The latest medical research on Plastic Surgery

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The Development and Initial Validation of PUMC Localized Scleroderma Facial Aesthetic Index: A Pilot Study.

Aesthetic Plastic Surgery

Localized scleroderma (LoS) is an autoimmune connective tissue disorder leading to serious long-term aesthetic impairment on patients. Objective evaluation methods are badly needed to facilitate the evaluation of the surgical treatment on individual patients and clinical studies.

To develop and assess the reliability and validity of Peking Union Medical College LoS facial aesthetic index (PUMC LoSFAI).

Twelve experts devoted their time and resources in the development and validation. LoS patients in the stable phase were recruited. Reliability and validity was then assessed. LoS patients were evaluated by two plastic surgeons using PUMC LoSFAI and LoS skin damage index (LoSDI). The PUMC LoSFAI comprises 4 domains for the local assessment (surface area of lesion, dyspigmentation, skin thickness and soft tissue atrophy) and 3 domains for the overall assessment (facial symmetry, proportion and profile) to describe LoS facial aesthetic impairment. Face-Q was completed by patients at each visit.

Thirty-two LoS patients had 96 visits, during which 138 lesions were assessed. PUMC LoSFAI and 7 domains demonstrated substantial to excellent inter- and intra-rater reliability (ICC 0.995, κw 0.72-0.91, r 0.85-0.99, respectively). Seven domains considered to be important to extremely important variables (mean rank 3.2-3.8) had high I-CVI (> 0.78) and S-CVI (0.93). PUMC LoSFAI correlated excellently with LoSDI (r = 0.933, P < 0.001), and correlated fairly with Face-Q (r = - 0.399, P = 0.001).

PUMC LoSFAI was developed and evaluated to play as a tool of aesthetic impairment assessment for LoS patients, which may facilitate the evaluation of the treatment on individual patients and clinical studies. PUMC LoSFAI demonstrated high reliability and validity, and further study in larger patient samples is needed to confirm these preliminary findings.

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors .

The Efficacy of Cell-Assisted Lipotransfer Versus Conventional Lipotransfer in Breast Augmentation: A Systematic Review and Meta-Analysis.

Aesthetic Plastic Surgery

Cell-assisted lipotransfer (CAL) is novel and controversial technique for breast augmentation.

This review and meta-analysis aimed to assess the clinical efficacy of CAL as compared with conventional lipotransfer.

PubMed databases were searched with no restrictions for randomized controlled trials (RCTs) and observational studies with control groups. Keywords included "fat graft," "lipotransfer," "lipofilling," "autologous fat," "fat transplantation," "stromal vascular fraction (SVF)," "stem cell," "adipose tissue-derived stromal cell (ADSC)," "adipose tissue-derived stromal cell (ASC)," "called adipose derived progenitor cells (ADRC)," "cell-assisted," "progenitor-enriched," "cell-enhanced" and "breast." Review Manager software (RevMan, version 5.3) was used to compute the pooled effect estimates for fat survival rate and complication rates. Outcomes were expressed as standard mean differences (SMDs) or odds ratios (ORs) and 95% confidence intervals (CIs). Subgroup analyses were performed based on different methods of cell-enhanced fat preparation.

Six studies were included (ntotal = 353 adult patients). The fat survival rate was significantly higher in the CAL group than in the control group (SMD = 1.79, 95% CI = 0.28, 3.31; P = 0.02). There were no significant differences in complication rates between the CAL group and the control group (OR = 1.34, 95% CI = 0.65, 2.73; P = 0.43). Subgroup analyses found no significant differences between the SVF and control groups in fat survival rate (SMD = 1.52, 95% CI = -0.21, 3.24; P = 0.08) among both manual and automatic subgroups (P = 0.28 and P = 0.10, respectively). The data analysis showed a significant heterogeneity between manual and automatic subgroups (I2 = 57.0%, P = 0.15).

This study suggests that cell-assisted lipotransfer is superior to conventional lipotransfer for improved fat survival rate in breast augmentation. However, analyses comparing the SVF-enhanced fat graft with the conventional fat graft noted no differences in fat survival rate. It is necessary to determine which protocol is most beneficial for patients, establish standardized methods of SVF isolation or adipose tissue-derived stromal cells (ADSCs) culture, and a constant percentage of injected cells in the graft. The long-term efficacy and safety of CAL should also be evaluated in further studies, and additional RCTs with larger sample sizes and better comparability are needed.

