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BACKGROUND: Gluteal fat augmentation has increased worldwide, and so have major complications. Brazilian plastic surgeons have been performing this procedure for more than 30 years, and more often every year. Therefore, the authors performed a study among board-certified plastic surgeons, members of the Brazilian Society of Plastic Surgery, to evaluate their techniques; identify their preferences, complications, and outcomes with this procedure; and make some recommendations. METHODS: An anonymous Web-based survey consisting of 16 questions was sent to 5655 members in July of 2017. A supplementary survey was subsequently sent to obtain more information about major complications. RESULTS: A total of 853 responses were analyzed. The highest percentage of responses in the different categories were as follows: fat decantation for processing, injection with a 3-mm-diameter cannula, use of superior incisions, subcutaneous fat grafting only, and with a volume of 200 to 399 ml of fat per buttock. The majority of surgeons received training in this procedure during residency. The most common complications were contour irregularities. The estimated mortality rate was one in 20,117 cases, and the rate of nonfatal fat embolism was one in 9530. The risk of death was 16 times greater when fat was injected intramuscularly. CONCLUSIONS: Based on this survey, the authors recommend injecting fat only subcutaneously, by means of superior incisions, using cannulas 3 mm in diameter or more. They find that by following these recommendations, this procedure can be as safe as any other. More research to establish guidelines and increase its safety is necessary.

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BACKGROUND: Patient demand for aesthetic genital surgery has markedly increased. The International Society of Aesthetic Plastic Surgery reported 95,010 labiaplasties and 50,086 vaginal rejuvenation procedures in 2015. METHODS: We performed an online anonymous survey to evaluate the teaching of female genital procedures in plastic surgery training programs worldwide. RESULTS: A total of 1033 board certified plastic surgeons answered the survey. Most respondents were from the USA, Brazil, Mexico and Colombia. The majority of plastic surgeons performing these procedures were in private practice (77.62%) and (22.38%) in academic settings. Most plastic surgeons (75.63%) did not receive formal education in female genital rejuvenation procedures however 54.31% did receive education in reconstruction procedures. During their training, most were exposed to vaginal reconstruction (15.94%), labia minora reduction (11.9%), vulva reconstruction (11.53%), flaps for vaginal agenesis (11.39%) and monsplasty (7.98%). Additional training for female genital procedures was mostly at meetings and shadowing experts. Sixty-two percent reported that patients seldom requested those procedures, and 63.73% reported these procedures comprised less than 5% of their practice. The most commonly performed procedures were labia minora reduction, labia majora augmentation or reduction and monsplasty. The materials used were mostly fat grafting, hyaluronic acid injections and lasers. CONCLUSION: Additional formal training during residency for aesthetic genital surgery would be beneficial. Additionally, courses at meetings would be useful for plastic surgeons who have had insufficient training. More studies need to be conducted on the different female genital rejuvenation procedures offered in order to evaluate patients' long-term outcomes and satisfaction. LEVEL OF EVIDENCE V: 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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BACKGROUND: The 2010 Haiti earthquake severely strained local healthcare infrastructure. In the wake of this healthcare crisis, international organizations provided volunteer support. Studies demonstrate that this support improved short-term recovery; however, it is unclear how long-term surgical capacity has changed and what role volunteer surgical relief efforts have played. Our goal was to investigate the role of international surgical volunteers in the increase of surgical capacity following the 2010 Haiti earthquake. METHODS: We retrospectively analyzed the operative reports of 3208 patients at a general, trauma and critical care hospital in Port-au-Prince from June 2010 through December 2013. We collected data on patient demographics and operation subspecialty. Surgeons and anesthesiologists were categorized by subspecialty training and as local healthcare providers or international volunteers. We performed analysis of variance to detect changes in surgical capacity over time and to estimate the role volunteers play in these changes. RESULTS: Overall number of monthly operations increased over the 2.5 years post-earthquake. The percentage of orthopedic operations declined while the percentage of other subspecialty operations increased (p = 0.0003). The percentage of operations performed by international volunteer surgeons did not change (p = 0.51); however, the percentage of operations staffed by volunteer anesthesiologists declined (p = 0.058). The percentage of operations performed by matching specialty- and subspecialty-trained international volunteers has not changed (p = 0.54). CONCLUSIONS: Haitian post-earthquake local and overall surgical capacity has steadily increased, particularly for provision of subspecialty operations. Surgical volunteers have played a consistent role in the recovery of surgical capacity. An increased focus on access to surgical services and resource-allocation for long-term surgical efforts particularly in the realm of subspecialty surgery may lead to full recovery of surgical capacity after a large and devastating natural disaster.

