challenge of running a successful cosmetic practice is staffing issues. Human beings are fickle, sensitive, petty, and so on, so half the battle is hiring right people and the other half is keeping them so you have continuity in your practice. But oftentimes what happens is certain staff drum up drama and key people quit from frustration and you are left with a mess. You do not know exactly WHAT these key people did and HOW they did it so the rest of the team is scrambling to fill in the blanks. I will show you an easy way to set yourself up so you are never again blindsided by staff leaving.
Take-Home Message: Don’t “hope” staff stays. Instead, prepare for staff turnover.
Psychological Triggers That Encourage Patients to Choose You
Catherine Maley, MBA
Disclosures: Nothing to disclose.
Category: Practice Management
It is getting increasingly more difficult to convert consumers into paid cosmetic revenues. So, the more you understand the psychology of a cosmetic patient, the faster you will get to a YES.
I will lay out the ins-and-outs of a cosmetic patient’s needs, wants, and desires, as well as strategies that encourage patients to choose you without being pushy or salesy.
Take-Home Message: Address the patients’ needs, wants, and desires so they happily choose you.
Asset Protection 101 for AACS Members
David B. Mandell, JD, MBA
Disclosures: Nothing to disclose.
Category: Practice Management
This talk reviews the importance of protecting assets for AACS members, who face liability in the areas of malpractice, employer liability, HIPAA breaches, slip, and falls, and so on. We introduce the asset protection “sliding scale” and discuss ways that physicians can increase the levels of protection for personal and practice assets. We also provide an overview of basic asset protection tools, including LLCs, trusts, exempt assets, and retirement plans.
Take-Home Message: The AACS members practice in a profession that contains liability exposure, as surgeons, practice and real estate owners, contract signers, and more. Understanding what options exist to better shield practice and personal assets from liability is wise and this lecture lays the foundation for that type of planning.
ERAS Protocol Reduces or Eliminates Postoperative Opioid Medications Following Cosmetic Surgery Procedures
E. Antonio Mangubat, MD, FAACS, Ashu Garg, MD, and Alexandra Birch, MD
Disclosures: Nothing to disclose.
Category: Preop and Postoperative Care
Introduction: Effective postoperative pain relief is crucial for surgical patients, offering significant physiological benefits and serving as a vital quality metric; minimizing opioid triggered nausea and vomiting, itching, and constipation were big advantages. Traditionally, opioids have been the mainstay of postoperative pain management; however, the opioid addiction crisis has compelled a nationwide effort to reduce the use of opioids. In 2022, we reported our preliminary experience using the opioid-sparing enhanced recovery after surgery (ERAS) finding the protocol to be a promising approach in postoperative recovery after cosmetic procedures, decreasing the need for opioid medication without affecting quality of pain control. Our experience with the ERAS protocol was previously reported. We will present an update to our findings on this important therapeutic approach.
Methods: In total, 159 consecutive patients having various cosmetic procedures were followed from January 1, 2023 through July 7, 2023. For this study, patients were followed at the immediate postop period, 3 days, and 3 weeks postoperatively. They were surveyed if they consumed any oxycodone for pain management requiring a YES or NO answer which was documented. The data are tabulated in Table 1.
Results: Overall, 33% of all patients required 0 (zero) opioids to control postoperative pain during this study period. The percentage of patients not requiring opioids are also reported per procedure. The most common procedure during this period is Female-to-male (FTM) mastectomy (n = 69) where 38% of these patients did not require opioids for pain management. The ERAS was effective in most procedures.
Conclusion: Out prior pain management protocols 100% of our patients required opioid medication for postoperative pain control. By instituting ERAS, we have eliminated the need for opioids in one-third of our patients, a significant decrease. Multimodal opioid-sparing regimens are valuable in cosmetic surgery’s enhanced recovery protocols, where they can reduce the side effects of opioid use. By adopting these approaches, surgical practitioners can enhance patient outcomes, minimize adverse effects, and ensure a smoother recovery, ultimately promoting optimal pain relief and improved overall well-being.
Take-Home Message: Opioid use for postoperative pain control can be systematically reduced and can be eliminated in a significant portion of our cosmetic surgery patient population. This decreases postoperative side effects of opioid use and decreases your practice’s visibility to government agencies that actively monitor opioid prescriptions.
Rhinoplasty Simplified: Rediscovery of the Cottle Technique
Jeffrey B. Marvel, MD
Disclosures: Nothing to disclose.
Category: Rhinoplasty
Preservation rhinoplasty has gained wide acceptance in the last couple of years and has revolutionized and simplified the procedure. Dr Maurice Cottle first described his technique in 1946, but the procedure fell into obscurity over the years until being reintroduced by Dr Yves Saban of France. The author will present his experience and results in adopting this procedure. He believes the Cottle technique provides superior results and avoids tip dissection and disruption of the bony cartilaginous dorsum and supporting ligaments.
Take-Home Message: The Cottle technique described decades ago has re-emerged as a choice procedure to obtain excellent results without dissection of the nasal tip (with the potential for scarring and poor outcomes) as well as preservation of the bony cartilaginous dorsum.
Free Autologous Fat Grafting to the Radix for Augmentation of the Nasofrontal Angle During Simultaneous Blepharoplasty and Endoscopic Brow Lift
Makayla McCoskey, MD, Karen R. Brown, MD, and Tanuj Nakra, MD, FACS
Disclosures: Nothing to disclose.
Category: Face
Introduction: The nasofrontal angle comprises the forehead, glabella, and radix. This triad is known to play an important role in rhinoplasty surgery and its aesthetic outcomes, and it has similar relevance in forehead and brow lifting procedures.1,2 Autologous fat grafting to this area has been performed in conjunction with rhinoplasty or independently to address the appearance of the nasal bridge.1,3 Other studies have shown the value of preserving the upper eyelid nasal fat pad for local repositioning during upper eyelid blepharoplasty.4,5 In the current study, autologous fat was harvested during blepharoplasty and placed over the radix during simultaneous endoscopic brow lift surgery to augment the nasofrontal angle, smooth the contour of the nasal bridge, and decrease the prominence of glabellar rhytids.
Methods: Twelve patients underwent simultaneous upper eyelid blepharoplasty and endoscopic brow lift procedures with sculpting of the central and medial upper eyelid fat pad. A standard blepharoplasty incision was made in the upper eyelid and skin was removed with electrocautery. The nasal fat pad was then exposed by dissecting through the nasal orbicularis muscle and orbital septum. This was sharply resected and set aside in saline soaked gauze. In some cases, lower blepharoplasty was also performed and portions of the medial, central, and/or lateral fat pads were similarly harvested and set aside. An endoscopic brow lift was then initiated in standard fashion, with special attention to the subperiosteal release over the dorsum of the nose. The previously harvested eyelid fat was then placed in this subperiosteal plane overlying the radix, inserted via sterile plastic suction tubing, and delivered via positive pressure created by rolling the proximal portion of tubing with a hemostat. The amount of fat and its positioning were adjusted via endoscopic visualization to achieve the desired nasal bridge contour. A rigid polycaprolactone thermoplastic splint was placed immediately postoperatively and secured with paper tape for 72 hours. ImageJ software was used to measure the nasofrontal angle in side-view preoperative photos and in postoperative photos taken at least 1 month after surgery. Patients were surveyed regarding their satisfaction with and subjective improvement in the nasal bridge contour after surgery.
Results: Autologous fat grafting of eyelid fat to the radix resulted in an increase in the nasofrontal angle in all patients. All patients reported subjective improvement in nasal bridge contour postoperatively. There was no seroma, hematoma, infection, or other complication from the procedure, but there was extended swelling in most cases from this procedure. All patients expressed satisfaction with the improvement in the aesthetic appearance of this area after surgery.
Conclusion: In patients with an acute nasofrontal angle, upper eyelid fat resected during blepharoplasty can be preserved and repurposed for autologous grafting to the radix, allowing for augmentation of the nasofrontal angle and smoothing of the nasal bridge contour.
References
1. Kornstein AN, Nikfarjam JS. Fat grafting to the forehead/glabella/radix complex and pyriform aperture: aesthetic and anti-aging implications. Plast Reconstr Surg Glob Open. 2015; 3(8):e500.
2. Guyuron B, Lee M. A reappraisal of surgical techniques and efficacy in forehead rejuvenation. Plast Reconstr Surg. 2014; 134(3):426-435.
3. Keyhan SO, Ramezanzade S, Bohluli B, Fallahi HR, Mirzahoseini S, Nahai F. Autologous fat injection for augmentation rhinoplasty: a systematic review. Aesthet Surg J Open Forum. 2021;3(2):ojab010.
4. Massry GG. Nasal fat preservation in upper eyelid blepharoplasty. Ophthalmic Plast Reconstr Surg. 2011;27(5):352-355.
5. Sozer SO, Agullo FJ, Palladino H, Payne PE, Banerji S. Pedicled fat flap to increase lateral fullness in upper blepharoplasty. Aesthet Surg J. 2010;30(2):161-165.
Take-Home Message: In patients with an acute nasofrontal angle, upper eyelid fat resected during blepharoplasty can be preserved and repurposed for autologous grafting to the radix, allowing for augmentation of the nasofrontal angle and smoothing of the nasal bridge contour.
In Situ Contouring of Tear Trough Implant for Treatment of Infraorbital Nerve Impingement
Makayla McCoskey, MD, Karen R. Brown, MD, and Tanuj Nakra, MD, FACS
Disclosures: Nothing to disclose.
Category: Face
Introduction: Tear trough implants are commonly used to enhance the suborbital rim and address tear trough deformity created by the orbicularis retaining ligament.1-4 Given the anatomic location, there is a risk of impingement of the infraorbital nerve as it exits the foramen with implant migration or without adequate contouring of the implant to allow space for the infraorbital nerve to course unopposed. Here we present a patient with tear trough implants impinging on the infraorbital nerve, causing symptomatic nerve compression, successfully treated with in situ contouring of the implant to allow decompression of the infraorbital nerve while maintaining the aesthetic benefit of the implant.
Case Report: A 67-year-old white female presented with concern for sharp pain in her malar region when smiling. She had a history of tear trough implants placed 5 years prior to presentation and had noted pain with smiling since the early postoperative period. Her pain was suspected to be due to trigeminal nerve pain due to compression of the infraorbital nerve by the implants. A Computed Tomography (CT) was obtained and demonstrated migration of the implant with compression of the infraorbital foramen by the implant bilaterally. Informed consent was obtained and the patient underwent maxillary nerve decompression via transgingival approach. The implant was providing aesthetic benefit, so the decision was made to leave the implant in place but remove the inferocentral aspect of the implant that was causing nerve compression. Monitored anesthesia care was induced and the surgical area was prepped and draped in sterile fashion. A Bard-Parker #15 blade was used to incise the oral mucosa approximately 1 cm superior to the border of the gingival margin. Dissection was carried down to the periosteum which incised with monopolar cautery. Dissection was then carried caudally in the subperiosteal plane until the tear trough implant was identified. Care was taken to avoid trauma to the infraorbital nerve as it exited the infraorbital foramen. Metzenbaum scissors were used to remove the inferocentral aspect of the implant while leaving the superior, medial, and lateral cuff in place, as the implant was providing aesthetic benefit. This was performed until adequate implant material was removed to fully decompress the nerve. This procedure was performed on both sides. The gingival incision was closed with a running locking suture using 4-0 polyglactin 910 (Vicryl) suture. She was transported to the postoperative recovery area in good condition. The patient tolerated the procedure well and there were no complications. At her postoperative appointment 1 month following surgery, she noted complete resolution of the right-sided malar pain with smiling. She notes persistence of the left side pain but with significant improvement. The persistence of the pain is likely due to long-term compression of the infraorbital nerve and is expected to improve with time.
Discussion: We present an efficient and safe method to preserve the aesthetic benefit of tear trough implants while also partially removing the implant in the case of direct infraorbital nerve compression.
References
1. Flowers RS. Tear trough implants for correction of tear trough deformity. Clin Plast Surg. 1993;20(2):403-415.
2. Flowers RS. Correcting suborbital malar hypoplasia and related boney deficiencies. Aesthet Surg J. 2006;26(3):341-355.
3. Nakra T. Biplanar contour-oriented approach to lower eyelid and midface rejuvenation. JAMA Facial Plast Surg. 2015; 17(5):374-381.
4. Stutman RL, Codner MA. Tear trough deformity: review of anatomy and treatment options. Aesthet Surg J. 2012;32(4): 426-440.