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors

Trinity Lift: A Unique Technique for Endoscopic Midface and Lower Periorbital Unit Lift.

Aesthetic Plastic Surgery

A harmonious face is defined in terms of a balanced relationship among all facial tissues. This balance among skin, fat, muscle, and bone is lost with aging as progressive changes occur in their volume, shape, position, and consistency. Aging of the human face generally starts in the third decade of life, mainly in the midface and periorbital areas. Traditional face-lifting surgeries result in minimal improvements in the midface area. Various techniques have been developed using different dissection planes and vectors with different forms of incision, including endoscopic techniques.

We attempted to combine endoscopic subperiosteal dissection techniques with the percutaneous needle technique, especially in young- to middle-aged patients. We aim to share technical details of our preferred suspension and fixation method for an endoscopic midface lift with the aid of a percutaneous needle and to present the outcomes of this particular technique in 75 patients.

Significant rejuvenation of the nasojugal groove was achieved, and patient satisfaction was high. All cases exhibited satisfactory, symmetrical, and stable elevation of the midface. None of the patients required a second surgery.

Trinity lift allowed for stronger, easier, and faster application of sutures during endoscopic facial surgery without any other mucosal or transcutaneous incisions.

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors .

Postdischarge Virtual Visits for Low-risk Surgeries: A Randomized Noninferiority Clinical Trial.

JAMA Surgery

Postdischarge video-based virtual visits are a growing aspect of surgical care and have dramatically increased in the setting of the coronavirus disease 2019 (COVID-19) pandemic.

To evaluate the outcomes of all-cause 30-day hospital encounter proportion among patients who have a postdischarge video-based virtual visit follow-up compared with in-person follow-up.

Randomized, active, controlled noninferiority trial in an urban setting, including patients from a small community hospital and a large, tertiary care hospital. Patients who underwent minimally invasive appendectomy or cholecystectomy by a group of surgeons who cover emergency general surgery at these 2 hospitals were included. Patients undergoing elective and nonelective procedures were included.

Patients were randomized in a 2:1 fashion to video-based virtual visit or in-person visit.

The primary outcome is the percentage of patients with 30-day hospital encounter, and we hypothesized that there would not be a significant increase in the 30-day hospital encounter proportion for patients who receive video-based virtual postdischarge care compared with patients who receive standard (in-person) care. Hospital encounter includes emergency department visit, observation, or inpatient admission.

A total of 1645 patients were screened; 289 patients were randomized to the virtual group and 143 to the in-person group. Fifty-three patients crossed over to the in-person follow-up group. The percentage of patients who had a hospital encounter was noninferior for virtual visits (12.8% vs 13.3% for in-person, Δ 0.5% with 1-sided 95% CI, -∞ to 5.2%). The amount of time patients spent with the clinician (mean of 8.4 minutes virtual vs 7.8 minutes in-person; P = .30) was not different, but the median overall postoperative visit time was 27.5 minutes shorter (95% CI, -33.5 to -24.0).

Postdischarge video-based virtual visits did not increase hospital encounter proportions and provided shorter overall time commitment but equal time with the surgical team member. This information will help surgeons and patients feel more confident in using video-based virtual visits. Identifier: NCT03258177.

Racial Disparities in the Use of Surgical Procedures in the US.

JAMA Surgery

The largest US federal action plan to date for reducing racial disparities in health care was implemented in 2011 and continues today. It is not known whether this program, along with other initiatives, is associated with a decrease in racial disparities in the use of major surgical procedures in the US.

To analyze whether national initiatives are associated with improvement in racial disparities between White and Black patients in the use of surgical procedures in the US.

In this case-control study, the national rates of use for 9 major surgical procedures previously shown to have racial disparities in rates of performance between White and Black adult patients (including angioplasty, spinal fusion, carotid endarterectomy, appendectomy, colorectal resection, coronary artery bypass grafting, total hip arthroplasty, total knee arthroplasty, and heart valve replacement) were analyzed from January 1, 2012, through December 31, 2017. Data analysis was conducted from May 1 to June 30, 2020. Population- and sex-adjusted procedural rates during the study period were examined and standardized based on all-payer insurance status. Racial changes were further analyzed by US census division and hospital teaching status for 4 selected procedures: coronary artery bypass grafting, carotid endarterectomy, total hip arthroplasty, and heart valve replacement.

Population- and race-adjusted procedural rates by year, US census division, hospital teaching status, and insurance status.

