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BACKGROUND: Biologic mesh in the form of allograft or xenograft products have been used in complicated abdominal hernia repair, but few comparative studies exist. METHODS: A systematic review of original incisional hernia studies was conducted to include 2 primary end points: hernia recurrence and surgical site occurrence. Analysis of variance and a Satterthwaite t test compared the devices. RESULTS: Twenty-nine studies were included in this analysis, which included 1,257 patients. The total number of studies and the total subjects for each device include the following: Permacol (Tissue Science Laboratories, Hampshire, UK) (4/64), Surgisis (Cook Medical, Bloomington, IN) (3/87), and Alloderm (LifeCell, Corp, Branchburg, NJ) (23/1,106). Device-specific recurrence rates and surgical site occurrence rates, respectively, were as follows: Alloderm (20.8%, 31.4%), Permacol (10.9%, 25%), and Surgisis (8.0%, 40.2%). A Satterthwaite t test comparison revealed significantly higher numbers of hernia recurrence (P = .006) and surgical site occurrence (P = .04) when comparing Alloderm with Permacol. CONCLUSIONS: Biologic mesh does play a beneficial role in abdominal wall reconstruction although allograft acellular dermal matrix does have a higher recurrence rate as compared with xenograft products, which limits its current role in hernia repair.

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BACKGROUND: The senior author's (H.S.B.) endoscopic brow and midface lift technique has a series of periorbital suture points. This study evaluated the efficacy of endoscopic treatment of the difficult lower eyelid and identifies the preoperative predictive patterns for additional suture placement and ancillary procedures within this population. METHODS: Patients who underwent endoscopic brow and midface lift performed by the senior author were stratified into categories of preoperative lower eyelid morphologies, including lower eyelid retraction, negative canthal tilt, negative vector orbit, exorbitism, and a deep tear trough. Intraoperative treatment and postoperative course were recorded and postoperative photographs were evaluated objectively. The data were analyzed to determine preoperative predictive patterns of endoscopic lower eyelid treatment. RESULTS: Three hundred patients who underwent an endoscopic brow and midface lift between 1999 and 2008 were included in the study, with an average follow-up of 1 year. Most patients were treated with endoscopic orbicularis oculi repositioning combined with midface elevation. Additional suture points were used in 12 percent, with preexisting scleral show being the most common indication for additional endoscopic suture placement. There were no cases of postoperative lower eyelid retraction. Skin resurfacing and volumetric filling were the most common revision procedures. CONCLUSIONS: The difficult lower eyelid can be treated effectively with endoscopic orbicularis repositioning and midface elevation. This technique preserves the innervation and continuity of the orbicularis oculi muscle, decreasing postoperative complications. Additional suture application is needed in only a minority of patients, and ancillary lower eyelid procedures can be performed safely in the same operative setting.

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LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Recognize risk factors for venous thromboembolism and identify patients who would benefit from prophylactic anticoagulation; 2. Describe the effects of hypothermia in the perioperative period. 3. Understand the importance of blood pressure control in the plastic surgery patient. SUMMARY: This article provides a summary of important factors that contribute to improved patient safety in plastic surgery. The identification of patients and procedures that have an increased risk of complications enables the physician to carry out prophylactic measures to reduce the rate of these complications. Venous thromboembolism, hypothermia, bleeding diathesis, and perioperative hypertension are identifiable risks of plastic surgery, which can lead to significant morbidity and mortality. An evidence-based system and individual practice measures can help to decrease these risks. Thorough preoperative patient evaluation, detailed informed consent, and perioperative care delivered in a safe environment can contribute to improved safety in plastic surgery.