Take-Home Message: We present a patient with tear trough implants impinging on the infraorbital nerve, causing symptomatic nerve compression, successfully treated with in situ contouring of the implant to allow decompression of the infraorbital nerve while maintaining the aesthetic benefit of the implant.
Labiomentoplasty During Genioplasty to Reduce the Labiomental Groove
Makayla McCoskey, MD, Karen R. Brown, MD, and Tanuj Nakra, MD, FACS
Disclosures: Nothing to disclose.
Category: Face
Introduction: The labiomental fold is the horizontal depression between the lower lip and soft tissue chin pad and is an important feature to consider in genioplasty. Aesthetically, the optimal depth of the labiomental fold is approximately 4 mm in women and 6 mm in men, located in the junction of the upper and middle third of the chin when measuring from the stomion to the cheilion.1,2 Alloplastic augmentation genioplasty aims to augment the sagittally deficient chin but poses the risk of deepening the labiomental groove in select patients, especially with horizontal augmentation or in patients with vertical deficiency and an already prominent labiomental fold.2-5 Various methods have been used to prevent deepening of the groove. Zide et al2 advocate for intraoperative sculpting of the implant to shorten the implant height in these cases. Rosen4 describe simultaneous advancement and lengthening of the menton during advancement (osseous) genioplasty with use of hydroxyapatite spacer into the osteomy gap. Carlino6 address the deepened fold with use of a solid graft (cartilage, cortico-cancellous bone, or commercial chin prosthesis) placed into the concavity to deemphasize the fold. In the current study, the authors illustrate soft tissue manipulation via mentalis redraping to mitigate the risk of a deepened labiomental fold in alloplastic augmentation genioplasty.
Methods: Six patients underwent mentalis redraping with alloplastic augmentation genioplasty with a silicone implant. A similar technique was also used for an additional patient with a prominent labiomental groove who underwent lower face and neck lift without genioplasty. Subperiosteal dissection of the central region of the chin was performed via a submental incision. Dissection was done rostrally to the alveolar process. The submental periosteum was fragmented via vertical spreading with a sharp tenotomy scissors, and similarly, the muscle belly was stretched longitudinally. In the patients who underwent alloplastic genioplasty, the silicone implant was placed in a subperiosteal plane in standard fashion and secured to the periosteum using nonabsorbable suture. The edge of freed periosteum and overlying soft tissue of the dissected chin pad were then engaged with nonabsorbable suture and secured to the intact periosteum, creating downward and posterior distraction of the mental soft tissue. The incision was then closed in a layered fashion without tension. Preoperative and postoperative sagittal photos were reviewed in Image J, with attention to the anterior-posterior depth of the labiomental groove.
Results: Mentalis distraction resulted in stable (±1 mm from preoperative measurements) labiomental fold depth in all patients. There were no cases of lower lip incompetence, increased mandibular incisor show, facial nerve injury, sensory injury, implant displacement, or chin ptosis. No patients required revision surgery. All patients were satisfied with the aesthetic results.
Conclusion: Mentalis distraction is a simple technique to help mitigate the risk of deepening of the labiomental sulcus in select patients undergoing augmentation genioplasty.
References
1. Lee EI. Aesthetic alteration of the chin. Semin Plast Surg. 2013;27(3):155-160.
2. Zide BM, Boutros S. Chin surgery III: revelations. Plast Reconstr Surg. 2003;111(4):1542-1550; discussion 1551-1542.
3. Naini FB, Garagiola U, Wertheim D. Analysing chin prominence in relation to the lower lip: the lower lip-chin prominence angle. J Craniomaxillofac Surg. 2019;47(8):1310-1316.
4. Rosen HM. Aesthetic refinements in genioplasty: the role of the labiomental fold. Plast Reconstr Surg. 1991;88(5):760-767.
5. Hazani R, Rao A, Ford R, Yaremchuk MJ, Wilhelmi BJ. The safe zone for placement of chin implants. Plast Reconstr Surg. 2013;131(4):869-872.
6. Carlino F. Too deep labio-mental fold after large advancement genioplasty: a proposal for its effective correction. Int J Oral Maxillofac Surg. 2020;78:E81.
Take-Home Message: Mentalis distraction is a simple technique to help mitigate the risk of deepening of the labiomental sulcus in select patients undergoing augmentation genioplasty.
Transblepharoplasty Corrugator Excision With Nasal Fat Pedicle Transposition: A Novel Technique
Makayla McCoskey, MD, Karen R. Brown, MD, and Tanuj Nakra, MD, FACS
Disclosures: Nothing to disclose.
Category: Face
Introduction: The transblepharoplasty approach to corrugator excision has been demonstrated to be an effective method for glabellar rhytid reduction.1-13 The surgical approach involves direct resection via upper blepharoplasty incision and can result in postsurgical glabellar volume depletion and contour irregularity. There are differing preferences for fat augmentation in this region postresection or deferring volume replacement.1-6 For volume replacement, fat may be placed into the corrugator space post resection both to prevent readhesion of the cut ends of the muscle which can lead to recurrence of rhytids and to replace volume to avoid postoperative contour depression. Common practice involves direct free grafting of fat excised during upper blepharoplasty into the corrugator space. Some surgeons will harvest fat from more distance sites, such as the abdomen, for fat transfer to this region.3,4 Here we present a novel alternative to fat grafting in the setting of transblepharoplasty corrugator excision. Analogous to transposition lower blepharoplasty, transposition of the upper eyelid fat pads has been used to augment upper eyelid volume in the setting of involutional volume loss.14-17 Volume augmentation of the orbitoglabellar groove with transposition of the nasal fat pad has been advocated to address age-related volume loss in this region.15,18 Here we present transposition of the nasal fat pad to the corrugator space as a vascularized pedicle to prevent volume loss after corrugator muscle excision.
Methods: This is a retrospective observational review of patients undergoing corrugator excision as an adjunct to upper blepharoplasty and a novel approach of direct volume transfer of the nasal fat pad as a vascularized pedicle. Patient charts were reviewed for demographic data, complications, and outcomes. Postoperative photos were graded by blinded observers for glabellar elevation and contour improvement using the following 0-4 scale: no improvement, mild improvement, moderate improvement, or substantial improvement.
Surgical technique: During routine upper blepharoplasty blunt trans-septal dissection was used to expose the nasal fat pad, which was then dissected from surrounding connective tissue to develop a mobile, vascularized fat pedicle. Dissection was then carried out superomedially in the subseptal plane to the superomedial orbital rim. The mid-belly of the corrugator muscle was identified, dissected from surrounding attachments, and isolated using a curved hemostat. The central portion of the muscle was then fully excised with monopolar cautery. Hemostasis was obtained at the cut ends of the muscle. The nasal fat pedicle was then transposed superomedially into the corrugator space and secured using an externalized 4-0 plain gut suture. The transposition suture was removed 1 week after surgery.
Results: Ten patients were identified who underwent transblepharoplasty corrugator resection with nasal fat pedicle transposition. There were no complications noted in the study cohort, including no cases of infection, hemorrhage, poor wound healing, or diplopia. All patients reported satisfaction with the glabellar contour and reported subjective improvement in corrugator rhytids at their postoperative appointment. Postoperative photos graded by blinded observers were deemed to have “substantial” or “moderate” glabellar elevation and contour improvement in all cases.
Discussion: Transblepharoplasty resection of corrugator muscle can lead to a contour deformity in the glabellar region. A common technique to replace the excised volume involves grafting the fat excised during upper blepharoplasty into the corrugator space. This may result in preservation of volume in this region; however, there can be limitation of fat uptake due to graft ischemia and necrosis. Fat transfer harvested from elsewhere on the body can also suffer from fat ischemia but importantly does not help prevent adherence of the corrugator muscle cut ends. Here we present an efficient, safe, and effective technique to preserve glabellar volume post corrugator resection by transposing the neighboring nasal fat pedicle, augmenting the region with fat with a preserved blood supply, resulting in substantial volume augmentation of the glabellar region, enhancing the corrugator resection results and preventing muscle readherence.
Conclusion: In patients undergoing transblepharoplasty corrugator excision to address glabellar rhytids, transposition of the neighboring nasal fat pad to the corrugator space provides a vascularized source of fat volume augmentation to prevent contour deformity and decrease likelihood of preserved corrugator function.
References
1. Knize DM. Transpalpebral approach to the corrugator supercilii and procerus muscles. Plast Reconstr Surg. 1995;95(1):52-60; discussion 61-52.
2. Guyuron B. Corrugator supercilii resection through blepharoplasty incision. Plast Reconstr Surg. 2001;107(2):604-605; discussion 606-607.
3. Guyuron B, Son JH. Transpalpebral corrugator resection: 25-year experience, refinements and additional indications. Aesthetic Plast Surg. 2017;41(2):339-345.
4. Marten TJ. Closed, nonendoscopic, small-incision forehead lift. Clin Plast Surg. 2008;35(3):363-378; discussion 361.
5. Wang J, Su Y, Zhang J, Guo P, Huang C, Song B. A randomized, controlled study comparing subbrow blepharoplasty and subbrow blepharoplasty combined with periorbital muscle manipulation for periorbital aging rejuvenation in Asians. Aesthetic Plast Surg. 2020;44(3):788-796.
6. Wang J, Su Y, Zhang J, Guo P, Song B. Subbrow blepharoplasty combined with periorbital muscle manipulation for periorbital rejuvenation in Asian women. Plast Reconstr Surg. 2019;144(5):760e-769e.
7. Georgescu D, Anderson RL, McCann JD. Brow ptosis correction: a comparison of five techniques. Facial Plast Surg. 2010;26(3):186-192.
8. Guyuron B, Michelow BJ, Thomas T. Corrugator supercilii muscle resection through blepharoplasty incision. Plast Reconstr Surg. 1995;95(4):691-696.
9. Kikkawa DO, Miller SR, Batra MK, Lee AC. Small incision nonendoscopic browlift. Ophthalmic Plast Reconstr Surg. 2000;16(1):28-33.
10. Langsdon PR, Velargo PA, Rodwell DW III. Surgical manipulation of the periorbital musculature. Clin Plast Surg. 2013; 40(1):125-131.
11. Lee EJ, Hwang K. Depressor muscle division through a subbrow excision for the improvement of brow ptosis. J Craniofac Surg. 2013;24(6):1987-1990.
12. Paul MD. Subperiosteal transblepharoplasty forehead lift. Aesthetic Plast Surg. 1996;20(2):129-134.
13. Weinstein C. Carbon dioxide laser resurfacing combined with endoscopic forehead lift, laser blepharoplasty, and transblepharoplasty corrugator muscle resection. Dermatol Surg. 1998;24(1):63-67.
14. Massry GG. Nasal fat preservation in upper eyelid blepharoplasty. Ophthalmic Plast Reconstr Surg. 2011;27(5):352-355.
15. Yoo DB, Massry GG. Upper eyelid fat repositioning. In: Hartstein M, Massry M, Holds G, eds. Pearls and Pitfalls in Cosmetic Oculoplastic Surgery. Springer; 2014:123-126.
16. Chen CC, Chen SN, Huang CL. Correction of Sunken upper-eyelid deformity in young Asians by minimally-invasive double-eyelid procedure and simultaneous orbital fat pad repositioning: a one-year follow-up study of 250 cases. Aesthet Surg J. 2015;35(4):359-366.
17. Li X, Xia L, Ma L. Sunken upper eyelid deformity correction by orbital fat pad repositioning and orbicularis oculi muscle folding in blepharoplasty. J Craniofac Surg. 2023;34(2):704-707.
18. Yoo DB, Peng GL, Massry GG. Effacing the orbitoglabellar groove with transposed upper eyelid fat. Ophthalmic Plast Reconstr Surg. 2013;29(3):220-224.
Take-Home Message: In patients undergoing transblepharoplasty corrugator excision to address glabellar rhytids, transposition of the neighboring nasal fat pad to the corrugator space provides a vascularized source of fat volume augmentation to prevent contour deformity and decrease likelihood of preserved corrugator function.
Functional and Aesthetic Septorhinoplasty: A Unified Method for Robust, Reliable Results
Scott McCusker, MD
Disclosures: No.
Category: Rhinoplasty
Introduction: Rhinoplasty is a notoriously complicated and challenging surgery. There are hundreds of published techniques, and it is often difficult to ascertain which is the optimal technique for a given situation. The author describes his personal, systematic approach that is applicable to essentially any case, and widely adaptable to almost any situation that will be encountered.