This study included national inpatient data from 2012 to 2017. In 2012, the national incidence rate of all 9 major surgical procedures was higher in White than in Black individuals. For example, the incidence rate of total knee arthroplasty in 2012 for White males was 184.8 per 100 000 persons and for Black males was 79.8 per 100 000 persons. By 2017, these racial disparities persisted for all 9 procedures analyzed. For example, the incidence rate of total knee arthroplasty in 2017 for White males was 220.5 per 100 000 persons and for Black males was 95.6 per 100 000 persons. Although the disparity gap between White and Black patients narrowed for angioplasty (-20.1 per 100 000 persons in males, -4.2 per 100 000 persons in females), spinal fusion (-7.7 per 100 000 persons in males, -15.0 per 100 000 persons in females), carotid endarterectomy (-4.3 per 100 000 persons in males, -4.6 per 100 000 persons in females), appendectomy (-12.3 per 100 000 persons in males, -12.2 per 100 000 persons in females), and colorectal resection (-9.0 per 100 000 persons in males, -12.7 per 100 000 persons in females), the disparity remained constant for coronary artery bypass grafting and widened for 3 procedures, total hip arthroplasty (11.6 per 100 000 persons in males, 20.8 per 100 000 in females), total knee arthroplasty (19.9 per 100 000 persons in males, 12.0 per 100 000 persons in females), and heart valve replacement(12.4 per 100 000 persons in males, 9.2 per 100 000 persons in females). In 2017, racial differences persisted in all US census divisions and in both urban teaching and urban nonteaching hospitals. When rates were adjusted based on insurance status, Black patients with Medicare, Medicaid, and private insurance underwent lower rates of all procedures analyzed compared with White patients. For example, rate of spinal fusion in Black patients was 70.2% of the rate in White patients with Medicare, 56.5% to that of White patients with Medicaid, and 61.2% to that of White patients with private insurance.

Results of this study suggest that despite national initiatives, racial disparities have persisted for all analyzed procedures and worsened for one-third of the analyzed procedures. These disparities were evident regardless of US census division, hospital teaching status, or insurance status. Renewed initiatives to help diminish racial disparities and improve health care equality are warranted.

Surgical Plating vs Closed Reduction for Fractures in the Distal Radius in Older Patients: A Randomized Clinical Trial.

JAMA Surgery

The burden of injury and costs of wrist fractures are substantial. Surgical treatment became popular without strong supporting evidence.

To assess whether current surgical treatment for displaced distal radius fractures provided better patient-reported wrist pain and function than nonsurgical treatment in patients 60 years and older.

In this multicenter randomized clinical trial and parallel observational study, 300 eligible patients were screened from 19 centers in Australia and New Zealand from December 1, 2016, until December 31, 2018. A total of 166 participants were randomized to surgical or nonsurgical treatment and followed up at 3 and 12 months by blinded assessors. Those 134 individuals who declined randomization were included in a parallel observational cohort with the same treatment options and follow-up. The primary analysis was intention to treat; sensitivity analyses included as-treated and per-protocol analyses.

Surgical treatment was open reduction and internal fixation using a volar-locking plate (VLP). Nonsurgical treatment was closed reduction and cast immobilization (CR).

The primary outcome was the Patient-Rated Wrist Evaluation score at 12 months. Secondary outcomes were Disabilities of Arm, Shoulder, and Hand questionnaire score, health-related quality of life, pain, major complications, patient-reported treatment success, bother with appearance, and therapy use.

In the 300 study participants (mean [SD] age, 71.2 [7.5] years; 269 [90%] female; 166 [81 VLP and 85 CR] in the randomized clinical trial sample and 134 [32 VLP and 102 CR] in the observational sample), no clinically important between-group difference in 12-month Patient-Rated Wrist Evaluation scores (mean [SD] score of 19.8 [21.1] for VLP and 21.5 [24.3] for CR; mean difference, 1.7 points; 95% CI -5.4 to 8.8) was observed. No clinically important differences were found in quality of life, wrist pain, or bother at 3 and 12 months. No significant difference was found in total complications between groups (12 of 84 [14%] for the CR group vs 6 of 80 [8%] for the VLP group; risk ratio [RR], 0.53; 95% CI, 0.21-1.33). Patient-reported treatment success favored the VLP group at 12 months (very successful or successful: 70 [89%] vs 57 [70%]; RR, 1.26; 95% CI, 1.07-1.48; P = .005). There was greater use of postoperative physical therapy in the VLP group (56 [72%] vs 44 [54%]; RR, 1.32; 95% CI, 1.04-1.69; P = 0.02).