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BACKGROUND: Given the wide application of autologous fat grafting, a new emphasis on fat processing techniques has emerged in an effort to limit unpredictable degrees of resorption often seen with this procedure. With the growing interest in regenerative medicine, approaches to supplement fat grafts with adipose-derived stem cells are evolving in hopes of promoting vascularization and neoadipogenesis. OBJECTIVE: The authors evaluated the outcomes of the most common processing techniques for fat grafting--decantation, washing, high-speed centrifugation--and stromal vascular cell-supplemented lipotransfer to determine which method yields a higher percentage of retention and better quality graft. METHODS: A total of 32 subcutaneous injections of processed human lipoaspirate were carried out in 8 athymic rats. Each animal received all 4 processing conditions, with end points at 4, 8, and 12 weeks postinjection. Evaluation of graft survival included serial measurements of volume retention and histologic analysis. RESULTS: At 12 weeks postinjection, cell-supplemented and centrifuged grafts showed the most consistent volume maintenance. Based on histologic analysis, cell-supplemented and washed grafts had higher scores of viability and vascularity, with the former presenting the least cystic necrosis and calcification as well as minimal inflammation. CONCLUSIONS: Cell-supplemented lipotransfer had optimal outcomes for graft retention, viability, and vascularity, while washing resulted in high viability with a less intensive process. High-speed centrifugation resulted in consistent volume retention but lower viability. Each of these approaches is ideal under different circumstances and contributes to the versatility and reliability of fat grafting.

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BACKGROUND: Preferred techniques for rejuvenation and contouring of the neck region have evolved over the past 40 years. A slender neckline is recognized as an attractive feature of youth, whereas aging of the lower face often includes ptosis of the soft tissues of the chin and banding or cording of the muscles of the anterior and lateral neck. Aesthetic rejuvenation of the face and neck involves repositioning of poorly supported soft tissues. OBJECTIVES: The authors review their 14-year experience with a technique incorporating standard submental liposuction with a method of triple suturing the medial platysmal bands associated with lateral plication of the superficial muscular aponeurotic system (SMAS)-platysma. METHODS: Between 1994 and 2008, 507 patients (451 women and 56 men) were treated with this technique which consisted of placing a first line of sutures distributing tension between the medial platysmal bands and the anterior belly of the digastric muscles, a second single suture at the distal medial borders of the platysma, and a third running suture starting at the level of the thyroid cartilage up to the supramental region. In most cases, a lateral plication of the SMAS-platysma and a "stair-like" SMAS plication were performed in order to define the cervicomandibular line and treat midface flaccidity, respectively. RESULTS: Mean follow-up was eight years. Complications included hematomas (4.6%) and seromas (3.6%). Four percent of patients underwent a second procedure approximately seven years after their primary procedure. Overall the majority of patients exhibited long-lasting results satisfactory to both patients and surgeons. CONCLUSION: The triple-suture technique for neck contouring creates a median vertical vector of traction, whereas lateral plication produces a lateral posterior oblique vector. The combination of these two procedures is an easily reproducible and reliable option for surgeons when patients are seeking a more youthful appearance of the neck.

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BACKGROUND: Both the aging process and postobesity deformities of the upper extremities are associated with lipodystrophy, loss of muscular mass, weakening of the fascia, and skin laxity. Many different surgical procedures have been described to correct these deformities, but most of them have limitations, particularly with respect to postsurgical scarring. OBJECTIVES: The authors present a technique in which plication of the brachial fascia is performed before dermolipectomy in order to obtain greater flap advancement and limit tension on the final scars, thereby diminishing postoperative complications. METHODS: From 1997 to 2007, the authors retrospectively followed 41 female patients who had undergone brachial dermolipectomy procedures associated with plication of the fascia on the internal aspect of the arm. This technique permitted greater advancement of the entire thickness of the flap, creating a better support for the flap with larger skin resection. The distance between the two incisions was also shortened, reducing dead space between the two planes, the incidence of seromas, and tension on the suture line. RESULTS: The scarring complications caused by tension on the skin were eliminated. Therefore, our complication rate was low, with only three cases of small foci of dehiscence, two cases of seroma, and four cases of hypertrophic scars in certain areas. The mean follow-up period was seven years, during which 92% of the patients were pleased with their outcomes. CONCLUSIONS: The described surgical approach provided excellent overall extremity contour with favorable scars while simultaneously addressing axillary contour and forearm deformities when present.