Premise: All cases are performed in the operating room under general anesthesia. Lidocaine is infiltrated, patient is prepped and draped, and complete dissection of the septum and dorsum performed. Septal cartilage is harvested and fashioned into grafts, supplementing with cadaver rib cartilage if needed. Dorsal hump takedown is performed when indicated, followed by osteotomies if needed. The grafts are secured to the septum and final trimming of grafts performed in situ. The lower lateral cartilages are secured to the grafts and suture techniques are used to refine their shape, along with cephalic trim or alar turn-in flaps as appropriate. Crushed septal cartilage is placed for camouflage if needed. The incisions are closed, and then Doyle splints and a thermoplastic splint applied. The patient is given prescriptions for antibiotics by mouth, topical antibiotic ointment, and narcotic pain medications. At the 1-week follow-up visit, the cast, splints, and sutures are removed. The patient is instructed to follow up at 1 month postop, and then again at 6 to 9 months postop.
Substantiating Data: Attached are representative photos of key steps of the operation. The full presentation will feature far more detailed representations of every step of the process. Additionally attached are several representative before/after pictures of various patients treated using this method. The author has used this method in more than 500 successful nasal surgeries. His personal success rate is around 95% to 99%, defined as happy with the shape of the nose and happy with nasal airflow, without need for further surgeries. Postoperative infection rates are less than 1%. Revision surgeries were required in approximately 2% of patients and were successful in all but 2 patients. Septal perforation was caused in <1% of patients.
Discussion: Rhinoplasty is a challenging operation, requiring meticulous technique for success. With use of the method presented above, rhinoplasty surgeons can achieve predictably excellent results with low rates of complications.
Take-Home Message: Rhinoplasty is a challenging operation, requiring meticulous technique for success. With use of the method presented above, rhinoplasty surgeons can achieve predictably excellent results with low rates of complications.
Designing Your Office and Surgery Center for Today’s Patient
Mary Alice Mina, MD, FAAD and Mark F. Baucom, MD, FAAD, FACMS
Disclosures: Nothing to disclose.
Category: Practice Management
Practicing medicine and cosmetics in today’s world requires the medical knowledge and skills to be a sought after cosmetic surgeon and physician, but how your office functions and runs is equally important! If you could set up your practice from the ground up, how would you do it? What elements would you require for optimal patient care and comfort, but ease for your staff and day-to-day business operations? As a physician-run practice, we have recently acquired a property which we are turning into our state of the art medical and surgery center. With a focus on design as well as function, and business optimization, we discuss how you can optimize your space for today’s patient. Videos will be shown.
Take-Home Message: Do not be afraid to rethink your office space! Sleek but functional design with patient comfort and staff ease can be achieved if you are willing to rethink how you have always practiced!
Local and Tumescent Anesthesia for In-Office Procedures
Mary Alice Mina, MD, FAAD and Mark F. Baucom, MD, FAAD, FACMS
Disclosures: Nothing to disclose.
Category: Other
Performing procedures without the need for general anesthesia can help patients recover quickly and have more favorable outcomes. We will describe our experience as Mohs reconstructive and cosmetic surgeons using local numbing techniques including tumescent anesthesia to remove large lipomas, cysts, neck lifts, and micro-coring device. By appropriately selecting the volume of tumescent anesthesia and then using appropriate cannulas, many larger procedures can be done safely in an office or ASC without the need for anesthesia and monitoring. We will describe our experience and use videos to help show the audience how to bring this technique to their practice.
Take-Home Message: Tumescent anesthesia has a place above and beyond liposuction making it a go-to anesthetic for large lipomas, cysts, neck lifts, and micro-coring obviating the need for general anesthesia which can render complications and slower recoveries for patients.
The Age of “Pro-Aging”—What is New in Skincare and Antiaging
Mary Alice Mina, MD, FAAD
Disclosures: Nothing to disclose.
Category: Skin Rejuvenation
Trends in skincare come and go but one that is likely here to stay is the concept of “pro-aging.” As people are living longer and more healthily, embracing aging, rather than fearing it or forcefully denying it, is on the rise. Gone are the days of trying to “reverse the clock” to look 20 when you are 40. Instead, people want to embrace maturity with realistic expectations and a proactive approach. In this talk I will discuss what proaging is, how it is incorporated with aesthetics in general and how overall wellness impacts our skin and aesthetic health. I will also review what is new in skincare and aesthetics that help promote a progenerative approach to aging, in lieu of negative antiaging tactics of the past. Instead of wishing for things to change and setting unrealistic expectations, I say we embrace each stage of life with vigor and excitement! But aging gracefully does not mean forgoing medical and aesthetic treatments if you wish. Instead of trying to turn back the clock, I say we confront aging in a proactive way. Instead of antiaging, let’s pro-age! What does this mean? Proaging is the acknowlegement and embrace of the aging process, with a focus on prevention and maintenance of our skin health. It is not an anti-aesthetic regime, nor is it the relentless pursuit of beauty. Proaging is making lifestyle and aesthetic choices to enhance your beauty, however that looks to you! Proaging is the embrace of life at every stage. Work on making proactive steps and changes in your life to maximize your skin and overall health.
Take-Home Message: People are moving away from the concept of antiaging and looking toward prejuvenation for optimizing their skin health. After this presentation, listeners will have a better understanding of how to assist patients and clients with proaging and their skin.
Awake Tummy Tuck, Safe? Practical? Video Description of the Technique Outcomes From a Single Surgeon, Study of 81 Patients Above 3 Years
Hamid Mirzani, MD
Disclosures: Nothing to disclose.
Category: Body Contouring
This study presents the technique and outcomes of Awake Tummy Tuck procedure performed on 81 patients over a 3-year period. Awake Tummy Tuck, also known as “tumescent abdominoplasty,” is a minimally invasive surgical technique that combines liposuction and abdominoplasty to remove excess abdominal fat and tighten the abdominal muscles. This abstract summarizes the key technical points and findings of this study, including patient demographics, surgical details, safety, and postoperative outcomes. The surgical technique involved tumescent liposuction to remove excess fat deposits in the abdominal area and flanks, followed by skin and direct fat excision and muscle tightening, to achieve a more toned appearance. The extent of liposuction and muscle tightening varied depending on the individual patient’s needs and goals. After initial liposuction, incision lines were infiltrated with 0.25% lidocaine with epinephrine, cutting skin and fat down to the fascia, followed by subfascial infiltration of lidocaine with epinephrine, using 2-mm infiltration cannula and continuation of the procedure similar to traditional abdominoplasty to the xyphoid. Plication was performed using the same concentration of lidocaine to numb the rectus sheath over the plication lines. The study included 81 patients (73 females and 8 males) who underwent Awake Tummy Tuck between June 2019 and June 2022. The age of the patients was 24 to 71. Body mass index of the patients ranged between 24 and 35. The procedure was performed under local anesthesia with oral sedation, allowing patients to remain awake during the surgery. There were 52 full, 23 mini, 5 revere, and 1 inverse tummy tuck. There was 7 minor and 1 major wound issue, 8 simple seroma collection, 1 infected collection, and 1 hematoma. No mortality. Most patients expressed high levels of satisfaction with the aesthetic results achieved and their level of comfort during the surgery. Patients reported improved body confidence, enhanced self-esteem, and increased comfort with their appearance following the Awake Tummy Tuck procedure. In conclusion, this study demonstrates that Awake Tummy Tuck is a safe and effective procedure for abdominal contouring if performed with the same technique described and showed. The minimally invasive approach, performed under local anesthesia with conscious sedation, provides favorable outcomes with minimal risks. Patient satisfaction and postoperative outcomes highlight the positive impact of the procedure on body image and self-confidence. Further long-term studies are warranted to evaluate the durability and lasting effects of Awake Tummy Tuck in larger patient cohorts.
Take-Home Message: Awake abdominoplasty is safe and practical provided using the correct technique, good patient selection, and being adequately patient.
Facial Implants: Achieving Facial Balance With Alloplastic Implants
Michael P. Morrissette, DDS, FACS
Disclosures: Nothing to disclose.
Category: Face
The placement of cosmetic facial implants beyond the usual areas of cheeks and chins has been increasing significantly over the past 7 years. Both custom and stock implants are now being placed along all areas of the facial skeleton. In the temporal region, implants are placed to diminish the temporal hollowing. Mandibular angle implants are placed to increase mandibular angle definition and projection. Orbital or tear trough deformities can be improved with orbital implants. Nasal and subnasal implants are being used to change the size and projection of the nose. Although there are multiple standard sizes and shapes to choose from, virtual surgical planning can enable the fabrication of custom implants for each patient. In some cases, the placement of facial implants can reduce the effects of aging. In most cases, there is an improvement of facial balance.
Take-Home Message: Facial implants offer one of the few permanent yet reversible treatment options in cosmetic surgery. The use of custom implants allows for the placement of implants anywhere along the facial skeleton. Silicone implants have the advantage of surgical placement through a very small incision in most cases.
Modified Deep Plane Lip Lift Technique
Tanuj Nakra, MD, FACS and Karen R. Brown, MD
Disclosures: 1. AVYA Skincare: Board Member; 2. AVYA Skincare: Ownership Interest (Ownership interest of an ineligible company).
Category: Face
Introduction: The surgical lip lift has been used by facial surgeons for decades, for enhancement of lip fullness and contour, to shorten the philtrum, to restore the natural teeth show that is lost with age, and for facial feminization surgery. However, subnasal lip lifting can poorly affect the lower nasal aesthetic contour and cause a visible subnasal scar. Variations on the gullwing subnasal resection have been the mainstay procedure with the above inherent limitations, but more recent deep plane approaches have offered a more robust lift with reduced tension in the subdermal plane. However, even these modern approaches can result in a visible subnasal scar.17 In this study, we present a modified deep plane lip lift surgery technique that enhances outcomes and mitigates risks to nasal and scar cosmesis through modified incision design, enhanced deep plane tissue management, modified SMAS fixation technique, and minimized skin tension during closure.
Methods: This a retrospective review of a single surgeon’s cases of modified deep plane lip lift in a private practice. Patients with previous oral or subnasal surgery were excluded. Using a 4-point scale, blinded graders reviewed preoperative and postoperative photos for scar visibility, lip rotation, teeth show, enhanced philtral contour, and overall aesthetic outcome. Subjective satisfaction was reviewed using a 4-point scale at final follow-up. Patient charts were reviewed for demographic information, as well as complications, infections, and postoperative interventions. The modified deep plane lip lift is performed after local anesthetic injection, followed by a standard gullwing incision that extends to the most lateral aspect of the alar-cheek junction. Subnasally, the incision follows the alar contour cephalad into the nasal sill, and then medially along the columellar-philtral junction. Generally, a 6- to 7-mm skin resection is planned, with a V-U incision design in the subcolumellar skin. Care is taken to explant the skin and subcutaneous tissue completely, leaving orbicularis oris fully exposed. A subnasal ellipse of orbicularis oris is resected with cutting cautery, exposing the sub-SMAS midline potential space. A 4-0 polyglactin suture on a taper needle is used paracentrally and laterally along the piriform aperture, anchored to periosteum to vertically displace the cut end of orbicularis oris, advancing the lip SMAS cephalad. Deep closure of the dermis is performed with interrupted 5-0 polydioxanone and superficial skin closure with a running locking 5-0 polypropylene suture. On a case-by-case basis, lateral commissure lift was performed by skin-only elliptical excision and closure with deep 5-0 polydioxanone, and superficial skin closure with 5-0 polypropylene. Superficial polypropylene sutures are removed between 5 and 7 days postop.
Results: In total, 39 patients were identified who underwent this modified deep plane lip lift technique. Average follow-up was 5 months (range = 2-12 months). Thirty-eight patients were female and 1 male. Average patient age was 59 years. Blinded graders reviewed lip rotation, teeth show, enhanced philtral contour, and overall aesthetic outcome to be “moderately improved” or “substantially” improved for all measures. Subjectively, patients judged their overall aesthetic outcome to be “moderately improved” or “substantially” improved. There were no cases of clinical scarring or infection. There was one case of extended postoperative suture granulomatous inflammation which resolved with conservative treatment.
Conclusion: The modified deep plane lip lift offers a comprehensive and effective solution to treating aging changes of the upper lip. The incision design offers a camouflaged scar, and the multipoint deep plane SMAS fixation after resection allows for powerful lift with ideal tension-free skin closure and healing.
