Scientific Abstract Presentations: Aesthetic 5 Sunday, October 29 Sun, Oct 29 2:30-3:30 p.m. CDT

BACKGROUND: High definition liposculpture (HDL) emerged as an innovative surgical technique that allowed plastic surgeons around the world to achieve higher aesthetic results by carving the underlying muscles and its contours in a new and different fashion compared to prior methods for lipoplasty . The innovative natural, anatomic, and athletic appearance of the body after surgery was achieved through minimal stealth incisions which ended up in imperceptible scarring . The technique has evolved throughout the years by incorporating different artistic concepts, new technologies, multiple approaches to protect the patient, and as a consequence improve the overall outcomes . One of the most recent improvements we have made to High-Definition Body contouring is the addition of bone remodeling surgeries to overcome the lack of silhouette over the waist, and as a result optimize the breast-waist-hip ratios.

METHODS: We are currently running a multi-center study in which we have completed 100+ surgeries of rib remodeling. UUAIST stands for Ultrasonic-piece and Ultrasound-Assisted Indentation Surgery of Torso, while RIBOSS does for Rib OsteoSynthesis Surgery. Both techniques have their ground on the previously described surgery for waist narrowing by Dr Kudzaev. However, we have improved the outcomes by doing minimally invasive surgery and also promoting fast recovery depending on each patient's case. We have also performed some cases of rib resection, under the technique of Dr Verdugo, however such technique is more time-consuming and technically riskier.

RESULTS: No major complications have been reported. Most common complication is related to prolonged pain, and contour asymmetry, which have both been associated with the non-compliance of constant garment + corset wearing. Riboss technique has a faster recovery and does not require constant use of corset. However, compression garments are required, and scar length is considerable bigger than that from UUAIST technique.

CONCLUSIONS: High Definition and Dynamic Definition liposculpture procedures are safe and reproducible techniques to attain not only an athletic and but also a natural body contour. The evolution of the technique has incorporated multiple technologies, advancements of the technique and also excisional procedures. Bone remodeling surgery might be the new game-changer for those individuals who require even more waist definition and improve the overall breast-waist-hip ratio. We have designed new approaches tailored to the needs and preferences of patients who usually lack a curvy structure of the body, especially for those extremely fit patients and those who seek gender affirming surgeries to change their overall body silhouette.

REFERENCES 1. Hoyos AE, Perez ME, Domínguez-Millán R. Variable Sculpting in Dynamic Definition Body Contouring: Procedure Selection and Management Algorithm. Aesthet Surg J. 2021;41(3):318-332. doi:10.1093/asj/sjaa133 2. Zarins U, Kondrats S. Anatomy for Sculptors: Understanding the Human Figure. Seattle, WA: Exonicus, LLC; 2019. 3. Hoyos AE, Cala LC, Perez ME, Mogollon IR, Dominguez-Millan R. High Definition Liposculpture's 18-year Evolution: Patient Safety and Aesthetic Outcomes [published online ahead of print, 2022 Dec 5]. Plast Reconstr Surg. 2022;10.1097/PRS.0000000000009988. doi:10.1097/PRS.0000000000009988 4. Kudzaev KU, Kraiushkin IA. Waist Narrowing without Removal of Ribs. Plast Reconstr Surg Glob Open. 2021;9(7):e3680. Published 2021 Jul 12. doi:10.1097/GOX.0000000000003680

Abstract:

Background: Primary and secondary rhinoplasty frequently requires addition of cartilage to support the osseocartilaginous framework of the nose. Autologous and irradiated homologous cartilage have been used as the cartilage graft source, each with its pros and cons. There has been an increasing popularity of fresh frozen rib grafts, which may mitigate the complications involved in using autologous or irradiated homologous costal cartilage, and may have a lower incidence of complications. However, the outcomes associated with the use of fresh frozen rib grafts have only been assessed in small clinical studies. Thus, we conducted a meta-analysis to provide a holistic, better-powered assessment of outcomes after primary and revision rhinoplasty using fresh frozen rib grafts.

