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BACKGROUND: There has been an increase in body contouring procedures following massive weight loss (MWL), including male breast reduction procedures. Treating male chest deformity after MWL using standard mastopexy techniques often leads to suboptimal results. OBJECTIVES: The authors describe a technique to treat pseudogynecomastia using a modified elliptical excision and nipple-areola complex (NAC) transposition on a thinned inferior dermal pedicle as an alternative to conventional techniques. METHODS: A retrospective chart review from January 2011 to January 2019 identified a total of 14 male patients who underwent excision of pseudogynecomastia using the described technique. RESULTS: Patients were characterized by age, method of weight loss, pre-weight loss body mass index (BMI), post-weight loss BMI, total weight loss, grade of pseudogynecomastia, and concurrent procedures performed. Patients were followed for a period ranging from 3 months to 1.5 years (average, 8.1 months). Pre-weight loss BMI and post-weight loss BMI averaged 52.0 kg/m2 and 29.6 kg/m2, respectively. The average weight lost was 79.72 kg and the average total amount of tissue removed was 2615 g. All patients had concurrent procedures with an average operative time of 274 minutes. Four out of 14 patients (28.6%) experienced minor complications, which included asymmetry, delayed wound healing, seroma, and hyperpigmentation. There were no wound infections, hematomas, flap necrosis, or dysesthesia. CONCLUSIONS: Due to several cosmetic advantages and low complication profile, our technique using a modified elliptical excision and NAC transfer on an inferior dermal pedicle is an attractive option for treating male chest deformity after MWL.

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Many rhinoplasty patients present with a chief complaint of nasal deviation and are unaware of any inherent facial asymmetries; however, recognizing and discussing the interrelation between the deviated nose and facial asymmetry is an important consideration in surgical planning. The objective of this study was to evaluate whether a surgeon's subjective assessment of facial analysis in the setting of nasal deviation correlates with objective anthropometric measurements. In addition, this study sought to further quantify the frequency of facial asymmetry associated with nasal deviation to highlight important anatomical trends for the rhinoplasty surgeon. Finally, this study presents the senior author's (R.J.R.) method of addressing a deviated nose on an asymmetric face. In this study, the authors demonstrated that nasal deviation is closely related to facial asymmetry. Furthermore, the authors demonstrated that objective facial analysis closely correlates to anthropometric facial measurements. In addition, the wide side of the face correlates to the short side of the face and the nose tends to deviate away from the wide side of the face. During surgical correction of the deviated nose in the setting of facial asymmetry, the surgeon's goal should be to obtain nasal symmetry and center the nose on a line between the mid glabella and the mid Cupid's bow. This may reduce the perception of a facial asymmetry, leading to increased patient satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

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BACKGROUND: Smooth, round, silicone implants predominate device-based breast reconstruction in the USA; despite their prevalence, complications can include bottoming out, superior contour deformity, rippling, and/or lateral malposition. This complication profile increases the need for revision surgery and subsequent patient dissatisfaction. With the resurgence of shaped, textured, silicone implants in the USA, we report the senior author's success with these devices and outline a strategy to optimize outcomes in breast reconstruction surgery. METHODS: A retrospective chart review was conducted on a prospectively collected IRB-approved database of nipple-sparing mastectomies (NSMs) with immediate breast reconstruction with smooth, round, silicone implants (Group A) in 2011 in comparison to textured, shaped, silicone implants (Group B) in 2012. Changes in operative technique were highlighted and extrapolated. Outcomes were reviewed. RESULTS: In Group A, 128 NSMs were performed in 76 patients. In Group B, 109 NSMs were performed in 59 patients. Thirteen percent of patients in Group A had direct to implant reconstruction as compared with 21% in Group B. Patients with textured, shaped implants were more likely to have acellular dermal matrix (61 vs 34%, p < 0.0001) than those with smooth, round implants. Patients who had smooth, round implants were more likely to have postoperative nipple malposition (18 vs 0%, p < 0.0001,) and rippling (29 vs 0%, p < 0.0001.) Patients with textured, shaped implants had fewer operative revision reconstructions as compared with those with smooth, round implants (36.71 vs 12.8%, p < 0.0001) Based on these results, our technique has evolved and has eight key technical modifications. CONCLUSION: With a few adaptations in surgical technique, the transition to textured, shaped, silicone devices for breast reconstruction can be seamless with superior breast contour and reduced complications/revision rates. LEVEL OF EVIDENCE IV: 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 www.springer.com/00266 .