Take-Home Message: The modified deep plane lip lift offers a comprehensive and effective method for a powerful lift while incorporating a camouflaged scar and tension-free closure.
Tragal Contouring During Facelift Surgery: A Novel Technique for Prevention of Postoperative Tragal Distortion
Tanuj Nakra, MD, FACS and Karen R. Brown, MD
Disclosures: 1. AVYA Skincare: Board Member; 2. AVYA Skincare: Ownership Interest (Ownership interest of an ineligible company).
Category: Face
Introduction: Posttragal incisions offer the benefit of avoiding a visible scar in this region. However, posttragal incision design can lead to tragal deformity if there is inadvertent tension with closure or advancement of the thicker cheek skin onto the tragus without sufficient thinning of the skin.1-17 The most common postoperative tragal deformities after facelift include blunting of the tragal contour, visible external auditory meatus, blunting of the anterior incisure and/or intertragal incisure, loss of the preauricular sulcus, and loss of tragal height. These tragal deformities are perceived negatively by patients2 and are visible evidence of prior surgery. Techniques to avoid these complications have been well described. A tension-free skin closure is advocated to minimize anterior distortion of the tragus. Normal tragal projection and contour can be maintained with sufficiently tension-free closure, defatting of the advanced skin, customizing the incision to preserve prominent supratragal tubercles or intertragal incisura, and placing pretragal tacking sutures to the parotid fascia in the pretragal sulcus to avoid sulcus effacement. These techniques are important considerations with management of the tragus and pretragral sulcus during facelift. However, additional techniques to further minimize the risk of tragal distortion are welcome adjunctions to facelift surgery in the persistent goal to optimize patient outcomes. Here we present a novel technique of tragal cartilage manipulation to prevent anterior displacement of the tragus and meatal show.
Methods: This a retrospective review of a single surgeon’s cases of tragal contouring during facelifting in a private practice. Using a 4-point scale, blinded graders reviewed preoperative and postoperative photos for peritragal contour, tragal contour, scar visibility, and overall aesthetic outcome. Subjective satisfaction was reviewed using a 4-point scale at final follow-up. Patient charts were reviewed for demographic information, as well as complications, infections, and postoperative interventions. During closure of the facelift, (1) the anterior mucopericondrium of the tragal cartilage was stripped, (2) the superior pole of the tragal cartilage was trimmed, (3) the tragal cartilage was scored vertically, (4) a horizontal mattress 4-0 polypropylene suture was placed to create a convex anterior face, and (5) deep skin sutures were placed anterior to the tragus secured to the immobile SMAS.
Results: In total, 28 patients were identified who underwent this modified deep plane lip lift technique. Average follow-up was 8 months (range = 4-12 months). Twenty-four patients were female and 4 male. Average patient age was 62 years. Blinded graders reviewed peritragal contour, tragal contour, scar visibility, and overall aesthetic outcome to be “good” or “excellent” improved for all measures. Subjectively, patients judged their overall tragal aesthetic outcome to be “excellent” in all cases. There were no cases of clinical scarring or infection.
Conclusion: Tragal contouring during facelift surgery is a novel technique that is safe and effective for prevention of postoperative tragal distortion, a common facelift complication. The technique can be easily incorporated into routine facelift surgery.
References
1. Aronsohn RB. The preauricular incision in the facelift. J Dermatol Surg Oncol. 1983;9(9):752-755. doi:10.1111/j.1524-4725.1983.tb00885.x
2. Becker FF. The preauricular portion of the rhytidectomy incision. Arch Otolaryngol Head Neck Surg. 1994;120(2):166-171. doi:10.1001/archotol.1994.01880260038008
3. Cremone J, Courtiss EH, Baker JL, Jr. Male rhytidectomy incisions. Plast Reconstr Surg. 1983;71(3):423-426. doi:10.1097/00006534-198303000-00027
4. Cristel RT, Irvine LE. Common complications in rhytidectomy. Facial Plast Surg Clin North Am. 2019;27(4):519-527. doi:10.1016/j.fsc.2019.07.008
5. de Castro CC. Preauricular and sideburns operating procedures for a natural look in facelifts. Aesthetic Plast Surg. 1991;15(2): 149-153. doi:10.1007/BF02273848
6. Ellenbogen R. Avoiding visual tipoffs to face lift surgery. A troubleshooting guide. Clin Plast Surg. 1992;19(2):447-454. https://www.ncbi.nlm.nih.gov/pubmed/1576788
7. Franco T. Face-lift stigmas. Ann Plast Surg. 1985;15(5):379-385. doi:10.1097/00000637-198511000-00003
8. Goldwyn RM. Are you an insider or an outsider? Plast Reconstr Surg. 1990;86(6):1176-1177. doi:10.1097/00006534-199012000-00023
9. Jacono AA, Parikh SS. The minimal access deep plane extended vertical facelift. Aesthet Surg J. 2011;31(8):874-890. doi:10.1177/1090820X11424146
10. Knize DM. Periauricular face lift incisions and the auricular anchor. Plast Reconstr Surg. 1999;104(5):1508-1520; discussion 1521-1503. https://www.ncbi.nlm.nih.gov/pubmed/10513937
11. Kridel RW, Liu ES. Techniques for creating inconspicuous face-lift scars: avoiding visible incisions and loss of temporal hair. Arch Facial Plast Surg. 2003;5(4):325-333. doi:10.1001/archfaci.5.4.325
12. Man D. Reducing the incidence of ear deformity in facelift. Aesthet Surg J. 2009;29(4):264-271. doi:10.1016/j.asj.2009.02.018
13. Man D. Modified rhytidectomy that produces a more natural look: experience with 110 cases. Aesthetic Plast Surg. 2016; 40(5):670-679. doi:10.1007/s00266-016-0670-5
14. McKinney P. The tragus and the incision for face lift. Plast Reconstr Surg. 1991;88(2):372. doi:10.1097/00006534-199108000-00048
15. McKinney P, Giese S, Placik O. Management of the ear in rhytidectomy. Plast Reconstr Surg. 1993;92(5):858-866. https://www.ncbi.nlm.nih.gov/pubmed/8415967
16. Miller TR, Eisbach KJ. SMAS facelift techniques to minimize stigmata of surgery. Facial Plast Surg Clin North Am. 2005; 13(3):421-431. doi:10.1016/j.fsc.2005.04.007
17. Ramirez OM, Heller L. The anchor tragal flap: a method of preserving the natural pretragal depression during rhytidectomy. Plast Reconstr Surg. 2005;116(4):1115-1121. doi:10.1097/01.prs.0000179189.87555.ce
Take-Home Message: Tragal contouring during facelift surgery is safe and effective for prevention of postoperative tragal distortion and can be easily incorporated into routine facelift surgery.
Simultaneous Lipofilling and High SMAS Facelift: A More Effective Way to Address the Effects of Aging
Ina A. Nevdakh, MD
Disclosures: Nothing to disclose.
Category: Face
Lipofill has radically changed the plastic surgical approach to many reconstructive as well as aesthetic challenges. The purpose of our study is to critically look at the procedure of lipofilling when simultaneously combined with a high SMAS facelift in the treatment of the aging face. We plan to show that the high SMAS facelift combined with simultaneous lipofilling has additional advantages over traditional rhytidectomy.
Take-Home Message: In our hands, the high SMAS facelift simultaneously with lipofilling is shown to improve outcomes in a series of consecutive patients. The result is a restoration of mid-facial youth with volume, a tightening of the entire musculo-fascial corset of the face, and improved skin quality. This combined technique has been shown to be a safe and effective method for restoring a youthful facial appearance.
Twenty Years of Laser Skin Resurfacing: The Agony and the Ecstasy
Joe Niamtu, III, DMD
Disclosures: Soniquence Radiowave Surgery: Consultant.
Category: Face
Introduction: Since the 1990s, laser skin resurfacing has become the most popular treatment for facial rejuvenation.
Materials and Methods: The author will present a multimedia presentation on his 20-year experience with more than 1000 laser resurfacing cases. The lecture will detail treatment and complications of CO2 laser resurfacing.
Conclusion: CO2 laser skin resurfacing remains the gold standard for facial rejuvenation. Although there are many successes, the learning curve is steep and outcomes can be unpredictable, even for the most experienced surgeons. The pros and cons of this procedure will be covered in this lecture.
Take-Home Message: Laser skin resurfacing is a popular procedure for facial skin rejuvenation. The learning curve is steep and treatment can be unpredictable. When mastered, the treatments can be extremely effective.
Pearls From 1600 Facelifts: From Plication to Deep Plane
Joe Niamtu, III, DMD
Disclosures: Soniquence Radiowave Surgery: Consultant.
Category: Face
Introduction: It takes decades to master face and neck lift surgery. Although there are many shortcut procedures touted to be effective, the traditional face and neck lift with platysmaplasty and SMAS treatment has withstood the test of time for safe, effective, and long-lasting results.
Materials: The author will present a multimedia presentation discussing his 20-year experience with 1600 face and neck lifts.
Conclusion: Traditional face and neck lift surgery has undergone many improvements over the years for patient safety and predictable outcomes. Beginning surgeons should transition through the various phases of facelift surgery to master this popular procedure.
Take-Home Message: Face and necklift surgery is more popular than ever. Many “minimal” techniques come and gone and traditional face and neck lift with platysmaplasty and SMAS treatment has withstood the test of time for patient safety and predictable outcomes. The author will detail his experience over 20 years with 1600 facelifts and discuss the journey from SMAS plication to deep plane face and neck lift.
Single Suture Canthopexy: An Easy Solution for Moderate Lower Eyelid Laxity When Performing Blepharoplasty
Joe Niamtu, III, DMD
Disclosures: Soniquence Radiowave Surgery: Consultant.
Category: Eyes
Introduction: Lower eyelid laxity is very common in the aging population, and if not identified and treated, performing lower lid blepharoplasty can cause significant lower lid retraction and corneal problems.
Materials: The author will present a multimedia lecture detailing 200 cases of single suture canthopexy with concomitant lower lid blephaorplasty.
Conclusion: Single suture canthopexy is a simple and effective technique that can easily be performed by any specialty that performs eyelid surgery.
Take-Home Message: Be aware of lower eyelid laxity when performing blepharoplasty and understand this simple procedure to treat most cases of moderate lower lid laxity.
Clinical Audit: A Tool for Improving Patient Care—Reduction of Hematoma in Gynecomastia Surgery
Hassan Nurein, MD, MRCS, MS
Disclosures: Nothing to disclose.
Category: Breast
Clinical Audit Reveals Significant Decline in Hematoma Incidence Following Double Compression in Breast Reduction Surgery: A Longitudinal Study
Improving health care requires continuous data collection and evidence-based practices. Clinical research often provides new evidence, but it does not always translate into clinical practice. Clinical audit, a systematic review of care quality, is a crucial tool for driving change. This study presents a clinical audit conducted at a clinic to assess the frequency of complications, with a focus on hematoma, in male adult patients who underwent breast reduction surgery for gynecomastia. The audit data collected from 2017 to 2022 revealed a consistent decline in hematoma cases following the introduction of double compression in postsurgical care. The incidence of hematoma decreased from 6.66% in 2017 to 0.625% in 2022, resulting in a tenfold reduction. Statistical analysis with 95% confidence intervals supported the efficacy of double compression in reducing hematoma risk.
Take-Home Message: These findings highlight the importance of clinical audits and the role of postsurgical care improvements in enhancing patient outcomes and reducing complications in surgery.
Delayed Skin Excision: A Strategy for Moderately Severe Gynecomastia
Hassan Nurein, MD, MRCS, MS
Disclosures: Nothing to disclose.
Category: Breast
Background: Gynecomastia surgery is usually treated with gland excision with or without liposuction. In severe cases, skin laxity is addressed by excision. Over the years, many techniques have been described.
Objective: Due to the increased trend toward minimally invasive procedures in surgery, we looked at the outcome of cases that could have benefited from some form of skin excision but were treated with minimally invasive skin tightening using the BodyTite radiofrequency modality instead to see whether this was a good way of avoiding large scars on the chest.
Methodology: Retrospective cases of gynecomastia of the year 2021-2022 were taken. The study involves the use of all grades of gynecomastia. All patients were called for follow-ups for 2 and 6 months.
Results: Total gynecomastia cases were present in 536 patients in 2021 and 640 patients in 2022. Of these, 212 needed touch-up liposuction, while only 6 need skin lift. In the case of skin laxity in 2021, 87 patients were present, while in 2022, 108 patients were present. At the same time, 31 patients needed touch-up liposuction.