Methods: For this systematic review and meta-analysis, MEDLINE, Embase, Scopus, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched for articles published from inception to January 2023. The following search strategy was used (septorhinoplasty OR rhinoplasty) AND (fresh frozen costal cartilage OR costal cartilage allograft OR rib graft OR cadaveric cartilage graft OR homologous costal cartilage graft). Inclusion and exclusion criteria was applied and patients receiving hybrid grafts were excluded to ensure a homogenous study sample. Data were pooled using a random-effects model and analysed using Open Meta Analyst. The effect size was measured for all reported complications including incidence of total complications, graft warping, resorption, infection, and revision surgery among patients receiving frozen aseptic grafts.

Results: Of 306 citations, 5 studies were included in our systematic review and meta-analysis. Our study, which captured 440 patients, concluded a low rate of all complications with total complications (4.4%; 95% CI, 1.1%-9.8%), infections (2.6%; 95% CI, 1.2%-4.6%), warping (2.3%; 95% CI, 0.9%-4.3%), revision surgery (4.4%; 95% CI, 1.0%-9.9%) and resorption (1.8%; 95% CI, 0.2%-5.2%).

Conclusion: This meta-analysis suggests that frozen cadaveric costal cartilage may be used for rhinoplasty with minimum and comparable complications with other commonly used graft types, along with the advantage of no donor site morbidity over autologous grafts and decreased resorption rates over irradiated homologous cartilage.

Keywords: Rhinoplasty; septorhinoplasty; rib grafts; costal cartilage;

Correlations of Psychiatric Comorbidities with Body Image and Maintenance of Weight Loss Following Body Contouring Procedures

Introduction: An estimated 46,000 patients undergo body contouring procedures in the U.S. each year. This patient population has a high prevalence of obesity and is subject to significant stigma. The relationship between obesity and psychiatric comorbidities is widely documented, and it has been estimated that anywhere between 20 and 60 percent of patients who pursue bariatric surgery suffer from axis I psychiatric disorders, especially anxiety and mood disorders. However, there is comparatively fewer investigations regarding psychosocial functioning of post-bariatric patients preparing to undergo body contouring surgery, though research in this field has been steadily growing over the past decade. This study aims to describe the implications of specific psychiatric comorbidities, including major depressive disorder (MDD) and generalized anxiety disorder (GAD) on the management and outcomes of patients who undergo body contouring procedures.

Methods: A retrospective review was performed of patients who presented to a single institution for body contouring procedures between 2002 and 2018. Variables studied included demographic information, medical and psychiatric history, smoking and drinking history, self- image, social support, procedure history, outcomes and follow up. Univariate analysis, two-sample t-tests, and multinomial logistic regressions were performed using R statistical software (Version 1.3.1093).

Results: A total of 1187 patients received at least one body contouring procedure within the study timeframe. The mean age of patients at presentation was 50.08 ± 0.78 years. The majority of our patient cohort was female (90.1 percent) and Caucasian (93 percent). Mean BMI at presentation was 31.21 ± 10.49 BMI units. A total of 50.2% of our patient cohort had history of at least one psychiatric comorbidity. GAD was found in 26.4% of the overall patient population. Patients with history of GAD were 1.4 times less likely to rate their pre-operative body image as "somewhat positive" or "very positive" (p<0.05) and were 1.69 times less likely to maintain 6-month post-op weight loss through regular exercise than patients without GAD (p<0.02). History of MDD or other psychiatric disorders was not significantly associated with lower ratings of pre-operative self-image (p>0.05). When controlling for the effects of a history of anxiety, larger decreases between a patient's historical maximum BMI and BMI at the time of pre-operative body contouring association were significantly associated with a 2% increased likelihood of reporting a "somewhat positive" or "very positive" self-image (p <0.05).

Conclusion: Psychiatric comorbidities such as GAD have important implications on management and outcomes in patients undergoing body contouring procedures. Patients with GAD are less likely to report positive pre-operative body-image and are less likely to maintain weight loss than patients without GAD.

Introduction Non-surgical rhinoplasty using dermal filler is gaining increasing popularity as a non-invasive, lower-cost alternative to surgery in the correction of nasal irregularity or deformity. Hyaluronic acid (HA) represents the most commonly used filler and is used across a variety of practitioner settings. In spite of this, outcomes and complications following HA use have not been studied using high-quality systematic review methodology. An overview of these measures can support clinicians in appropriate selection of patient and technique as well as in guiding patient expectations. We conducted a systematic review to this end to evaluate clinical and patient-reported outcomes following non-surgical rhinoplasty using HA filler.