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BACKGROUND: Breast reconstruction using the deep inferior epigastric perforator (DIEP) flap is becoming more common and can help reduce donor site morbidity. The authors proposed that dissection of the deep inferior epigastric artery (DIEA) and vein (DIEV) to their external iliac source may not be required for safe flap transfer. METHODS: Sixteen whole fresh cadaveric hemiabdomens were used to dissect transverse abdominal-based flaps. Latex injection of the DIEA system was carried out, and the diameters of the DIEA/DIEV vessels were assessed at various points along the course of the pedicle from the origin to the perforator. A clinical study of 26 patients who underwent a short and ultrashort pedicle DIEP flaps was carried out. RESULTS: The average DIEA and DIEV vessel diameters were relatively similar from the external iliac origin to a point just caudal to the bifurcation. At the lateral rectus edge, the average DIEA diameter was 3.2 mm, and the DIEV diameter was 3.1 mm. The average pedicle length obtained with classic DIEP dissection was 16.9 cm, short-pedicle DIEP dissection 10.4 cm, ultrashort technique 8.1 cm, and free TRAM technique 6.5 cm. Venous injection study demonstrated rich venous interconnections between both venae comitantes. In their clinical study, the authors were able to achieve average pedicle lengths of 11.0 cm when transecting cranial to the lateral edge of the rectus, with average diameters of 2.5 mm (artery) and 2.9 mm (vein). CONCLUSION: Transection of the DIEA/DIEV pedicle at the lateral rectus edge or more proximally is safe and can help reduce operative time and donor-site morbidity. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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INTRODUCTION: In the facelift patient, uncontrolled perioperative hypertension is a difficult, acute condition that can lead to significant complications. Although the treatment of hypertension in the ambulatory medical setting has been standardized, its management in the cosmetic surgery setting has been ambiguous. OBJECTIVES: The authors evaluate the results of a survey to assess current national trends in perioperative facelift hypertension management. METHODS: A 13-question survey regarding perioperative hypertension management was sent by postal mail to 1776 members of the American Society for Aesthetic Plastic Surgery (ASAPS). Respondents were queried about their geographic location, caseload volume, facelift method, and hematoma rate. RESULTS: A 35.4% response rate was attained (629 respondents). Superficial musculoaponeurotic system (SMAS) plication performed under general anesthesia as an outpatient procedure was the most common facelift technique. Perioperative blood pressure management was consistent among all respondents. Beta-blockers were commonly utilized throughout the preoperative period. Administration of alpha agonists was reported more frequently by surgeons with higher-volume caseloads and more years in practice. Reported hematoma rates did not vary with medication. Medical treatment at an intraoperative systolic blood pressure (SBP) threshold below 100 (p < .04) and a postoperative SBP of greater than 139 (p < .05) significantly increased reported hematoma rates. CONCLUSIONS: The data generated from the survey suggest that the timing of treating hypertension deserves more attention than the actual medication administered. Proper perioperative care of the facelift patient is paramount in the reduction of hematoma rates. Preexisting hypertension correlates with a higher hematoma rate, though this study also suggests that normotensive anesthesia, as well as strict postoperative blood pressure control did contribute to a reduction in hematoma rate.

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BACKGROUND: The superficial musculoaponeurotic system (SMAS) has inherent viscoelastic properties, although the optimal tension levels to minimize tissue relaxation have not been defined. This study evaluated the viscoelastic properties of the SMAS within the biomechanical parameters of the high-SMAS rhytidectomy. METHODS: Patients (n = 30) underwent a high-SMAS face lift performed by the senior author (F.E.B.) with intraoperative tension at the superior (preauricular) and inferior (mastoid) points of SMAS fixation sequentially measured with a tensiometer. Fresh samples of lateral, preparotid SMAS were then harvested and evaluated ex vivo for bursting strength, stress relaxation, and creep. RESULTS: The force applied to the superior, preauricular SMAS intraoperatively (7.21 ± 0.87 N) was significantly lower than that of the inferior mastoid point of fixation (9.59 ± 1.8 N) (p < 0.001). The bursting force of the SMAS was 55.7 N, with the average bursting pressure of 224.97 PSI. The in vivo force applied to the SMAS was found to be only 15 percent of its total bursting strength. The deformational load of the high-SMAS face lift caused only a 14 percent creep in the tissue ex vivo. CONCLUSIONS: The in vivo tension in a high-SMAS face lift is predictable, with the force applied to the mastoid point being significantly greater than that of the superior preauricular point. This intraoperative force is only a fraction of the tissue's inherent bursting strength, contributing to the minimal stress relaxation and creep observed in this study. These biomechanical properties likely contribute to the effective and long-lasting correction of facial aging with the high-SMAS technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