Conclusion: In the case of severe gynecomastia, with moderate severe skin laxity where skin excision is an option, BodyTite (minimally invasive radiofrequency) was used as an effective procedure for skin tightening to avoid or delay skin excision and resultant scars. More evidence and better classification is needed for moderately severe skin laxity to avoid unnecessary skin excision.
Take-Home Message: Minimally invasive radiofrequency was used as an effective procedure for skin tightening to avoid unnecessary skin excision and resultant scars in most suitable patient.
Auto-augmentation in the Massive Weight Loss Patient: Outcomes, Complications, and Patient Satisfaction
Erik J. Nuveen, MD, DMD, FAACS, Carisa R. Champion, DO, JD, MPH, and Darby Heath, CSFA
Disclosures: 1. Deep Blue: Consultant; 2. Deep Blue: Ownership Interest (Ownership interest of an ineligible company); 3. Deep Blue: Stock Holder.
Category: Full Body
Introduction: The trends in buttock augmentation have varied throughout history with multiple developments. The history of the buttock auto-augmentation procedure demonstrates the remarkable progress made in the field of cosmetic surgery. Buttock auto-augmentation is a combined surgical procedure that provides consistent enhancement of the buttocks projection, shape, and form through the use of a vascularized rotational flap while elevating lax tissue above the gluteus maximus.
Objective: There are benefits and risks associated with buttock auto-augmentation that require careful patient selection and optimized surgical technique. This study aims to evaluate and summarize selection criteria and methods to reduce surgical complications.
Materials and/or Methods: This study is a retrospective review of 29 patients performed at one AAAHC-accredited surgery facility who have had the auto-augmentation procedure performed and had complete medical and photographic records. We evaluated patients’ comorbidities, past surgical history, tobacco usage, and other significant factors in demonstrating risk factors for reduced ideal outcomes from the procedure.
Discussion/Results: Our findings show a high success rate with careful patient selection. Taking the patient’s comorbidities, aptitude for following postop instructions and surgeon comfort with the procedure into account demonstrates important factors to consider when choosing an appropriate candidate. Operative efficiency and surgical competence within this region are mandatory for ideal risk reduction and improved outcomes. A multiple operator model was used in all cases.
Conclusion: The survival of the auto-augmentation fat flap and the success rate can vary depending on several factors, including the surgical technique employed, the skill and experience of the surgeon, patient characteristics, and postoperative care.
Take-Home Message: The auto-augmentation procedure is grossly underutilized. The average duration of this surgical procedure is 1 hour. A combination of undesirable results occur from massive weight loss. Atrophy of the gluteal region in combination with skin laxity and excess area frequently encountered concerns of this distinct patient cohort. This procedure avoids the use of alloplastic implants and its well-known complications while resolving the most common concerns of the gluteal region in massive weight loss patients with minimal complications and prolonged satisfaction.
Combining Skin Resurfacing
Suzan Obagi, MD
Disclosures: 1. Nextcell Medical: Consultant; 2. Obagi Cosmeceuticals: Consultant.
Category: Skin Rejuvenation
Skin resurfacing remains a very important aspect of overall rejuvenation. While many modalities can be used to resurface skin, oftentimes, one must safely combine resurfacing treatments to address all aspects of aging or damaged skin. This presentation will provide a step-by-step algorithm to combining ablative, nonablative lasers with peels for safely combining skin resurfacing. Factors that will be considered are the skin phototype of the patients, skin assessment for vascular and pigmented lesions, and the correct order in which to perform the procedures.
Take-Home Message: The best approach to skin rejuvenation is one that combines different modalities safely so that one achieves the optimal skin rejuvenation outcome. Understanding why there is a need to combine modalities and the limitations of each modality if used independently. Maximizing results during one recovery period to minimize the time that patients have to take off from work or social activities.
Transumbilical Silicone Breast Augmentation
Gabriel H. Patino, MD, FAACS, FCACS, FASOCP, FASCBS
Disclosures: Nothing to disclose.
Category: Breast
Objective: I would like to present a NEW surgical technique for the insertion of SILICONE breast implants through the umbilicus.
Technique: I use the transumbilical instruments to make a tunnel from the umbilicus to the subpectoral pocket. Subglandular placement is also possible using this approach. Once the pocket dimensions are completed, the prefilled SILICONE implants can be inserted manually using a Keller funnel.
NO ENDOSCOPE, NO BLEEDING, NO DRAINS,NO ELECTROCAUTERY
Application: I love combining an abdominoplasty with a breast augmentation in selected patients because the operation can be done safely and does not significantly increase the operating room time. Both procedures can be done under tumescent and general anesthesia. Silicone or saline implants can be used.
Results: This technique is very comfortable for the patient; provides faster recovery, excellent results; and significantly decreases the risks and complications.
Take-Home Message:
One tiny scar in the only natural occurring umbilical scar.
The lowest risk of capsular contracture at 0.2% because of the near zero risk of infection and bleeding.
The lowest risk of infection at near zero because the incision is much smaller and far away from the implants. One of the theories on breast augmentation infection etiology is that the implants are pressing against the breast incisions causing wound edge ischemia with resulting edge necrosis and infection.
The lowest risk of of bleeding specially when using the tumescent anesthesia.
The risk of pneumothorax is near zero because I do not use electrocautery.
The risk of intra thoracic or intra-abdominal cavity penetration is near zero.
The risk of synmastia is near zero.
The risk of implant mal position is near zero.
Precision Sculpted Monsplasty
Marco Pelosi, III, MD, FACOG, FACS, FICS, FAACS
Disclosures: Nothing to disclose.
Category: Male/Female Genitourinary
Introduction: Achieving excellent monsplasty results consistently can be difficult. The ptotic mons pubis is commonly accompanied by an excess of localized fat. Overtreatment of either laxity or excess fat or both will yield suboptimal results. A stepwise tactical approach to this operation eliminates overtreatment and produces excellent aesthetic results.
Technique: A videotaped surgical demonstration illustrates the steps and the tactics that allow for maximal control of fat extraction, fat excision, and flap development to produce precise, sculpted contours. The procedure is conducted with tumescent local anesthesia under intravenous sedation. It begins with liposuction and concludes with fat excision and flap development.
Discussion: A stepwise tactical approach to monsplasty eliminates overtreatment and produces excellent aesthetic results. It is neither difficult nor complex.
Take-Home Message: A stepwise tactical approach to monsplasty eliminates overtreatment and produces excellent aesthetic results. It is neither difficult nor complex.
Achieving Temporomandibular Joint Pain Relief and Facial Symmetry Restoration With Botulinum Toxin
Steven P. Porto, DO, FAACS
Disclosures: Nothing to disclose.
Category: Injectables
Chronic temporomandibular joint (TMJ) disorder, or more commonly known as TMJ, affects more than 10 million Americans and 12% of the global population through pervasive and persistent symptomology in varying degrees of severity. Common presentations of issues stemming from TMJ can include all or a combination of temporal headaches, aching along the jaw and masticatory muscles, abnormal jaw noise when eating or speaking, difficulty articulating the lower facial muscles, periauricular discomfort, and asymmetry of the hyperactive masseter muscle from bulking. Introduction of Botulinum toxin, or Botox, into the overactive masseter muscle and the resulting relaxation of this hyperactivity improve patient quality of life from both a pain management and aesthetic standpoint. Botox injections for chronic TMJ sufferers offers a viable therapeutic option for sustained pain relief prior to more invasive, and sometimes irreversible surgical treatment options involving the jaw and the surrounding muscles. Restoration of facial symmetry, oral muscle imbalances, and distortion of the bulky masseter muscle from overuse allow patients to regain control of at times moderate to severe symptoms, additionally can give an aesthetic look either “jaw slimming” or “youthful V look.” Thus, implementing Botox injections as a treatment option for TMJ patients can benefit medically and aesthetically in more ways than one.
Take-Home Message: Neuromodulators when injected into the masseter muscle correctly can be an effective therapy for TMJ symptoms. In addition, the same treatment can elicit facial aesthetic outcomes desirable to most individuals seeking a more youthful appearance.
Excisional Versus Minimally Invasive Interventions for Loose Skin
Giselle Prado-Wright, MD, MBA
Disclosures: Apyx Medical: Consultant.
Category: Body Contouring
Loose skin is a common concern for patients presenting for cosmetic surgery. This complaint varies greatly in degree of severity from mild early signs of aging to severe excess skin due to massive weight loss. Treatment options for loose skin range from excisional to minimally invasive to noninvasive. The modalities differ in terms of downtime, scar appearance, and efficacy. Some patients may benefit from a less invasive treatment option with satisfactory appearance and minimal risks and downtime. Patient preference has shifted toward less invasive yet highly efficacious treatments. An algorithm for determining how to choose the treatment type helps surgeons make a best recommendation to their patient. Patient preference for both procedure and outcome should be of the utmost importance when recommending treatment. This presentation will describe excisional, minimally invasive, and noninvasive treatments for loose skin and present examples of each type throughout the body.
Take-Home Message: Minimally invasive techniques for treating loose skin can be as efficacious as excisional procedures for certain patients. Surgeons should consider minimally invasive technologies such as radiofrequency energy to maximize results while minimizing scars.
Pearls and Pitfalls of Ultrasound-Guided Gluteal Fat Transfer
Giselle Prado-Wright, MD, MBA
Disclosures: Apyx Medical: Consultant.
Category: Body Contouring
Gluteal fat transfer is a highly requested yet dangerous procedure that has increased dramatically in popularity. Social media and celebrity culture have influenced many patients, both men and women, to desire larger glutes. Gluteal implants, traditionally made from silicone, have the disadvantage of becoming palpable or visible. Autologous fat transfer provides a low-cost and “natural’ option for gluteal augmentation. However, gluteal fat transfer is the most dangerous cosmetic surgery procedure due to fat embolism syndrome. The pathophysiology of this dreaded complication is theorized to be microscopic or macroscopic fat embolization into the gluteal venous circulation due to inadvertent uptake of reinjected fat into traumatized vasculature deep within the gluteal muscles. A Aesthetic Surgery Education and Research Foundation (ASERF) task force for safe gluteal fat transfer suggested superficial reinjection into the subcutaneous fat layer would minimize the risk of fat embolization. Florida, a center of cosmetic surgery and poor outcomes, prohibits intramuscular fat injection in the office setting. A recent emergency order requires ultrasound guidance during fat reinjection. Other states may choose to implement similar rulings. This novel technique may not be familiar to most surgeons and requires both training and practice to master. There are the intricacies related to probe placement, depth visibility, sterility concerns, hand positioning, and using assistants. A surgeon adept at ultrasound-guided fat transfer will maximize patient safety while efficiently decreasing operating room and anesthesia time. All surgeons should consider implementing ultrasound guidance during gluteal fat reinjection for patient safety.
Take-Home Message: Ultrasound-guided fat transfer is the new standard of care for gluteal fat reinjection. Some states are now requiring this technique for surgeons. This technique is likely to become widespread and decrease patient morbidity and mortality.
Efficacy of a Combination Approach Using Subcision, Fillers, and Fractional Carbon Dioxide Laser for the Treatment of Facial Acne Scars
D. Shome, MD, FRCS (Glasgow), FACS, FAACS, MBA and Priyanka Mhamunkar, MDS
Disclosures: Nothing to disclose.
Category: Face
Introduction: Acne is one of the most common skin diseases, causing scars as a common and persistent complication. A single modality of treatment is not completely effective, and hence a combination of therapeutic modalities is required for the treatment. As the condition is very distressing in nature and leaves an impact at a psychological level, the patient often seeks quick results.
Objective: Efficacy of combined approach using subcision and fillers followed by fractional carbon dioxide laser for the treatment of facial acne scars in Fitzpatrick IV-VI skin types.
Materials and Methods: One hundred sixty-five patients with Fitzpatrick IV-VI skin types and grades 2-4 acne scars, as per Goodman and Baron Acne Grading Scale, were enrolled. Subcision followed by hyaluronic acid filler was performed initially, followed by fractional carbon dioxide laser 2 weeks later. Standardized digital global photographs were obtained before treatment, before every laser session, and 6 months after the last laser session.
Results: Using Goodman and Baron’s Global Acne Scarring System, the patients showed significant improvement of both clinician and subjective scores in all grades of acne scars. No significant adverse events were noted.