This randomized clinical trial found no between-group differences in improvement in wrist pain or function at 12 months from VLP fixation over CR for displaced distal radius fractures in older people. identifier: ACTRN12616000969460.

Use of an Orbital Septum Flap for Correcting Severe Blepharoptosis.

Aesthetic Plastic Surgery

Several surgical procedures are available for the treatment of severe blepharoptosis with poor levator function. However, the procedures have advantages and disadvantages. Particularly, complications such as lagophthalmos and lid lag are commonly observed after conventional interventions. Thus, the present study aimed to introduce a surgical technique that uses an orbital septum flap without the orbital oculi muscle for the correction of severe blepharoptosis.

The technique utilizes the orbital septum flap, which is connected with the frontalis muscle via the galea aponeurosis and frontal periosteum, to suspend the tarsal plate. In this case series, the technique was used for the correction of blepharoptosis in 16 eyes from 12 patients.

The margin reflex distance in all patients improved at 6 months after surgery. Two patients presented with lagophthalmos and three with mild recurrence. However, revision surgery was not required, and none of patients presented with lid lag.

For the correction of blepharoptosis, the use of the orbital septum flap without the orbital oculi muscle can be easily selected compared with other conventional methods that are more likely to cause overcorrection and closure disorders.

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors .

Application of Three-Dimensional Imaging in Asian Rhinoplasty with Costal Cartilage.

Aesthetic Plastic Surgery

3D computer-simulated technology is becoming popular in China. Rhinoplasty with costal cartilage is a good option for Asians. However, the application of 3D imaging in Asian rhinoplasty with costal cartilage has not been systematically assessed.

To analyze the effect of 3D imaging in Asian rhinoplasty with costal cartilage.

In this study, 44 patients were included and randomly divided into 3D and non-3D imaging groups. We performed a prospective survey on the aesthetic scores for preoperative, simulated, and postoperative images and calculated the relative nasal index scores of patients in both groups. Additionally, surveys on satisfactions with surgical outcomes and doctor-patient communication in both groups were conducted.

The actual postoperative result was well consistent with the preoperative simulation result. The 3D computer simulation did not impact the satisfaction with surgical outcomes but increased that with doctor-patient communication. The 3D computer-simulated technology was an effective tool for doctor-patient communication and surgery planning in Asian rhinoplasty with costal cartilage.

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors .

The Anatomical Study of the Nasal Septal Cartilage with its Clinical Implications.

Aesthetic Plastic Surgery

Several rhinoplasty and nasal reconstruction procedures require cartilage. Various studies have reported on the nasal septal cartilage as a donor site for Caucasian and Asian populations. However, studies regarding the Thai nasal septal cartilage dimensions are rare. This study aimed to examine the length, height, area, and thickness of the nasal septal cartilage, along with implications of the size and quantity of the available cartilage, for grafting in Thai cadavers.

We analyzed the nasal septal cartilage in 42 Thai cadavers. The length, height, area, and thickness were digitally measured using ImageJ 1.52 software, along with the size and area of the available cartilage for grafting after preserving a 10-mm L-strut. Data were compared between sexes.

The mean height, length, and area of the nasal septal cartilage were 30.96 ± 5.90 mm, 26.13 ± 6.90 mm, and 636.10 ± 196.13 mm2, respectively. The length did not differ significantly between sexes. However, the height and area in male cadavers were greater than those in female cadavers. The mean thickness ranged from 0.77 to 1.02 mm depending on the area, with the thickest and thinnest areas being the superoposterior and inferoposterior parts, respectively. The mean height, length, and area of the harvestable cartilage were 20.96 mm, 16.13 mm, and 384.84 mm2, respectively, after excluding the L-strut.

Our results provide major anatomical data of the Thai nasal septal cartilage. Its implication for use of the septal cartilage for grafting is 21 mm in height and 16 mm in length, which is sufficiently safe to maintain nasal support.

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors

Harvesting Split Costal Cartilage Graft in Revision Rhinoplasty Without Disturbing the Costal Integrity.

Aesthetic Plastic Surgery

Graft use is inevitable in some primary and secondary rhinoplasty cases with cartilage or bone deficiency. Although rib graft is one of the best graft sources, it has several disadvantages. The purpose of this study is to minimize the risks of using rib grafts.