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BACKGROUND: The use of liposuction combined with abdominoplasty has been controversial. The combination of techniques has been associated with an increased rate of venous thromboembolism and wound-healing complications. Through improvements in venous thromboembolism prophylaxis, refinements in liposuction techniques, and an understanding of anatomy, this cumulative risk has decreased, although the negative stigmata persist. This study describes the evolution of abdominal body contouring through a critical review of a single surgeon's 20-year experience with abdominoplasty. This clinical outcome analysis will highlight the significant contributions that have led to the improvement in the safety and efficacy of this technique. METHODS: A retrospective review of patients undergoing abdominoplasty procedures was performed. Patient demographics and procedural information, including postoperative course and complications, were recorded. Preoperative and postoperative photographs were scored by blinded evaluators for aesthetic result and scar quality. RESULTS: Two hundred fifty patients undergoing abdominoplasty from 1987 to 2007 were included in the study. The use of a "superwet" liposuction technique in combination with abdominoplasty significantly decreased intraoperative blood loss (p < 0.04) and length of hospital stay (p < 0.05). Liposuction volume and region had no significant effect on abdominoplasty outcome, although refinements in operative technique, including abdominal and flank ultrasound-assisted liposuction, high superior tension, and limited abdominal undermining, did improve the postoperative aesthetic score. Venous thromboembolic events significantly decreased with aggressive venous thromboembolism prophylaxis (p < 0.001). CONCLUSIONS: The technical evolution of a single surgeon's 20-year experience demonstrates that liposuction can be safely and effectively combined with abdominoplasty. Preoperative trunk analysis, intraoperative surgical refinements including superwet technique and ultrasound-assisted liposuction, and perioperative venous thromboembolism prophylaxis significantly improve the outcome of abdominoplasty.

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BACKGROUND: The frontal branch has a defined course along the Pitanguy line from tragus to lateral brow, although its depth along this line is controversial. The high-superficial musculoaponeurotic system (SMAS) face-lift technique divides the SMAS above the arch, which conflicts with previous descriptions of the frontal nerve depth. This anatomical study defines the depth and fascial boundaries of the frontal branch of the facial nerve over the zygomatic arch. METHODS: Eight fresh cadaver heads were included in the study, with bilateral facial nerves studied (n = 16). The proximal frontal branches were isolated and then sectioned in full-thickness tissue blocks over a 5-cm distance over the zygomatic arch. The tissue blocks were evaluated histologically for the depth and fascial planes surrounding the frontal nerve. A dissection video accompanies this article. RESULTS: The frontal branch of the facial nerve was identified in each tissue section and its fascial boundaries were easily identified using epidermis and periosteum as reference points. The frontal branch coursed under a separate fascial plane, the parotid-temporal fascia, which was deep to the SMAS as it coursed to the zygomatic arch and remained within this deep fascia over the arch. The frontal branch was intact and protected by the parotid-temporal fascia after a high-SMAS face lift. CONCLUSIONS: The frontal branch of the facial nerve is protected by a deep layer of fascia, termed the parotid-temporal fascia, which is separate from the SMAS as it travels over the zygomatic arch. Division of the SMAS above the arch in a high-SMAS face lift is safe using the technique described in this study.

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BACKGROUND: Difficulties that arise with subpectoral breast implant placement include the following: malpositioning of the implant; improper superior contouring; and unnatural movement with chest muscle contraction. Correction of these deformities is easily achieved by removal of the subpectoral implant, resuspension of the pectoralis major muscle to the chest wall, and reaugmentation with a new implant in the subglandular plane. This study defines a correction modality for the adverse results of subpectoral implant placement in augmentation mammaplasty. METHODS: Pectoralis major resuspension was performed in 36 patients undergoing revision aesthetic breast surgery from 1995 to 2006. All patients had previously placed subpectoral breast implants performed elsewhere with unwanted movement, malposition, and/or capsular contracture. All patients underwent explantation of the breast implant, modified capsulectomy, pectoralis major resuspension, and reaugmentation of the breast in the subglandular position. In cases of symmastia, medial capsulodesis and sternal bolster sutures were used. Patients were evaluated for resolution of symptoms, satisfaction, and complications. RESULTS: Malposition (62 percent), capsular contracture (53 percent), and symmastia (10 percent) were the most common indications for revision, but 100 percent of patients were dissatisfied with abnormal breast movement. The average follow-up time was 20 months. The silicone implants were commonly used, with an average volume change decrease of 27 cc. Unwanted implant movement was eliminated completely (100 percent), symmastia was corrected (100 percent), and capsular contraction was significantly decreased in each respective group. Patient satisfaction with this procedure was high, with a low complication rate. CONCLUSIONS: Pectoralis major resuspension can be performed successfully in aesthetic breast surgery. It can be applied safely to correct problems of unwanted implant movement, symmastia implant malposition, and capsular contraction. The use of silicone gel implants in a novel tissue plane may be beneficial in this diverse, reoperative patient population.