Conclusion: To the best of our knowledge, this is the first study to date which involves the combined approach of subcision and fillers, followed by fractional carbon dioxide laser sessions for the treatment of acne scars. The results show significant and persistent improvement, without considerable complications, in Fitzpatrick’s skin types IV to VI. This protocol should thus be considered for the management of acne scars of the face.
Take-Home Message: Combination approach of subcision and fillers followed by fractional carbon dioxide laser increases the efficacy of treatment. The results show significant and persistent improvement, without considerable complications, in Fitzpatrick’s skin types IV to VI.
Facial Engineering Procedures for the Aging Indian Face—How Asian Indian Faces Age: Surgical Versus Nonsurgical Treatment Modalities
D. Shome, MD, FRCS (Glasgow), FACS, FAACS, MBA, R. Kapoor, MD, DDV, R. Shah, MDS, V. Kumar, MDS, PhD, FRSPH, FPFA, FICD, and H. Tandel, MDS, MPH
Disclosures: Nothing to disclose.
Category: Face
Background: Asian Indians make up almost one-sixth of the world’s population. Although some aspects of facial beauty are universal, anthropometric morphology and age-related changes differ in all ethnic groups. Caucasian face has different anthropometry which leads to lesser skin sagging at middle and lower third of face compared with Indian Asian face. Due to low bone to skin ration in Indian Asian face compared with Caucasian face, sagging is significant in nature leading to loss of definition of bony structures. We aimed to discern the aging patterns among different ethnic subgroups within Asian Indians and establish effective treatment algorithms to correct and engineer it.
Method: Participants, above 30 years of age, were selected from different Indian ethnic groups and zones (North, South, East, West). Various treatment modalities were implemented, as per indication and clinical judgment—that is, surgical (facial liposuction, midface lift), nonsurgical (Botulinum toxin, facial fillers, threads, energy-based device such as HiFU), alone or in combination. Clinical parameters were assessed via treatment outcomes, effects, and validated grading score of 1 to 5 was used for assessing various parameters on the Global Aesthetic Index Score.
Results: Significant improvement was established with a multimodality approach. The surgical approach was implemented for correction of severe deformity, whereas nonsurgical modalities were administered for mild and moderate cases. Significant result was noted in clinical outcomes achieved via midface lift surgery, as compared with facial liposuction; the latter, however, shoeing superior results for submental fat reduction. Nonsurgical therapy was initiated with HiFU (Ultherapy) to lift the mild sagging face followed by thread for moderate sagging face, Botulinum toxin for wrinkles correction, and facial fillers for volumizing the face. Patient satisfaction reflected increased scores in the nonsurgical modalities compared with surgical counterparts, sue to increased downtime and complications in the latter.
Conclusion: This study attempts to understand in greater detail the aging process of the Asian Indian population and the various treatment modalities, in the field of facial aesthetic and cosmetic surgery, that are advocated to correct it.
Take-Home Message: Facial aging is a complex, multifactorial process. Hence, multimodality approach is necessary to achieve the optimum results. This study establishes an algorithmic approach for specific treatment protocols to treat the age-related regressive alterations among the targeted Asian Indian population.
Patterns and Trends of Facial Fractures at a Tertiary Care Trauma Center in India
D. Shome, MD, FRCS (Glasgow), FACS, FAACS, MBA and R. Shah, MDS
Disclosures: Nothing to disclose.
Category: Face
Study Design: Retrospective study
Background: Trauma is the most common cause of death in the first 40 years of life. As per the WHO (World Health Organization) statistics, approximately 1 million people die and 15 to 20 million individuals get injured annually due to road traffic accidents (RTAs). Face being one of the most exposed parts of the human body is commonly injured during RTAs. It is also the least protected organ and the first point of contact in accidents and also the target for blows during assaults.
Objective: The purpose of this study was to retrospectively analyze the prevalence, pattern, diagnosis, and treatment of the facial fractures falling under ambit of facial plastic surgery in a multispecialty hospital at India from the year 2006-2019.
Methods: This retrospective study analyzed 1508 patients, having orbital fractures (from 2006 to 2019) for demographic data, cause of trauma, type of fracture, and the treatment given. The data were compiled in excel and analyzed by using SPSS version 21.0.
Results: Of these 1508 patients (1127 [74.73%] males and 381 (25.27%) females), the etiology of injuries was RTA (49.20%), assault (26.52%), and sports injuries (11.47%). The most common fracture pattern was isolated orbit and/or orbital floor fracture in 451 patients (32.08%), followed by mid-facial fractures (21.93%). Also, 105 patients (6.96%) experienced ocular/retinal trauma along with other fractures.
Conclusion: Orbit, periocular, and midface trauma comprised a large position of this study. It requires a great deal of expertise to treat such complex trauma, which is not covered in one specialty alone. Hence, a holistic approach of craniofacial fracture management, rather than limiting these skills to water-tight craniofacial compartments, becomes necessary.
Take-Home Message: Facial trauma majorly involves upper and middle third of the face. This study highlights the critical need of multidisciplinary approach for predictable and successful management of such complex cases.
Surgical Versu Nonsurgical Rhinoplasty: A Clinical Evidence-Based Perspective
D. Shome, MD, FRCS (Glasgow), FACS, FAACS, MBA, R. Kapoor, MD, DDV, V. Kumar, MDS, PhD, FRSPH, FPFA, FICD, P. Mhamunkar, MDS, and P. Mhatre
Disclosures: Nothing to disclose.
Category: Rhinoplasty
Introduction: Rhinoplasty is a cosmetic surgical procedure that is among the top 5 most popular cosmetic surgeries. It is a definitive surgery for permanent correction of nasal reengineering. However, surgical rhinoplasty is associated with high risks and potentially limited predictability, functional disturbances, dissatisfaction with the final results, and botched outcomes due to surgical complications that in turn lead to revision rhinoplasties. Nonsurgical rhinoplasty offers the advantage of being a less invasive procedure with minimal downtime, and reversible, semi-permanent results making it the treatment of choice in today’s day and age.
Materials and Methods: Patients requiring rhinoplasty were selected according to severity of nasal deformity and recommendation for surgical versus nonsurgical techniques. Conventional rhinoplasty techniques were used for structural and functional modifications of the nose in the indicated subjects, whereas nonsurgical techniques using fillers, threads, and combination techniques were implemented for those indicated for the same. Subjects were assessed preoperative and postoperatively under parameters ranging in the domains of clinical outcomes, patient satisfaction, and complications. The patients were divided into 2 groups—surgical group and nonsurgical group, depending on the severity of nasal deformity. Postprocedure, the patients were assessed for clinical outcome, patient satisfaction using the ROE (Rhinoplasty Outcome Evaluation), FACE-Q rhinoplasty module, and complications were assessed.
Results: Recontouring of the nose for the structural correction and enhancement of nasal features was achieved by nonsurgical rhinoplasty techniques with hyaluronic acid fillers, among others. Certain cases achieved predictable outcomes with a combination of threads and fillers. Patient satisfaction was higher in the nonsurgical rhinoplasty group as compared with surgical. However, results for advanced cases of nasal deformity, involving functional rehabilitation, were achieved through conventional surgical rhinoplasty procedures. The study patients yielded some temporary complications such as transient edema and erythema, postinjection pain, and bruising with nonsurgical rhinoplasty. Rare complications that were reported were vascular impairments and hematoma.
Conclusion: Nonsurgical rhinoplasty is a good, minimally invasive alternative over conventional surgical rhinoplasty.
Take-Home Message:
It is imperative for clinicians to determine the treatment modality, surgical or nonsurgical, depending on the level of nasal deformity, patient expectation, and expected clinical outcome.
With good case selection and proper treatment planning, nonsurgical rhinoplasty techniques serve to be a predictable alternative for desirable clinical outcomes and show higher scores for patient acceptance.
Innovative Approach for Tear Trough Deformity Correction Using Higher G Prime Fillers With Lateral Injection Technique: A Prospective Study
D. Shome, MD, FRCS, FACS, FAACS, MBA and Priyanka S. Gupta, BDS, MDS
Disclosures: No disclosure information submitted.
Category: Eyes
Introduction: Facial rejuvenation of the lower eyelid presents challenges, including the presence of lower lid bags due to protruding orbital fat and a distinct issue known as “tear trough deformity.”
Objective: The study aims to compare and assess the effectiveness of tear trough deformity correction using the standard technique with a low G prime filler versus the lateral injection technique with a high G prime filler. The goal is to establish guidelines for the safe and efficient correction of tear trough deformity.
Materials and/or Methods: A prospective double-blinded study was conducted involving 30 participants aged between 35 and 60 years. The participants were divided into 2 groups with 15 patients in each group. Group A received the conventional technique using G prime filler, while Group B received the lateral injection technique with a high G prime filler.
Discussion/Results: All patients in both groups experienced significant improvement in appearance and skin quality. Notably, the lateral injection technique required a mean 0.5 mL of filler to lift the cheek and reduce the tear trough, whereas the standard technique (Mauricio de Mai’s 3-point tear trough reshape technique) necessitated a mean of 1.2 mL of filler for the same outcome. Postprocedure complications, such as bruising and the Tyndall effect, were significantly higher when using the standard medial technique for tear trough correction.
Conclusion: Achieving aesthetically satisfying results for tear trough correction is possible without directly injecting the tear trough. Instead, using knowledge of the underlying anatomy can lead to successful outcomes.
Take-Home Message: The study highlights the benefits of using a higher G prime filler with a lateral injection technique for tear trough deformity correction. Compared with the standard technique, this innovative approach offers safe, efficient, and long-lasting results with reduced filler volume requirements and a lower risk of postprocedure complications. Understanding the underlying anatomy and employing the lateral injection technique can lead to aesthetically satisfying outcomes for tear trough correction.
Awesome Abdominoplasty: What Can You Tuck and Where Can You Liposuction?
Robert A. Shumway, MD, FACS, FAACS
Disclosures: Nothing to disclose.
Category: Body Contouring
It is often confusing to beginning and intermediate experienced cosmetic surgeons regarding what is safe and appropriate to actually surgically lift over the anterior torso and where one can perform liposuction without incurring unacceptable complications. The methodology and results of a sequential review of 31 years in a solo practice with AACS Fellows provide valuable data concerning safe cosmetic torso and abdominal surgery. There are several variable factors that must be reviewed and accepted for success: overall patient health, body mass index, abdominal flap characteristics, liposuction locations and aggressiveness, type of anesthesia, and postoperative care. A thorough presentation of do’s and don’ts will assist cosmetic surgeons in our quest for perfection without sequalae.
Take-Home Message: A step-by-step guide for cosmetic surgeons, fellows, and experienced operators to help with their tummy tuck—liposuction combination operations by knowing anatomy, blood supply, preexisting patient risks, and better postprocedure follow-up medical care.
Bioidentical Hormone Optimization Therapy (BHOT) 2024
Robert A. Shumway, MD, FACS, FAACS
Disclosures: Nothing to disclose.
Category: Regenerative Medicine
The concept that the presence of plentiful levels of natural hormones circulating throughout the body dictates better longevity and a healthier qualify of life is not new! The large and powerful pharmaceutical industry generally prefers patents of “new” molecules to nonpatentable natural existing human hormones because profits take prescience over purpose. Therefore, it is key for cosmetic surgeons to understand the “how and why” natural bioidentical hormones control the regenerative, enigmatic biochemical reactions within their patients for better healing and maintenance of healthy minds and bodies. This talk will detail the great need for cosmetic surgery and cosmetic medicine to be one in the same! This prospective concept was planned over 15 years ago with a focus on “results” regarding the quality and time of postoperative healing, youthful appearance, over all body strength, and sense of well-being. There are many other reasons to use natural hormone optimization advantages in the practice of cosmetic surgery, but this the presentation will reveal profound objective and subjective improvements in patient health and happiness.
Take-Home Message: Participants will be exposed to data, photos, and studies that elucidate the absolute importance to understand and use bioidentical hormone optimization supplementation within the practice of medicine, and particularly within the specialty of cosmetic surgery, which is driven by appearance, patient results, and well-being.
Restoration Open Rhinoplasty Using Advanced Suture Techniques
Robert A. Shumway, MD, FACS, FAACS
Disclosures: Nothing to disclose.