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The use of neuromodulators has increased by approximately 748 percent from 2000 to 2014 and has become an integral adjunct for facial rejuvenation. Knowledge of facial anatomy, accurate facial analysis, and familiarity with neurotoxin characteristics will minimize complications and optimize results. Current U.S. Food and Drug Administration-approved neurotoxins in the United States include onabotulinumtoxin A (Botox), abobotulinumtoxin A (Dysport), and incobotulinumtoxin A (Xeomin). The dosage and effect of these products are not interchangeable, so practitioners should master the utility and response of one product before trying the other products. All products have equivalent success in appropriately trained hands; the senior author (R.J.R.) favors no particular neurotoxin. This article provides a stepwise approach to treat dynamic facial rhytides with neuromodulators, including indications, facial analysis, preparation and injection technique, post-procedure care, and complications.

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Upper arm contouring is based on the location and amount of excess skin and fat. The short-scar brachioplasty addresses minimal to moderate skin laxity and lipodystrophy in the proximal arm in patients with appropriate skin tone and quality. This article highlights technical refinements of the senior author's (R.J.R.) approach to short-scar medial liposuction-assisted brachioplasty to maximize results and minimize incision length. To highlight this simple and safe approach with high patient/surgeon satisfaction, the authors discuss the following in this Video Plus article: patient examination, preoperative assessment, surgical pearls, and postoperative outcomes.

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Fillers temporarily augment deflated or ptotic facial compartments to restore a youthful appearance. Hyaluronic acids predominate the fillers market because of their focal volumization, duration of effect, low incidence of adverse reactions, and reversibility. Being able to properly perform these in-office procedures will ensure safety for patients and provide aesthetically optimal results. This communication provides the senior author's (R.J.R.) stepwise approach to facial aging and deflation with soft-tissue injectable fillers.

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Circumferential bodylift is a powerful procedure for achieving dramatic and natural body contouring changes in the massive weight loss patient. The care of these patients has raised our awareness of several important issues including safety, nutritional status, skin quality, recurrent laxity, surgical steps, and postoperative scars. Integration of this knowledge with various technical modifications over the last 15 years has improved our care for this cohort. We have not only seen a rise in the number of surgeries performed, but also the development of principles, techniques, and details that the authors feel necessary to share to achieve improved contour and more predictable outcomes. LEVEL OF EVIDENCE 4: Therapeutic.

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BACKGROUND: High-tension lateral abdominoplasty provides ideal central contouring of the abdomen, but it inadequately addresses laxity and fullness in the flank and lateral thigh. The adjunct of liposuction improves abdomen contour, but excess flank soft tissue often persists. Small case series in the literature have suggested an extended abdominoplasty to address these deficits with variable outcomes. The senior author (S.T.H.) reports his successes in the largest series to date of a 270-degree extended lipoabdominoplasty (cosmetic body lift) for non-massive weight loss patients to optimally contour the abdomen, hips, and flanks while lifting the lateral thigh and reducing thigh circumference. METHODS: A retrospective chart review was conducted on patients who had a cosmetic body lift between 2004 and 2014. On average, outcomes were reviewed 1 year postoperatively. RESULTS: From 2004 to 2014, 72 consecutive patients (one male patient) with an average age of 53 years (range, 33 to 73 years) had a cosmetic body lift. All patients were nonsmokers and had insignificant preoperative comorbidities. Average total liposuction volume was 3067 cc. Complications included seroma in 2.8 percent (two of 72), infection in 4.2 percent (three of 72), delayed wound healing in 5.6 percent (four of 72), necrosis/ischemia in 4.2 percent (three of 72), revision in 18.1 percent (13 of 72), and deep vein thrombosis in 1.4 percent (one of 72), with zero hematomas. CONCLUSIONS: This investigation is the largest series to date to evaluate the cosmetic body lift for the non-massive weight loss population. Consistent with reported complication rates of lipoabdominoplasty in the literature, the cosmetic body lift is a safe and effective operation for optimal waist contouring. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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BACKGROUND: Alar rim deformities such as retraction, notching, collapse, and asymmetry are common problems in rhinoplasty patients. Although alar rim deformities may be improved through rhinoplasty, this area is prone to late changes because of scarring of the soft triangles and a paucity of native structural support. The purpose of this study was to analyze the effect of alar contour grafts on primary rhinoplasty. METHODS: Fifty consecutive primary rhinoplasty patients with preoperative and postoperative photographs who received alar contour grafts were evaluated for alar aesthetics; 50 consecutive primary rhinoplasty patients without such grafts served as controls. Differences among alar retraction, notching, collapse, and asymmetry from anterior, lateral, and basal views were evaluated. Follow-up ranged from 1 to 4 years and was graded on a four-point scale. RESULTS: The average difference between the two groups' aggregate preoperative scores was 0.21 (p = 0.24). The average preoperative and postoperative scores in the nongraft group were significant for worsening retraction, notching, and collapse but insignificant for asymmetry. The preoperative and postoperative scores for the graft group were insignificant for retraction but improved significantly for notching, collapse, and asymmetry. Postoperatively, the aggregate average of the scores in the nongroup was 0.32 points worse (p < 0.01), whereas the graft group had a 0.33-point improvement (p < 0.01). CONCLUSIONS: Alar contour grafts have a clear and important impact on cosmetic results of primary rhinoplasty. Use of alar contour grafts has been shown to improve aesthetics, whereas there is a worsening of the measured parameters postoperatively without use of these grafts. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

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The aging hand is characterized by skin changes and soft-tissue deflation, which leads to rhytides, dermal atrophy, and distinct anatomical structures. Soft-tissue deflation and prominent hand anatomy can be corrected with volume augmentation using dermal fillers or lipofilling. Fat transfer volumizes the hand with prolonged durability and efficacy, autologous tissue replacement, and possible dermal regeneration. The senior author's (R.J.R.) technique for hand rejuvenation is described, which uses minimal access and blunt dissection to effectively augment the soft-tissue compartments of the hand. This approach addresses the prominent aged anatomy of the hand, providing excellent contour and aesthetic outcomes.

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LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Identify the essential anatomy of the aging face and its relationship to face-lift surgery. 2. Understand the common operative approaches to the aging face and a historical perspective. 3. Understand and describe the common complications following face lifting and treatment options. SUMMARY: Surgical rejuvenation of the aging face remains one of the most commonly performed plastic surgery procedures. This article reviews the anatomy of the face and its impact on surgical correction. In addition, this review discusses the evolution of various face-lift techniques and the current surgical approach to the aging face. Finally, this article discusses potential postoperative complications after rhytidectomy and management solutions.

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Breast augmentation remains one of the most commonly performed plastic surgical procedures worldwide; however, Food and Drug Administration clinical trials have suggested that this procedure has a reoperation rate of 14% to 24% after 3 years. Recent literature has proposed that breast augmentation should not only be a surgical procedure but ultimately a surgical process to reduce postoperative complications and enhance patient satisfaction. The process of breast augmentation has been documented to optimize postsurgical outcomes and includes the following 4 steps: patient education, tissue-based planning, refined surgical techniques, and defined postoperative management.

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BACKGROUND: Autologous fat transfer to the deep compartments of the face has proven to be a powerful adjunct to volume restoration during rhytidectomy. However, to treat all components of volume deflation in facial aging, the perioral superficial compartments must be addressed. Various fillers have been used to augment these compartments; however, few studies have assessed the efficacy of autologous fat transfer to these areas. This study is the largest series to date to assess the utility of autologous fat transfer to the perioral superficial compartments. METHODS: A retrospective chart review was conducted on an individualized component rhytidectomy database. Patients who underwent autologous fat transfer to the perioral superficial fat compartments were identified; patients who did not undergo autologous fat transfer served as controls. All patients had follow-up images that had been obtained a minimum of 1 year postoperatively. Three independent observers reviewed preoperative and postoperative images using the Modified Fitzpatrick Wrinkle Scale. RESULTS: Sixty-five consecutive patients underwent rhytidectomy without perioral rejuvenation (group A), and 65 patients underwent rhytidectomy with autologous fat transfer to the perioral superficial compartments (group B). Group B had a two times more significant improvement in perioral aesthetics than group A. CONCLUSIONS: This study is the largest review to date demonstrating safety, longevity, and success of autologous fat as an ideal filler of the perioral superficial compartments. In light of the aesthetic improvements with autologous fat transfer to the perioral region, this surgical adjunct should be a fundamental component to achieve global facial rejuvenation during rhytidectomy.

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Three-dimensional surface imaging has gained clinical acceptance in plastic and reconstructive surgery. In contrast to computed tomography/magnetic resonance imaging, three-dimensional surface imaging relies on triangulation in stereophotography to measure surface x, y, and z coordinates. This study reviews the past, present, and future directions of three-dimensional topographic imaging in plastic surgery. Historically, three-dimensional imaging technology was first used in a clinical setting in 1944 to diagnose orthodontologic conditions. Karlan established its use in the field of plastic surgery in 1979, analyzing contours and documenting facial asymmetries. Present use of three-dimensional surface imaging has focused on standardizing patient topographic measurements to enhance preoperative planning and to improve postoperative outcomes. Various measurements (e.g., volume, surface area, vector distance, curvature) have been applied to breast, body, and facial topography to augment patient analysis. Despite the rapid progression of the clinical applications of three-dimensional imaging, current use of this technology is focused on the surgeon's perspective and secondarily the patient's perspective. Advancements in patient simulation may improve patient-physician communication, education, and satisfaction. However, a communal database of three-dimensional surface images integrated with emerging three-dimensional printing and portable information technology will validate measurements and strengthen preoperative planning and postoperative outcomes. Three-dimensional surface imaging is a useful adjunct to plastic and reconstructive surgery practices and standardizes measurements to create objectivity in a subjective field. Key improvements in three-dimensional imaging technology may significantly enhance the quality of plastic and reconstructive surgery in the near future.

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