Methods The study protocol was registered in PROSPERO a priori (ID: CRD42022369278). MEDLINE, EMBASE and Cochrane databases were searched systematically and bibliographies of reviewed articles screened for all relevant English-language papers. Included articles were original studies that reported on clinical patient-reported outcomes, patient satisfaction or complications as outcomes of interest following non-surgical rhinoplasty using HA filler. In all stages of the search, PRISMA guidelines were adhered to. Risk of bias and methodological quality were assessed using MINORS criteria and methodological quality and synthesis of case series.

Results Of 874 publications, 23 full-text studies comprising 3928 patients were included. Nasal hump deformity was the most common indication for non-surgical rhinoplasty using HA filler, with the nasal tip as the most commonly injected site (13 studies), followed by the columella (12 studies). JUVÉDERM ULTRA® was the most widely used HA filler and high levels of patient satisfaction were reported in all studies that recorded this outcome measure. Pooled post-procedural patient satisfaction was 93.4% [95% CI: 90-97%] from studies using verbal patient self-assessment scales and the majority of patient satisfaction scores were >7.5/10 in studies using numerical self-assessment scales. Follow-up duration ranged from 2 weeks to 18 months. Major complications (skin necrosis, pustules, vascular impairment and infection) were reported in 6/23 studies (n=8). Minor complications (edema, bruising, erythema and pain) were more common and recorded in 16/23 studies.

Conclusion Non-surgical rhinoplasty using HA filler demonstrated few side effects and a short recovery period in this systematic review. High rates of patient satisfaction were recorded unanimously across the literature. However, evidence is limited by an absence of randomized controlled trials (RCTs) reporting on outcomes or complications and variability in outcome measurement, technique used and duration of follow-up. Standardized outcome measures and further, well-designed RCTs will optimize the available evidence base for HA fillers.

Introduction: Autologous fat transfer is a method that plastic surgeons often use to improve asymmetries and contour deformities.1 For post-mastectomy breast reconstruction patients, an important metric to evaluate operative outcomes is the degree of patient satisfaction. The Breast-Q is a validated questionnaire designed to evaluate patient reported outcomes following breast surgery in domains pertaining to breast appearance, physical wellbeing, psychosocial wellbeing, sexual wellbeing, and satisfaction with overall treatment.2 The objective of this study is to provide a standardized analysis of patient input and feedback before and after autologous fat grafting, and assess whether the technique of lipid transfer affects patient satisfaction and self-reported quality of life.

Method: Female adults aged >18 with a history of prior breast surgery (either complete or partial mastectomy) undergoing fat grafting from available donor sites, BMI >20, and anticipated harvested fat volume >50 cc were enrolled in the study. Patients were randomized into one of three treatment arms in a 1:1:1 ratio (standard decantation, active filtration, low pressure decantation). The pre-operative BreastQ survey was administer at the initial consultation. The post-operative BreastQ survey was given at the three-month follow-up after fat grafting surgery completion. Unpaired t-test and One-way ANOVA were used to evaluate statistically significant differences between the cohorts.

Results: When comparing post-operative measures, active filtration achieved the highest patient satisfaction in categories of physical wellbeing of the back, animation, psychosocial wellbeing, and overall satisfaction. The standard decantation group reported the highest level of physical wellbeing of the chest and sexual wellbeing. Overall, pre-operative survey results did not differ significantly from post-operative results, and the three treatment groups did not differ significantly from each other.

Conclusion: The BreastQ survey is a useful tool for evaluating and improving patient outcomes and satisfaction following breast surgery. Within the context of fat grafting, it helps elucidate patient needs and preferences, identify areas for improvement, and tailor care to individual patients. Our results show that patient satisfaction and wellbeing did not consistently improve after the procedure, and that the method of fat grafting did not lead to significant differences from the patient's perspective. Therefore, it may be important to manage patient expectations during preoperative counseling and educate patients on the potential need for multiple surgeries to achieve the desired result.