Category: Open Reconstruction Rhinoplasty for Cosmetic Regeneration pays huge dividends for patients and physicians. The complex anatomy of human noses necessitates the specific need to understand variable nasal anatomy and physiology. This lecture will include understanding structure and function of nasal reconstruction as a “How I Do Rhinoplasty” using powerful open suture revision and refurbishment of nasal structure. The author will literally reconstruct a nose by open reduction visually and then putting the complex anatomy back together again. The Webster concept of the nasal triangle and pyramid will be emphasized including how and what to suture. It is highly satisfying to patients and surgeons to improve another’s appearance and their ability to breathe appropriately through their nose.
Take-Home Message: The take-home message will include nasal anatomy and nasal function as to why 3 specific calibrated items need to to achieved with each rhinoplasty. Also, the audience will appreciate how important the nose (center of the face) really is to overall facial appearance and beauty.
The AI Revolution Is Here: How Your Practice Can Leverage AI to Win the Marketing Game
Jason Sievert
Disclosures: Nothing to disclose.
Category: Practice Management
Introduction: As the frontiers of technology continue to expand, artificial intelligence (AI) is pioneering unprecedented transformations within the health care and wellness sector. Your practice can seize this wave of innovation, fundamentally reshaping the approach to marketing in several powerful ways. I will provide an overview of the innovative ways AI can boost your practice, transforming marketing from a necessity to an adventure in creativity and efficiency.
Method: Together, we will uncover the methodologies behind AI-enhanced ideation and brainstorming, enabling your team to craft groundbreaking strategies swiftly. We will explore how AI’s robust structuring capabilities provide a framework for compelling, persuasive narratives. Experience how AI-generated content, with its quality and consistency, can revolutionize the way you present your brand’s mission and offers.
Results: We will delve into the tangible outcomes of AI-powered marketing, from extending the lifespan of your content through skillful repurposing, to generating unique graphics and art. I will share inspiring examples of how AI transforms simple descriptions into stunning visuals, enriching your brand with aesthetic allure, and sparking client interest like never before.
Take-Home Message: To conclude, we will discuss the future of AI in the cosmetic surgery industry. I will guide you on harnessing these powerful tools, illustrating how the AI revolution can transform your practice into a marketing powerhouse. Together, we will envision a future where marketing is not a chore, but an exciting journey of continual innovation and growth.
The Technoplasty: Treat Your Website Like a Patient to Increase Conversions
Jason Sievert
Disclosures: Nothing to disclose.
Category: Practice Management
Introduction: This presentation will come not merely as a marketing expert, but as a co-surgeon, ready to embark with you on a transformative operation we call “The Technoplasty.” Our patient? Your medical website. Just like in a real clinical setting, we will strive to build a genuine, visceral connection between your potential clients and your practice, all through the intricacies of your website.
Method: Imagine this: A website with the simplicity and intuitive flow of a well-led consultation, guiding visitors to key areas, steering them toward effective Call to Actions that feel as natural as the next step in a treatment plan. We will nurture each page, crafting proper formatting for treatment descriptions, not unlike preparing for a delicate procedure. The “education” phase of any treatment is vital, and the same applies to your website. We will construct valuable, enlightening content that answers queries before they form, similar to preprocedure briefings. To truly foster trust, we will design patient journeys, narratives that resonate with visitors, just as shared experiences foster bonding between patients in the waiting room.
Results: Our postop reveals vividly, the tangible transformation of your website. The before and afters? A showcase of consistency and depth, reflecting the quality of your actual clinical results. Now, your website is not just a digital placeholder, it is a digital extension of your practice, a space mirroring your professional ethos, your commitment, your expertise.
Take-Home Message: After our technoplasty, your website recovers not merely with a facelift, but with a renewed vitality to actively engage and convert visitors. They now connect with you, trust you, and are keen to embark on their personal treatment journey. So, dear colleagues, let us prepare for surgery, let us reshape our online presence and increase those conversions, one click at a time.
The Double-Break Nasal Profile: Use of Contour Sutures
Ronald W. Strahan, MD
Disclosures: Nothing to disclose.
Category: Rhinoplasty
Background: Creation of a double-break nasal profile (DBNP) in rhinoplasty surgery has been at best unpredictable especially in patients with thick skin in the lower half of the nose (TSLH).
Objective: This presentation introduces a technique that produces dependable results in creating the DBNP.
Methods: Ultrasound studies illustrate the cause of supratip fullness in cases with TSLH. External sutures passed from the skin into the nasal passage, through the septum and back out through the skin and tied approximate (SCS) the nasal skin to the cartilaginous framework, thus eliminating any space that might be the site of fluid collection or fibrosis. Similar sutures are used to further define the tip cartilaginous architecture. Photos of patients before, immediately after and at 1 to 5 years after present typical results.
Results: The postoperative follow-up in this study was 12 to 60 months. The creation of a DBNP was achieved in all 31 cases treated with this technique.
Conclusion: The SCS properly applied for creation of the DBNP as well as defining other aspects of the cartilaginous lower nose produces consistent results. The SCS has been used by the senior author in more than 250 cases of rhinoplasty surgery.
Take-Home Message: The SCS is a valuable adjunct in the creation of a DBNP. The SCS is useful in cases of cosmetic surgery of the nose that have TSLH.
Management of Backrolls: A Nightmare for Women—Staging and Treatment Strategy
Mohan Thomas, MD, DDS
Disclosures: Nothing to disclose.
Category: Body Contouring
Introduction: Back fat rolls have a negative impact on the feminine figure and her self-confidence. There are many fibrous connections between the superficial fat of the back and the underlying fascia causing the formation of rolls specially with excess weight. This fat is hard to reduce with diet and exercises, and even with liposuction, the swelling is persistent because patients tend to lie on their back making the fluid collect in that region. Injection lipolysis done over few sessions is a very useful technique to reduce these bulges in people who do not want surgery. Others with significant weight gain may need liposuction and/or removal of excess skin. Here I will present my experience of the last 7 years with people who have undergone procedures for correction of back rolls, the staging of the back rolls, and their treatment options.
Method: Ninety patients who have undergone a combination of procedures were taken up for the study—40 patients who were grade 1 had undergone nonsurgical treatment with local application of EMLA cream prior to the injections. Significant improvement was seen in the back rolls after 3 sessions of injection lipolysis using phosphatidyl choline and deoxycholate done at intervals of 4 weeks. Forty-four patients (grade 2) underwent VASER-assisted liposuction as a single-stage treatment along with liposuction of other body parts. Six patients (grade 3) who had skin laxicity underwent excision of the roll with primary suturing and healing.
Results: The results achieved showed significant improvement in the back rolls even in patients who had not worked out to reduce the body weight.
Conclusion: A combination of treatment which includes nonsurgical, minimally invasive, and surgical excision may be required to achieve a flat back devoid of rolls.
Take-Home Message: A combination of treatment which includes nonsurgical, minimally invasive, and surgical excision may be required to achieve a flat back devoid of rolls.
Thread Lift as an Adjunct to Liposuction in Grade 3 Gynecomastia
Mohan Thomas, MD, DDS
Disclosures: Nothing to disclose.
Category: Full Body
Objective: Grade 3 gynecomastia is associated with excess and lax skin causing significant drooping of the Nipple-areola complex (NAC)s. Multiple possible procedures have been written about, wherein the NAC can be relocated to an ideal position after reduction of the tissue bulk. We present a novel procedure of using absorbable barbed sutures in association with liposuction to reposition the NAC after tissue reduction in grade 2 and grade 3 gynecomastia.
Methods: Two barbed sutures were used on either side of the NAC to lift the drooping NAC akin to being used on the face. This prevents major scars associated with NAC reposition and helps in an elevated position of NAC during healing.
Results: Of 15 patients of grade 2 and grade 3 gynecomastia who underwent this combination procedure, all were very happy with the outcome.
Conclusion: Support of NAC by repositioning it using absorbable barbed sutures has shown significant improvement in its position after a healing of 3 months.
Take-Home Message: Support of NAC by repositioning it using absorbable barbed sutures has shown significant improvement in its position after a healing of 3 months.
Five Characteristics of a High-Performing Practice
Vahe Tirakyan
Disclosures: Nothing to disclose.
Category: Practice Management
Most practice management sessions seem to include generic and often repetitive tips for success. This presentation will cover 5 best practices which are observed in some of the most successful plastic surgery practices and not commonly talked about.
Take-Home Message:
Discuss best practices and protocols of ensuring consistent and high quality before/after photos of patients. Touch on some options for setting up a photo room or DIY-ing a professional photo setup.
Identify key performance indicators for all departments/team within your practice and how to measure the success of employees based on these indicators.
Outline the process of creating standardized operating protocols.
Discuss the benefits of using a call center to increase your consult/appointment bookings and patient reviews.
Introduce audience to the benefits or utilizing a Customer relationship management (CRM) or similar lead tracking software to increase their booking rates and conversions.
Using a Professional Employer Organization Versus Handling HR, Benefits, and Payroll In-House
Vahe Tirakyan
Disclosures: Nothing to disclose.
Category: Practice Management
Professional employer organizations (PEOs) are companies that become the employer of record for your staff, provide full HR support, payroll, benefits, and so on. and take on the burden of employer liability and compliance. This presentation will provide a detailed overview of the pros and cons of using a PEO for the audience can determine whether this might be a better route for their practice. The PEO’s are generally good for practices with less than 25 employees which, I assume, is what most practices who attend the conference would fall under.
Take-Home Message: The PEOs can provide assistance with HR and compliance along with giving the practice and its employees access to Fortune 500 level benefits (health, retirement, life insurance, etc). However, it is important to weight the benefits with the drawbacks which can include higher costs to the practice, reduced flexibility when it comes to selecting employee benefits, as well as giving up control over certain HR functions. After reviewing the pros and cons, most of the audience will have a good idea of whether it makes sense for them to outsource to a PEO or keep these functions in-house. The audience will leave with a checklist of questions they can go over when evaluating different PEOs to make sure they cover all pertinent details and not fall victim to sales tactics.
Eye-Enhancing Injection Brow Lift With Acellular Adipose Tissue Matrix—Reproducible Results
Walter W. Tom, MD, FACS, FAACS
Disclosures: Nothing to disclose.
Category: Injectables
Facial aging in part includes the continued descent of the forehead resulting in hooding of the eyebrow region. This descent is in part due to a combination of reduced skin elasticity, diminished frontalis muscle function, and forehead/supraorbital fat volume depletion. There is a growing demand for a nonsurgical browlift. The use of acellular adipose tissue matrix—cadaver fat is a unique tissue that can add volume to the forehead/supraorbital region resulting in a more wide-eyed, vibrant cosmetic effect. The injection technique will be demonstrated in a step-wise reproducible fashion. Because of the biostimulatory properties of this tissue matrix, long-term results can be achieved.
Take-Home Message: Injecting acellular adipose tissue matrix in the forehead/supraorbital region can be easily adopted to achieve a nonsurgical browlift.
Ultrasound-Guided Gluteal Fat Grafting: Correlation Between Subcutaneous Space, Fat Injection Volume, and Body Fat Index
Cesar Velilla, MD
Disclosures: Nothing to disclose.
Category: Body Contouring
Gluteal fat grafting has gained popularity as a cosmetic procedure to enhance the aesthetic appearance of the buttocks. However, limited research exists on optimizing the procedure for improved outcomes and patient satisfaction. This study aimed to investigate the relationship between the subcutaneous space in the gluteal region, the volume of fat injected during surgery, and its correlation with patients’ body fat index (BFI). The objective was to develop more accurate predictions for the amount of fat injected, leading to more informed preoperative discussions and realistic patient expectations. This study provides valuable insights into the correlation between subcutaneous space measurement, fat injection volume, and patients’ BFI in gluteal fat grafting. Understanding this relationship can help surgeons customize the procedure based on individual patient characteristics, leading to improved outcomes and enhanced patient satisfaction. Moreover, incorporating BFI in preoperative discussions enables more realistic expectations, ensuring patients are well-informed about their potential outcomes. The use of ultrasound guidance is paramount in achieving precision and reproducibility during gluteal fat grafting procedures. Future research should focus on exploring the long-term outcomes and safety aspects of this technique, further refining and optimizing gluteal fat grafting procedures. By considering patients’ unique anatomical characteristics and BFI, gluteal fat grafting can be tailored to deliver more satisfactory and gratifying results.
Take-Home Message: During this presentation, we will delve into the crucial relationship between the measurement of the subcutaneous space using ultrasound, its correlation with the amount of fat injected during gluteal fat grafting, and how it associates with the patients’ body fat percentage. Understanding this relationship will provide patients with more realistic expectations during their preoperative visit. By using ultrasound to assess the subcutaneous space and its correlation with the amount of fat to be injected, surgeons can better predict the outcome and tailor the procedure to individual patient characteristics. In addition, we will explore how patients’ body fat percentage influences the results, leading to more informed discussions during preoperative consultations. This comprehensive understanding will empower both patients and surgeons to set realistic goals, improve overall patient satisfaction, and enhance the success of gluteal fat grafting procedures.