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BACKGROUND: To ensure that patients receive appropriate thromboembolic prophylaxis, other specialties have begun using risk stratification models. Because these models do not include plastic surgery patients, research must be directed toward exploring the risk associated with these operations. A systematic review of the literature was performed to address these issues. METHODS: A thorough search for all articles discussing abdominal contouring surgery was conducted. Data were collected from this institution through a retrospective chart review and included in the analysis. Procedures were divided into four groups, dependent on what was reported, as follows: abdominoplasty alone, abdominoplasty with an intraabdominal procedure, abdominoplasty with another plastic surgical procedure, and circumferential abdominoplasty. Frequencies of venous thromboembolism were recorded. Chi-square analysis was performed to examine for statistical differences. RESULTS: One hundred fourteen articles were reviewed; 30 articles were included in the analysis. Circumferential abdominoplasty was associated with the highest venous thromboembolism rate (3.40 percent). This was statistically higher than the thromboembolic rate of abdominoplasty (0.35 percent) (p < 0.0001) and abdominoplasty with concomitant plastic surgery (0.79 percent) (p < 0.0001). Abdominoplasty combined with an intraabdominal procedure was associated with the second highest rate of thromboembolism (2.17 percent). This rate was higher than abdominoplasty alone (p < 0.001) and abdominoplasty with concomitant plastic surgery (p = 0.02). CONCLUSIONS: Circumferential abdominoplasty and abdominoplasty performed in combination with an intraabdominal procedure were demonstrated to have significantly increased risk for venous thromboembolism. Patients undergoing these procedures should be risk stratified and have perioperative prophylaxis managed accordingly. It is suggested that both of these operations be placed into a higher exposing risk category within the modified Davison-Caprini risk assessment model.

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BACKGROUND: Trichloroacetic acid is a commonly utilized agent for chemical resurfacing of the face. Jessner's solution in combination with trichloroacetic acid has been previously described for the treatment of facial rhytids in the dermatology literature. The purpose of this study was to describe the application technique and examine the clinical results of Jessner's solution in combination with trichloroacetic acid in a diverse plastic surgery patient population. METHOD: A retrospective chart evaluation of 105 patients undergoing combination Jessner's and 35% trichloroacetic acid facial peel procedures by the senior author was performed. Patient demographics, anatomic location of peel, concomitant surgical procedures, and postoperative complications were noted. Technique and endpoints are described. RESULTS: Between January of 2000 and April of 2007, 115 chemical peels were performed by the senior author. All patients were female, ranging in age from 32 to 83 years (mean, 54 years). Of the 115 chemical peels performed, 104 were done with concomitant procedures. Eleven peels were performed alone. The most significant complications related to the combination peel were fungal infections (7.8 percent overall rate). In addition, the senior author performed 27 face/neck lifts with superficial musculoaponeurotic system (SMAS)-ectomy or SMAS plication along with full face combination peel, with minimal postoperative complications and no evidence of hypertrophic scarring. CONCLUSIONS: The combination of Jessner's solution and 35% trichloroacetic acid is an effective, safe resurfacing tool that can treat superficial to moderate rhytids. Despite the apparent simplicity of the procedure, there is a significant learning curve to understand the intricacies of chemical penetration in the skin. Consistency in results is achieved with experience and proper preoperative patient evaluation and selection.

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The endoscopic midface lift procedure has evolved from experience with postreduction soft tissue repair after facial fracture fixation. The procedure elevates and repositions midface soft tissue, which descends with facial aging; as well, it can correct periorbital congenital abnormalities, such as exorbitism and lateral canthal displacement. The procedure has been refined by the senior author to employ a temporal endoscopic approach alleviating the need for a lower eyelid incision. The plane is sub-SMAS (superficial muscular aponeurotic system) within the pre-zygomatic space with release of the zygo-orbicular ligament and the malar retaining ligament. Using an endoscopically placed suture in the malar retaining ligament, the midface and orbicularis oculi are elevated en bloc, with additional selective sutures applied for specific lower eyelid and cheek morphology. Ancillary lower eyelid procedures including skin resurfacing, skin excision, soft tissue augmentation, and a transblepharoplasty septal reset can all be safely applied to the lower eyelid in the same operative setting. All procedures are technically advanced though once executed deliver an exact correction of the midface, which can be combined with both brow and lower face rejuvenation. The procedure offers limited recovery time and few complications as the facial surgeon becomes facile with the technique.