1. Strong, Amy L. Ph.D., M.P.H.; Cederna, Paul S. M.D.; Rubin, J. Peter M.D.; Coleman, Sydney R. M.D.; Levi, Benjamin M.D.. The Current State of Fat Grafting: A Review of Harvesting, Processing, and Injection Techniques. Plastic and Reconstructive Surgery 136(4):p 897-912, October 2015. | DOI: 10.1097/PRS.0000000000001590
2. Pusic AL, Klassen AF, Scott AM, Klok JA, Cordeiro PG, Cano SJ. Development of a new patient-reported outcome measure for breast surgery: the BREAST-Q. Plast Reconstr Surg. 2009 Aug;124(2):345-353. doi: 10.1097/PRS.0b013e3181aee807. PMID: 19644246.

Introduction: The FACE-Q Aesthetics module is a validated patient-reported outcome measure (PROM) that evaluates perspectives on facial aesthetic treatments. Improper administration and poor study methodology can compromise the validity and interpretation of this PROM. This systematic review sought to evaluate the administration and scoring of the FACE-Q Aesthetics scales within the literature.

Methods: A search of Ovid Medline, Embase, Cochrane, and Web of Science was performed on December 20, 2022 with the assistance of a health-research librarian (CRD42022383676). Studies that examined facial aesthetic interventions using the FACE-Q Aesthetics module as a primary or secondary outcome measure were included for analysis.

Results: There were 114 studies included. The Face Overall (n=52, 45.6%), Psychological (n=45, 39.4%), and Social (n=43, 37.7%) scales were most frequently reported. Errors in FACE-Q administration were identified in 30 (26.3%) studies. The most common error was the presentation of raw ordinal scores rather than the converted Q score (n=23). Most studies reported a time horizon for their primary analysis (n=76, 66.7%); however, only four studies provided a rationale for this selection. Sample size calculations for the primary outcome were rarely performed (n=9, 7.9%).

Conclusion: There continues to be limitations in PROM administration and the quality of articles that report FACE-Q Aesthetic scale data. The authors suggest that future investigators using the FACE-Q refer to the User's Guide regarding administration and scoring of this scale, report and provide a rationale for the study time horizon and provide an apriori sample size calculation for the primary outcome of interest.

Background: Willingness to pay (WTP) has been an important tool in healthcare used to understand public priorities and satisfaction rates. To our knowledge, no study compared WTP for pediatric and adult patients in scenarios applicable to both populations, such as scars. We assessed general public's WTP for scar removals on adults and children. We hypothesized that scar location and age of the person with a scar would have a significant effect on WTP. We also assessed the effect of respondents' income, gender, and having own children.

Methods: Shutterstock, a free image database, was used to obtain images of scars on adults and children. Focus group was used to match images in terms of scar severity and location. Two pairs of images were selected (Figures 1 and 2). Two Qualtrics surveys were created. Each consisted of three blocks of questions. First two blocks included either a picture of a child's or an adult's scar, and assessed WTP supposing no insurance coverage and severity rating from 1 to 5. Third block assessed demographics of interest. Surveys were dispersed via social media platforms. Identifying information was not collected. Partially completed surveys were not excluded. Data was analyzed using IBM SPSS to identify significant predictors of higher WTP for scar removal.

Results: Face scar survey obtained 100 responses. 37% were males, 34% were females, 14% were non-binary/third gender, and 15% chose not to respond. WTP was higher for child's face scar removal than adult's ($4,946 vs $3,130; p<0.001). Higher income correlated with higher WTP for both child (p=0.011) and adult (p<0.001). Having children correlated with higher WTP for child (p=0.01) but not adult (p=0.52). Overall, women with children and income over 200k reported highest WTP for both child's and adult's face scars. For each point on the severity perception scale, respondents were willing to pay extra $2800 (p<0.001; r2=0.259) for a child, and extra $2240 (p<0.001; r2=0.194) for an adult. Hand scar survey obtained 142 responses. 38.7% were males, 37.3% were females, 8.5% were non-binary/third gender, and 15.5% chose not to respond. WTP was higher for child's hand scar removal than adult's ($1,418 vs $807; p<0.001). Neither higher income range nor having children correlated with higher WTP. Overall, women with children and income over 200k reported highest WTP for child's hand scar, and non-binary folks without children and income range 15-25k reported highest WTP for adult's. For each point on the severity perception scale, respondents were willing to pay extra $1390 (p<0.001; r2=0.217) for a child, and extra $562 (p<0.001; r2=0.104) for an adult. This study was limited by inadvertent exclusion of cohorts that don't use social media.