Why You Should Consider Adding Platelet-Rich Plasma to Your Practice
Carlos R. Veliz, MD
Disclosures: Nothing to disclose.
Category: Regenerative Medicine
Background: As physicians dedicated to cosmetic medicine and surgery, we have the opportunity to use platelet-rich plasma (PRP) injections to treat a wide spectrum of aesthetic conditions. To do so, we should employ this kind of procedure in combination with other ones to improve cosmetic results. In the following cases, platelet-rich plasma treatment was used for (1) facial rejuvenation, (2) hair loss, (3) remodeling scars after cosmetic surgery, (4) tightening the skin, and (5) dyschromia on the skin. Combining PRP injections with other procedures widens the spectrum of treatments offered and allows us to reach a more effective and lasting cosmetic appearance in our patients.
Objective: The aim of this presentation is to demonstrate the effectiveness of the use of PRP, in combination with other treatments, to increase the desired outcomes in cosmetic surgery and cosmetic medicine.
Methods: Platelet-rich plasma as the principal option was applied to my selected patients over a span of 10 years (from June 2013 to July 2023) in conjunction with the adequate treatment according to each of their aesthetic conditions. There was a simple selection of patients following the 5 pathological criteria mentioned above. In addition, follow-ups 1, 3, and 6 months after the procedure were done.
Results: The implementation of PRP in combination with other treatments has shown to be effective in improving cosmetic appearances and achieving a safe and lasting result, increasing the satisfaction of the patients.
Conclusion: The application of PRP in conjunction with other procedures in selected patients is a reliable and effective treatment when seeking to improve aesthetic outcomes in your practice.
Take-Home Message: The effectiveness of the use of platelet-rich plasma, in combination with other treatments, to increase the desired outcomes in cosmetic surgery and cosmetic medicine.
The Use of a Hemostatic Net Following Dorsocervical Liposuction
Grant Wagner, BS, William Hedden, MD, and Pasha Mostofi, MD, DMD
Disclosures: Nothing to disclose.
Category: Liposuction
Patient Presentation
We present the following case of a 30-year-old woman who presented to our practice for evaluation of an accentuated dorsocervical fat pad, also known as a “buffalo hump,” for which she desired surgical intervention. The patient was seeking intervention purely for cosmetic purposes, as she presented without any symptoms or functional limitations. Her past medical history is noncontributory; she has known attention-deficit/hyperactivity disorder controlled with lisdexamfetamine. She denies any history of Cushing’s syndrome or disease, and she denies any history of prolonged steroid use. She has no known drug allergies. In terms of previous surgical history, she underwent an appendectomy and dilation and curettage without any complications. Her family history is significant for hypertension, ovarian cancer, and prostate cancer on the paternal side. She globally denies any alcohol, tobacco, or illicit drug use. The patient’s ethnicity is both Iranian and Caucasian American. She denies any history of skin fragility, tendency to burn, hypertrophic scarring, or cold sores. On initial evaluation, the patient’s body mass indec was 28.9, blood pressure was 153/107, and heart rate was 80 bpm. She had never been evaluated for hypertension before. On examination, there was an excess accumulation of adipose tissue in the dorsocervical regions, measuring about 8 cm × 8 cm. The remainder of her physical examination was unremarkable. She was cleared from an anesthetic standpoint and thus was an ideal candidate for liposuction to the dorsocervical region.
Background: As with any procedure, liposuction is associated with various postoperative complications (1), most of which can be avoided with optimal management during the recovery period (2). Specifically, hematoma and seroma formation are always of concern whenever removing tissue and creating dead space within the body. The risk of hematoma or seroma formation can be lessened with adequate compression garments and dressings, and these have shown to be effective in cases of liposuction to the abdomen and flanks (3). However, in our experience, the dorsocervical region presents a challenge in this regard. There are no true compression garments for this area, and dressings do not provide adequate pressure and/or do not stay adherent due to movement of the head and neck. Recently, the use of a hemostatic net has been shown to be a safe, reproducible, and effective technique to reduce the risk of hematoma formation following a facelift (4). The hemostatic net allows for small areas of fibrosis to occur at point of contact with the underlying tissue, in efforts to decrease dead space and subsequent fluid accumulation. In this case study, we report on the use of a hemostatic net to the dorsocervical region following liposuction in one patient.
Treatment: The procedure took place on May 31, 2023. Once the patient was consented, the area of excess adipose tissue was marked preoperatively with the patient standing upright. In the operating room, the patient was in the prone position for the procedure. First, local anesthetic was injected intradermally throughout the area of concern. One small 5-mm stab incision was made at the inferior border of the dorsocervical fat pad for eventual passage of liposuction cannula. Through the incision, tumescent solution was infiltrated using standard technique. Liposuction was then performed on the area using a standard cannula, and the total volume of aspirate was 100 mL. The stab incision was closed with a simple 3-0 Monocryl suture. The hemostatic net was placed with 5-0 Prolene running sutures throughout the treated area, spaced about 1 to 2 cm apart. Specifically, 5 columns of running sutures were placed adjacent to each other. Each column of running suture began on the superior aspect of the area and extended down to the inferior border. The patient tolerated the procedure well without any complications.
Outcome: The hemostatic net was left in place for 48 hours, after which the sutures were removed in-office without issue. The patient came back for follow-up 2 days after removal of the net, as to ensure there were no signs of fluid collections or infection following net removal. The patient is postoperative day 4 from liposuction, and there is already noticeable improvement in the appearance of her neck. Furthermore, the puncture sites from the hemostatic net have started to epithelialize appropriately. Overall, this patient experienced no postoperative complications following liposuction to her dorsocervical fat pad and placement of a hemostatic net. The patient received an excellent result, as evidenced by the significant volume loss and smooth contour of her dorsocervical region at the 6-week postoperative mark. The placement of a hemostatic net did not cause any complications in this patient and did not result in visible scarring or hyperpigmentation. To our knowledge, this is the first case report applying the hemostatic net technique to the dorsocervical region. Our successful outcome in this patient serves as a positive example that the benefits of the hemostatic net technique can be applied to other areas of the body.
Take-Home Message: To our knowledge, this is the first case report applying the hemostatic net technique to the dorsocervical region. Our successful outcome in this patient serves as a positive example that the benefits of the hemostatic net technique can be applied to other areas of the body.
African Ethnocentric Torso, Hips, Buttocks, and Thighs Rejuvenation: Personalized, Best Results Combining Abdominoplasty, Liposuction Torso, and Fat Transfer
John W. T. Walker, MD
Disclosures: Nothing to disclose.
Category: Body Contouring
African ethnocentric torso, hips, buttocks, and thighs rejuvenation in women requires close attention to key transition zones that make or break a successful and appropriate result. African ethnocentric shapes differ substantially from other ethnic backgrounds. Specific note is made of the waist:hip ratio which is substantially different in the African ethnocentric females, with the largest ratio’s seen in any ethnicity. This and other key targets in the rejuvenation of the African ethnocentric body shape are described, concentrating on the gradual transition between key aesthetic zones notably lower back and buttocks, waist, hips, buttocks, as well as the lateral, posterior thighs, and gluteal fold.
Take-Home Message: Knowledge of a patient’s African ethnocentric torso, hips, buttocks, and thighs area, and how to optimize these, is essential to obtaining an appropriately excellent, idealized, ethnocentric result. Attention to key transition zones, especially around the lower back, waist, hips, and thighs, is key for obtaining excellence in results with the African ethnocentric shape. Each key transition zone is described to maximize results and patient satisfaction when treating African ethnocentrically shaped Women.
The Powerful Role of Regenerative Medicine in Hair Restoration
Ryan Welter, MD, PhD
Disclosures: Nothing to disclose.
Category: Hair Restoration
The treatment options for thinning hair in men and women have been traditionally limited to a few medications, low-level laser therapies, and surgery when indicated. Over the past decade, however, several cell-based therapies have emerged which continue to show great promise in both the stabilization and improvement of hair loss in the thinning scalp. These modalities include derivatives of both autologous and nonautologous source materials from a wide range of sources including adipose-derived stem cells and placental tissues and cord blood. Many off-the-shelf growth factors and serum samples have been introduced and studied in recent years as well. The presentation provides a brief systemic review of the history of cell-based regenerative therapies for hair with reference to research literature and published studies beginning with the use of platelet-rich plasma and then moving toward the employment of other autologous sources such as adipose-derived stem cells for induction of anagen. Nonautologous source material and off-the-shelf growth factor and serum use will also be discussed and clinical studies will be summarized. Finally, current initiatives in hair cloning as well as other regenerative technologies that are on the horizon will be summarized. This presentation will offer an enticing overview of the research surrounding cellular regenerative therapies for hair loss as well as provide clinical direction for the safe use of regenerative for practices eager to provide the benefits of cellular therapy to their patients.
Take-Home Message: Emerging and existing regenerative technologies for the stabilization and treatment of hair loss in both men and women are reviewed and discussed with an emphasis on currently available research data and published literature.
Satisfaction in Physician Versus Nonphysician-Owned Medical Spas in Georgia
Samantha Zhan-Moodie, BS, America S. Revere, MD, Kallie Wynens, MD, and Jack C. Yu, DMD
Disclosures: Nothing to disclose.
Category: Practice Management
Introduction: According to the American Society of Plastic Surgery (ASPS), it is to the patient’s “advantage to seek a med spa under the supervision of a board-certified plastic surgeon” to be “directed in the best direction to achieve” their goals. Medical spas or “med spas” are facilities that offer traditional spa services, such as skincare and massages, in addition to medical aesthetic treatments, such as lip fillers and neurotoxin injections. Med spas have become an increasingly popular and profitable business in the last decade, prompting many types of providers to join the field. This study set out to define the current status of med spa ownership in Georgia, and whether or not satisfaction differs in plastic surgeons, non-plastic surgeon physicians, or nonphysician providers.
Objective: To determine whether there is a difference in customer satisfaction at med spas owned by different medical professionals.
Methods: Three researchers compiled a list of med spas in Georgia using Google Maps. Only businesses who mentioned “medical spa” or “med spa” in their website were included. The owner’s occupation, the presence of a medical director, as well as services provided were recorded as provided by the med spa’s website. Customer ratings from Google, Facebook, and Yelp were collected. SAS 9.4 was used to perform Dwass, Steel, Critchlow-Fligner multiple comparison procedure.
Results: A total of 115 Georgia med spas were included in our study and 35% of those are concentrated in Atlanta. In all, 43.5% are owned by a physician. Of the med spas owned or overseen by a physician, they were most commonly trained in plastic surgery (27.8%), family medicine (16.7%), or internal medicine (13.9%). Roughly 17% of med spas do not have an owner listed, and when they are owned by nonphysicians, the majority (64%) of med spas do not have a listed medical director. When comparing the med spas of plastic surgeons, other physicians, and nonphysicians, average review scores do not statistically differ; however, plastic surgeons offer significantly more services (P = .018). The most popular services offered at med spas in Georgia are neurotoxin injections, filler, chemical peels, and facials.
Conclusion: Currently, many Georgia med spas are owned by plastic surgeons. However, they share the field with physicians of mainly nonsurgical specialties including internal and family medicine, as well as estheticians, nurses, and mid-level providers. Although med spas owned by plastic surgeons are recommended by ASPS, owner occupation does not appear to have a significant impact on online customer reviews. However, med spas owned by plastic surgeons do offer significantly more services, which can be a persuasive factor. Of note, though the state of Georgia identifies med spas as medical facilities that require ownership or supervision by a physician, most med spas owned by nonphysicians will not have a listed medical director on their business website. This is concerning because, although the booming med spa business will unquestionably allure providers of all kinds, it is in the best interest of Georgia residents’ safety to ensure all rules and regulations are followed and monitored.
Take-Home Message: Many Georgia med spas are owned by plastic surgeons. However, they share the field with physicians of mainly nonsurgical specialties, as well as estheticians, nurses, and mid-level providers. Although med spas owned by plastic surgeons are recommended by ASPS, owner occupation does not appear to have a significant impact on online customer reviews. Med spas owned by plastic surgeons do offer significantly more services, which can be a persuasive factor.