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INTRODUCTION: Despite high success rates with free-tissue transfer, flap loss continues to be a devastating event. Flap salvage is often successful if vascular complications are recognized and treated early. However, delayed presentation of flap compromise is an ominous predictor of flap loss. Late free-flap salvage has been described with poor long-term results. Catheter-directed thrombolysis (CDT) has only been described in context with free-tissue transfer in a case of distal bypass salvage. OBJECTIVES: The authors examined the efficacy of highly selective CDT in late salvage of free-flaps with vascular compromise. METHODS: Two patients underwent highly selective CDT after delayed presentation (>5 days) of flap compromise. Patient 1 is a 59-year-old woman who underwent delayed breast reconstruction with a free TRAM flap and presented with arterial thrombosis 12 days postoperatively. Patient 2 is a 53-year-old man who underwent fibular osteocutaneous free-flap reconstruction of a floor of mouth defect who developed venous thrombosis 6 days postoperatively. Patient 2 underwent two attempted operative anastamotic revisions with thrombectomies and local thrombolysis prior to CDT. RESULTS: The average time of presentation was 9 days, with the average time to CDT being 9.5 days. Patient 1 had an arterial thrombosis, whereas Patient 2 had a venous thrombosis. Both patients underwent successful thrombolysis after super-selective angiograms. Continuous infusions of thrombolytic agents were used in both patients for approximately 24 h. Average length of stay postCDT was 7 days with no perioperative complications. Long-term follow-up demonstrated complete flap salvage with no soft tissue loss. CONCLUSION: Despite extremely delayed presentation, aggressive CDT was successful in both breast, and head and neck reconstructions with excellent long-term flap results. CDT appears to be a useful modality in managing difficult cases of free-flap salvage.

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BACKGROUND: Lip augmentation is used to enhance a thin upper lip or correct lip deficiencies. The palmaris longus tendon, an accessory tendon of the wrist, has been used successfully for upper extremity reconstruction and was used in this case series for upper lip augmentation. METHODS: Patients underwent upper lip augmentation using palmaris longus tendon grafts at the University of California, Los Angeles from 1998 to 2005 (n = 38). Vertical lip height, lateral lip projection, and dynamic smile length were measured preoperatively, at 6 weeks, and at 1-year follow-up, and complications, lip mobility, and physician/patient outcome surveys were recorded. RESULTS: Palmaris graft lip augmentation was performed for cosmetic (n = 21) and reconstructive (n = 17) indications. There were two infections and two graft exposures, with no long-term sequelae. The vertical height of the upper lip had a mean increase of 204 percent and a mean relapse of 9 percent (change from postoperative period to follow-up). Lateral projection of the upper lip showed a mean increase of 180 percent and a relapse rate of 7 percent. Dynamic lip mobility had a mean grade of 4.7 of 5 at 1 year, and the postoperative smile length was close to the preoperative length (mean postoperative length was 96 percent of preoperative length). One patient developed a stiff upper lip and required reoperation and therapy for a good final outcome. CONCLUSION: The authors' case series shows that the palmaris longus tendon provides a reliable option for soft-tissue upper lip augmentation, with improved vertical height and lateral projection and maintenance of lip mobility.

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LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Identify pertinent findings in the preoperative evaluation of the blepharoplasty patient that could affect operative management. 2. Describe different techniques of upper and lower lid blepharoplasty. 3. Describe ancillary procedures that could blend the lower eyelid-cheek junction and optimize the aesthetic result of blepharoplasty surgery. 4. Identify common postoperative complications and describe their treatment. SUMMARY: Blepharoplasty plays a vital role in facial rejuvenation, with direct aesthetic connection to the brow and the cheek. Upper and lower eyelid blepharoplasty may be indicated for the presence of excess skin and/or orbital fat. Preoperative evaluation should include a thorough medical and ophthalmic history, along with a vision examination. Symptoms of preexisting dry eye should be elicited preoperatively, as they directly correlate with postoperative complications. Physical examination should take into account brow position, eyelid ptosis, lower eyelid position, and cheek projection. Blepharoplasty is a broad topic with many operative approaches. Skin-only upper blepharoplasty with medial orbital fat excision is an effective procedure. Lower eyelid blepharoplasty is a more controversial topic. The senior author (R.J.R.) uses a transconjunctival orbital malar retaining ligament disruption along with a lateral retinacular canthopexy, and a lower eyelid skin pinch excision for his lower blepharoplasty. Postoperative care should include aggressive corneal lubrication with eye protection, eye drops, and ointment. Small amounts of lagophthalmos are tolerated postoperatively but usually correct within 7 days. Complications may include retrobulbar hematoma, lower eyelid malposition, dry eye, and need for revision surgery. In summary, blepharoplasty is a common procedure in cosmetic surgery, with important contributions to facial rejuvenation.

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