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BACKGROUND: Centrifugation is one of the preferred methods of fat processing. Although it has been promoted for nearly three decades to separate adipose tissue components before grafting, there remain many controversies regarding the results obtained with centrifuged adipose tissue. OBJECTIVES: The authors demonstrate the effects of centrifugation on the cellular components of aspirated fat. METHODS: Fat harvested from the lower abdomen of 10 female patients undergoing liposuction was divided in two equal parts, then processed by decantation or centrifugation and sent to the laboratory. Each processed lipoaspirate was analyzed histologically after hematoxylin and periodic acid-Schiff staining for the presence of intact adipocytes. It was then cultured and analyzed by multicolor flow cytometry for identification of adipose-derived mesenchymal stem cells. RESULTS: The middle layer of the centrifuged lipoaspirate, which is used by many surgeons, showed a great majority of altered adipocytes and very few mesenchymal stem cells in comparison with the decanted sample, which maintained the integrity of the adipocytes and showed a greater number of mesenchymal stem cells. The pellet observed as a fourth layer at the bottom of the centrifuged lipoaspirate showed the greatest concentration of endothelial cells and mesenchymal stem cells, which play a crucial role in the angiogenic and adipogenic effect of the grafted tissue. CONCLUSIONS: If centrifuged lipoaspirate is used, the pellet (rich in adipose-derived mesenchymal stem cells) and the middle layer should be employed to increase fat graft survival.

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BACKGROUND: In the last decade, controversy has arisen regarding the influence of fat harvesting, processing and injection techniques on adipose tissue graft. The aim of this study is to compare the influence of three widely used fat processing techniques in plastic surgery on the viability and number of adipocytes and mesenchymal stem cells (MSCs) of aspirated fat. METHODS: A prospective cross-sectional study was conducted in 20 adult healthy female patients in whom material obtained by liposuction of the lower abdomen was separated and processed by decantation, washing or centrifugation. The morphology and quantity of adipocytes were determined by histological analysis. The viability and number of MSCs in the middle layer of each lipoaspirate and the pellet derived from centrifuged samples were obtained by multi-colour flow cytometry. RESULTS: Cell count per high-powered field of intact nucleated adipocytes was significantly greater in decanted lipoaspirates, whereas centrifuged samples showed a greater majority of altered adipocytes. MSC concentration was significantly higher in washed lipoaspirates compared to decanted and centrifuged samples. However, the pellet collected at the bottom of the centrifuged samples showed the highest concentration of MSCs. CONCLUSION: Based on the theory of cell survival stating the importance of adipocytes' integrity for graft survival and the theory claiming the importance of regenerative MSCs in the maintenance and stabilisation of fat transplant, washing may turn out to be the best processing technique for adipose tissue graft take. While eliminating most contaminants during the process, it preserved and maintained the quantity, integrity and viability of the most important components of aspirated adipose tissue.

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The ability to bring aesthetic harmony back into the ageing face requires the blending of surgical technique, anatomic knowledge and artistic sensitivity to individualise the surgical approach for each given patient. Since the advent of endoscopic techniques for facial rejuvenation, there has been an increase in the number of patients who seek alternative facial procedures, refusing a conventional face-lift. Limited-scar rhytidectomies offer patients with mild-to-moderate facial ageing an alternative to traditional face-lift surgery. The authors present a prospective study using the endoscopically assisted limited-incision face-lifting technique. Indications for using this technique include young patients with a relatively small amount of skin excess, older patients with thick skin and minimal skin redundancy, smokers and bald people. A set of incisions in the forehead, pre-auricular area, ear lobe and post-auricular area are done. Frontal and temporal endoscopic lifting is performed, followed by middle third and cervical undermining and transposition of a 2×5.5 cm rectangular pre-auricular superficial musculo-aponeurotic system (SMAS) flap. Overall satisfaction with the facial appearance after this procedure was rated on a scale of 1 to 5. A total of 54 patients were operated upon during January 1997 and January 2007, which represents 13% of the total number of face-lifting procedures performed during that period. Their age ranged from 28 to 55 years old (mean 38 years), and 35% of them were men. There were two cases of haematoma formation (1%) and four patients (2%) required further liposuction of the submental region. There were no cases of nerve injury or infection. Six patients (3%) requested revision surgery after 2-4 years after the first procedure (median 3.5 years). They underwent a secondary round of face-lifting. The mean follow-up period has been 5.5 years (range 1-9 years). Sixty-nine percent reported that their appearance after limited-incision rhytidectomy was 'very good' to 'excellent' and 22% responded that their appearance was 'good'. Only 9% of patients thought their appearance was less than good. This is not a mini-lift technique but rather a full face-lift performed through minimal incisions and assisted by the use of the endoscope. Although the endoscopically assisted limited-incision rhytidoplasty is reserved for a specific category of patients and requires a learning curve, it appears to be a procedure with a low rate of complications and a high patient satisfaction.

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