Conclusion: This study demonstrated that WTP was highest for child's face scar. Higher income had an effect on WTP for face, but not hand scars. Having children had an effect on WTP for child's face scar only. Women with children and income 200k+ were willing to pay most for scar removal from child's and adult's faces and child's hand, but not adult's hand.

Background: The prevalence of men seeking plastic surgery has been increasing in recent years, especially as societal attitudes towards plastic surgery continue to evolve. By delving into the factors driving male patients to seek plastic surgery and the obstacles they encounter, this study aims to facilitate the development of more inclusive and effective approaches to cater to the unique needs and goals of male patients.

Method: An anonymous 41 question survey was conducted among adult men in the United States via the Amazon Mechanical Turk crowdsourcing platform. Questions assessed demographic information and identified factors that influenced males to seek plastic surgery care, the barriers they experienced while seeking care, and their preferences. Multivariate logistic regression was used to assess relationships between demographic variables and likelihood of getting cosmetic surgery.

Results: Four hundred and eleven complete responses were analyzed. The median (IQR) age of respondents was 32 (30, 40) years old. Of the respondents, 60% had previous experience with plastic surgery. Functional improvement (40%), personal aspiration (32%), and partners' opinions (22%) were the most commonly cited reasons for undergoing procedures. The most common barriers faced by this population were recovery time following a procedure (52%), perceived risk of complications (48%), cost (43%), fear of being identified as having had plastic surgery (32%), and surgeons not being able to meet expectations (31%). 89% of respondents who underwent plastic surgery procedures reported facing at least one barrier. Multivariate regression demonstrated that higher education levels were strongly associated with a likelihood of undergoing cosmetic surgery (p < 0.001). Income (p = 0.44) and region (p = 0.23) did not significantly affect the likelihood of undergoing plastic surgery.

Conclusion: Despite improving societal stigma, many male patients continue to face barriers when obtaining plastic surgery care. Efforts should be made to alleviate these barriers and surgeons looking to expand their practice may benefit from increased outreach to male patients. This outreach should be compounded with improved education targeting stigma and risks of procedures, increasing male specific advertisement to make them feel welcome in an industry predominantly focused on female patients, and offering male tailored procedures.

Purpose: Facial sexual dimorphism influences facial appearance. Understanding how differences in forehead and jawline morphometrics create distinct facial contours in attractive men and women is important in planning facial aesthetic surgery. In this study, facial measurements of male and female celebrities and models were analyzed and compared to investigate the anthropometrics of attractive individuals. 

Methods:  47 Caucasian female and 21 Caucasian male celebrities were included. Full-face front view photos were evaluated by a facial analysis program using Vision framework and MATLAB to detect facial landmarks. Pixel distances were converted to physical distances by dividing the pixel measurement by the subject's white-to-white corneal diameter in pixels, and then multiplying the ratio by the average white-to-white corneal diameter in millimeters (11.71 +/0 0.42 mm in Caucasians). Morphometrics of the upper and lower third of the face were compared between males and females. Additionally, measurements from the subnasale to 24 facial contour points were calculated to create the average facial contour for both genders. 

Results:  The mean ages of the female and male celebrities at the time of the photo were 29 and 31, respectively. Forehead height (trichion-glabella) and width (at the same horizontal level as the glabella) were similar among attractive males and females. Forehead height to width ratios were not significantly different between genders. The facial contour of attractive males exhibited significantly greater lateral forehead heights (hairline to lateral brow) than that seen in attractive females, while the medial forehead height was similar between the two groups. The average lower facial height (subnasale to menton) and bigonial width were greater in attractive males than in females, making the lower facial contour in males significantly longer at all points. The ratio of facial height (trichion to menton) to lower facial height more closely approximated 3:1 in female faces than in male faces. This indicates that the rule of horizontal facial thirds is more applicable in attractive female faces, while a longer lower facial height is more common in the attractive male face. The female facial contour was also more tapered at the gonial angles and chin compared to the males. Interestingly, a greater variety of jawline shapes were observed in attractive female faces, even those not classically narrow and oval-shaped.  

Conclusion:  Distinct facial contours of attractive males and females were created by differences in lateral forehead heights and lower face size and shape. Central forehead heights and forehead widths were similar among attractive males and females; however, lateral forehead height was significantly shorter in female faces. While the lower facial contour was more tapered at the chin and gonial angles in females, the other lower facial ratios were similar between the two genders.