Between 2018 and 2020, a total of 21 patients aged between 25 and 55 have undergone revision rhinoplasty under general anesthesia with a split cartilage graft of central origin. A 3-4-mm-thick bridge was left at the superior and inferior edges of the donor area, and the graft was harvested from the central region without disrupting the costal integrity. A special retractor was placed between the perichondrium and the rib at the posterior of the costa to prevent damage to the pleura while cutting the rib. The previously marked grafts were cut in the donor area and harvested ready for use. The harvested grafts were used as spreader, strut, alar rim and nasal valve grafts.

None of the patients had complications due to rib graft harvesting. After the operation, pain in the donor region and analgesic requirement of these patients were less compared to the patients with full-layer grafts.

The grafts taken from the center of the costa without breaking its integrity seem quite suitable for revision rhinoplasty surgeries. This technique prevents various morbidities and enables patients to have a more comfortable postoperative period.

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors .

A Modified Superior Pedicle Mastopexy Technique With an Inferolateral-Based Auto Augmentation Flap.

Aesthetic Plastic Surgery

Current mastopexy techniques have evolved to decrease scar length and maintain a more consistent upper pole fullness, improving the breast shape. Many different approaches have tried to suspend breast tissues to achieve a more attractive upper pole. Most of the auto-augmentation mastopexy techniques use inferior-based breast parenchymal tissues to fill the upper part.

This paper presents a modified approach to fill the breast's upper pole, with an inferolateral-based breast flap. The advantages of changing the inferior-based auto-augmentation technique to the inferolateral comprise improving blood supply and increasing repositioned breast flap's mobility. In our technique, the breast tissue used to auto-augment the upper pole receives its blood supply from pectoral perforators and lateral breast tissue. When surgeons need more flap mobility, they can raise the medial edge of this flap from the pectoral fascia to mobilize this flap higher on the chest wall, depending on the lateral blood supply. One other advantage is that when the inferolateral-based breast tissue is pulled in a superomedial direction to fill the upper part, the lateral ptotic breast tissues come closer to the breast meridian to meet with medial breast parenchyma easily. The tension on the vertical parenchymal suture line is reduced with this approach.

Our technique can be used in most mastopexy operations and for all types of ptosis except for cases with insufficient breast volume. It brings safety to the auto-augmentation procedure and is also time-saving. The stability of breast shape and upper pole fullness lasts as long as other auto-augmentation procedures; therefore, it can be an excellent alternative to other techniques.

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors .

Rapamycin and 3-Methyladenine Influence the Apoptosis, Senescence, and Adipogenesis of Human Adipose-Derived Stem Cells by Promoting and Inhibiting Autophagy: An In Vitro and In Vivo Study.

Aesthetic Plastic Surgery

We aimed to clarify the changes in apoptosis, proliferation, senescence, and adipogenesis after promoting and inhibiting autophagy in adipose-derived stem cells (ADSCs) by rapamycin and 3-methyladenine in vitro and in vivo.

After rapamycin and 3-methyladenine pretreatment, ADSC autophagy was detected by immunofluorescence for LC3, RT-PCR for ATG genes, and western blotting (WB) for the LC3 II/I and p62 proteins. TUNEL staining, PCR of BAX, and WB of Caspase-3 were preformed to assess ADSC apoptosis. The adipogenesis of ADSCs was evaluated by Oil red O staining and PCR of PPAR-γ. CCK8 assays were conducted to detect proliferation. Senescence was tested by Sa-β-gal staining and PCR of the P16/ 19/21 genes. Moreover, the mass and volume retention rate were determined, and perilipin and CD31 staining were performed in vivo.

Rapamycin and 3-methyladenine pretreatment increased and decreased autophagy of ADSCs, respectively, under normal and oxygen-glucose deprivation conditions. Apoptosis and senescence of ADSCs were decreased, and adipogenesis was increased along with the upregulation of autophagy. However, the proliferation of ADSCs was inhibited after either rapamycin or 3-methyladenine pretreatment. In vivo, the volume and mass retention rate and the angiogenesis of the grafts were also improved after rapamycin pretreatment.

Rapamycin pretreatment reduced apoptosis, delayed senescence, and promoted adipogenesis of ADSCs. These effects were inhibited by 3-methyladenine, indicating that the changes may be mediated by autophagy. Moreover, the survival rate and angiogenesis of the grafts were increased after upregulation of ADSC autophagy in vivo, which may help improve the efficiency of clinical fat transplantation.

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors .