Scientific Abstract Presentations: Aesthetic Session 6 Sunday, October 12 Sun, Oct 12 8:00-9:30 a.m. CDT

Background: Prior studies have illustrated different complication profiles with male facelifts versus female facelifts. For example, the literature historically reports higher hematoma rates in men, possibly due to observations that men often have thicker skin with more robust subcutaneous tissue and hair follicles, use nicotine products, consume alcohol at higher rates, and have higher baseline blood pressure than female patients. This study aims to add to the available literature by investigating differences in complications between matched groups of male and female patients undergoing facelift procedures by a single surgeon implementing consistent, standardized hematoma prevention precautions. Methods: A retrospective analysis of consecutive patients undergoing primary facelift surgery by a single surgeon between 2014 and 2024 was performed. Patients were subdivided into male and female patient groups. Age, BMI, revisions, local tranexamic acid (TXA) use, and comorbidities (Hypertension and diabetes mellitus) status were matched to minimize bias. Patient demographics, surgical time, minor complications, and major complications were examined. SPSS 29.0 was used for analysis. T-test, Mann-Whitney U test, and Chi-Square were used as appropriate. Results: A total of 68 patients were included (34 male, 34 female). Median follow-up time was 302 days, IQR [76,537]. Mean operative time was 40 minutes longer for male patients than female patients (P < 0.001). Estimated blood loss exceeding 100cc was significantly higher in the male group (34.78% and 6.9%, respectively, P = 0.011). There were no statistically significant differences in minor or major complications, including delayed wound healing, hypertrophic scarring, infection, hematoma (1/34 men, 1/34 women, P= 1), and reoperation rate. Conclusions: This single-surgeon study reports no significant differences in minor or major complications between matched male and female patients undergoing primary facelift. Notably, longer operative times and higher incidences of estimated blood loss exceeding 100cc for male patients in this study may reflect anatomical, behavioral, and medical factors that explain higher reported hematoma rates in men. Nevertheless, hematoma rates were comparably low and did not differ between gender groups in this study. Diligent and evidence-based hematoma precautions, strict perioperative pressure control, emesis precautions, and, more recently, the addition of local TXA seem to be effective means of optimizing prospective hemostasis and equalizing hematoma rates between male and female facelift patients. However, special efforts to prevent hematoma in high-risk male patients may bias results in the current study and explain nonconformity to the literature.

Introduction Providing effective postoperative guidance is essential for improving patient outcomes and satisfaction in plastic surgery. Retrieval-Augmented Generation (RAG) models powered by Large Language Models (LLMs) hold significant promise in delivering personalized and accurate postoperative support. However, their success is highly dependent on the optimization of prompts, which shape the model's reasoning and response generation. This work highlights the transformative potential of incorporating Prompt Agents and Chain-of-Thought (COT) strategies to optimize reasoning and elevate AI-driven postoperative care. By leveraging these techniques, we aim to set new standards for accuracy, relevance, and decision-making performance in clinical applications. Method The study evaluated two distinct RAG architectures integrated into Gemini 1.0 Pro using a curated set of 32 postoperative questions covering five common plastic surgery procedures: liposuction (n=7), breast augmentation (n=6), abdominoplasty (n=6), mastopexy (n=6), and blepharoplasty (n=7). The first architecture utilized a naive RAG pipeline as a baseline, while the second introduced an advanced framework with Prompt Agents incorporating COT strategies. This advanced pipeline enhanced reasoning capabilities, allowing the system to generate more precise, accurate, and contextually relevant responses tailored to postoperative queries. Performance was systematically assessed using key metrics, including medical accuracy, relevance, precision, recall, and F1 score, ensuring a robust evaluation of each model's effectiveness in addressing complex patient concerns. The Prompt Agent-COT framework was designed to improve clinical reasoning and ensure alignment with medical standards, particularly in addressing nuanced and detailed postoperative questions. Results The results demonstrated the superiority of the Prompt Agent-COT framework over the naive RAG pipeline across all performance metrics. The advanced architecture achieved exceptional results, including a precision of 0.81, recall of 1.0, and an F1 score of 0.90. The relevance of its responses was similarly impressive, with 88% rated as highly relevant, 12% as moderately relevant, and 0% as low relevance. The accuracy distribution further underscored its effectiveness, with 81% of responses classified as highly accurate, 19% as moderately accurate, and 0% as low accuracy. In contrast, the naive RAG model underperformed significantly, achieving a precision of 0.50, recall of 0.33, and an F1 score of 0.39. Its relevance distribution showed only 43% of responses rated as highly relevant, 44% as moderately relevant, and 13% as low relevance. Accuracy metrics reflected similar challenges, with 50% of responses falling in the low accuracy range, 25% in the medium range, and only 25% in the high range. These results emphasize the transformative impact of integrating Prompt Agents with COT strategies, showcasing the ability of this advanced framework to outperform baseline models in delivering high-quality responses. Conclusion This study demonstrates the pivotal role of Prompt Agents and Chain-of-Thought strategies in enhancing the reasoning capabilities of RAG-based LLMs for postoperative care. The advanced framework not only improves the precision and accuracy of responses but also ensures greater contextual relevance, tailoring guidance to the unique needs of postoperative patients. By addressing the limitations of naive implementations, this approach provides a transformative solution for delivering superior patient care, paving the way for more reliable, precise, and intelligent AI-driven systems in plastic surgery.

Background: Reduction mammaplasty is one of the most common procedures in plastic surgery, particularly among premenopausal women. Hormonal fluctuations throughout the menstrual cycle have been postulated to influence wound healing. Elevated progesterone and reduced estrogen levels during the postovulatory (luteal) phase have been linked to higher inflammatory responses, disrupted tissue remodeling, and poorer postoperative outcomes, compared to the preovulatory (follicular) phase. The study aimed to evaluate the impact of surgical timing during the menstrual cycle on post-operative complications and wound healing following bilateral reduction mammaplasty.

Methods: A retrospective review was conducted on 1,618 female patients who underwent a bilateral reduction mammaplasty from January 2013 through December 2024. Patients with a recorded last menstrual period (LMP) within 35 days of surgery were included. Breast cancer patients and patients with irregular periods were excluded. The menstrual cycle phase (pre- versus postovulatory) at the time of surgery was determined based on the LMP. Patient characteristics, ovulatory cycle details, peri-operative data, and postoperative surgical outcomes were collected. Statistical analysis included descriptive statistics, t-tests, and multivariate regression analysis to examine the independent impact of menstrual timing while addressing the effect of other confounders.

Results: A total of 129 patients were included, of which 46 (35.7%) were operated during the preovulatory phase, and 83 (64.4%) during the postovulatory phase. Both groups had similar distributions of age, ethnicity, body mass index, comorbidities, and resected breast mass (p>0.05). The postovulatory group had a significantly higher total surgical complications rate (e.g. seromas, hematomas, or surgical site infections) (RR=2.40, 95% confidence interval [CI] 1.07–5.41; p=0.032) and wound dehiscence incidence (RR=2.08; 95% CI 1.04–4.15, p=0.042,) compared to the preovulatory group. Additionally, the postovulatory group was associated with higher rates of fat necrosis (RR=2.77; 95% CI 0.33–23.01) and hypertrophic scar formation (RR=1.94; 95% CI 0.68–5.55), though these findings were not statistically significant (p>0.05).

Conclusions: Undergoing bilateral reduction mammaplasty performed during the postovulatory phase is associated with an increased risk of postoperative wound dehiscence and total complications rate. Considering the timing of the menstrual cycle when scheduling this elective surgery may be a modifiable factor to optimize outcomes in elective breast surgery.

Purpose: Excessive gingival display, often referred to as "gummy smile," is a common aesthetic concern that can adversely affect patients' self-esteem and facial harmony. Minimally invasive correction has gained traction as a viable alternative to more invasive surgical approaches. While existing reviews have centered primarily on Botox injections, emerging techniques such as dermal fillers and autologous fat grafting offer additional avenues for gummy smile correction. This systematic review and meta-analysis aims to comprehensively assess the efficacy, safety, and aesthetic outcomes of these non-surgical interventions. By comparing relative effectiveness, patient satisfaction, and associated complications across treatment modalities, we seek to better inform clinical decision-making and expand the range of minimally invasive options available to patients.

Methods: Literature review was conducted across PubMed, Medline, and Web of Science according to PRISMA guidelines, for articles published up to November 2024. Data extracted included author, specialty, year of publication, sample size, age, sex, follow-up period, minimally-invasive technique employed, total injection units, number of injection points, muscle targets, pre-procedure gingival exposure, post-procedure gingival exposure at each follow-up time point, patient satisfaction measured during each reported follow-up time point, complications. A meta-analysis was performed across all follow-up time points for each technique and reported gingival exposure, with statistical significance set at p < 0.05.

Results: Our search identified 619 publications, of which 33 met the inclusion criteria, examining a total of 717 patients aged 16 to 50 years. Non-surgical techniques for the correction of excessive gingival display decreased gingival exposure by 0.85 mm in the first month following treatment (95% CI: -1.0, -0.7, p<0.0001, I2=56.4%). Further investigation into treatment type, follow-up time, and administered units found that each additional follow-up day significantly increases gingival exposure by 0.0037 mm (95% CI: 0.003,0.005, p<0.0001), Botox significantly reduces gingival exposure by 0.52mm (95% CI: -0.79,-0.25, p<0.001) compared to non-Botox treatment, and the units of Botox applied does not significantly influence gingival exposure (p=0.64). Lastly, patient satisfaction was assessed across studies, finding that 78% of patients who underwent non-surgical treatment for excessive gingival display reported satisfaction with their results (95% CI: 0.7233; 0.8401, p<0.001, I2=58.1%).

Conclusions: Minimally invasive therapies, including botulinum toxin injections, dermal fillers, and autologous fat grafting, significantly reduce excessive gingival display and provide high patient satisfaction. Botox yields greater immediate reductions compared to non-Botox approaches, and the overall dose does not appear to significantly influence outcomes. These findings underscore the value of non-surgical options as viable first-line therapies for correction of excessive gingival display, though further long-term research is needed to assess durability and refine treatment protocols.

BACKGROUND: Celebrities substantially influence public behavior and trends, particularly in cosmetic surgery. When celebrities publicly disclose their own plastic surgery procedures, it can drive societal interest and enhance acceptance of these interventions on a wide scale. Understanding the extent of this influence is essential for plastic surgeons, as it provides insights into shifting trends in cosmetic surgeries and patient motivations. These trends can significantly impact various aspects of cosmetic plastic surgery, shaping the types and frequency of elective procedures patients pursue, the materials and devices used, and the demand for surgeons skilled in specialized techniques. The purpose of this study is to explore the relationship between celebrity announcements of cosmetic procedures and the resulting changes in public interest towards these procedures, as reflected through Google search volume data.

METHODS: We identified 19 celebrities with publicly announced cosmetic procedures, totaling 27 procedures. 63 search terms related to these procedures, based on the 2023 Aesthetic Plastic Surgery Statistics, were entered into Google Trends to gather search volume data for one year before and one year after each announcement (inflection point). Paired t-tests compared search volumes in the pre- and post-announcement periods to detect significant changes in the public interest. A bivariate regression analysis was performed to evaluate the relationship between the timing of celebrity disclosures and changes in search volumes over time, with significance set at p < 0.05.

RESULTS: The aggregate search volumes one year before and after each celebrity's procedure announcement were compared, revealing significant changes in 13 of the 27 cases. Significant increases in search volume were observed for Kim Kardashian's botox, Chrissy Teigen's mastopexy, Iggy Azalea's rhinoplasty, Kris Jenner's facelift, Christina Aguilera's botox, Simon Cowell's botox, and Red Ewing's cheek implants (p < 0.05). Significant decreases in search volumes were noted for Kylie Jenner's lip augmentation, Bella Hadid's rhinoplasty, Cardi B's butt injections, butt injection removal, and nose fillers, and Khloe Kardashian's rhinoplasty (p < 0.05).

CONCLUSIONS: This study underscores the influence of celebrity cosmetic surgery announcements on public interest, with significant changes in search volumes for various procedures. Increased searches following announcements, such as Kim Kardashian's Botox or Chrissy Teigen's Mastopexy, suggest that celebrity endorsements can drive interest, while declines, like that of Kylie Jenner's lip augmentation, may reflect shifting beauty standards or evolving public attitudes. For instance, Cardi B's public regret over her procedures aligns with the observed decrease in searches for butt injections, highlighting how celebrity sentiment may shape public perception. These insights offer plastic surgeons valuable understanding of patient motivations and shifting aesthetic preferences, enabling them to anticipate changes in patient demand for cosmetic procedures and adapt their services, technologies, and training to meet evolving expectations. Future research should expand the celebrity sample and examine how celebrities' attitudes toward their procedures influence the public perception of cosmetic surgery.

Background "Plunging tip" is a common nasal deformity, characterized by excessive downward drooping of the nasal tip while smiling. Accurate assessment and correction of a plunging tip are essential components of rhinoplasty. This study aims to measure changes in the nasolabial and columellar-labial angles before and after smiling as well as assess the efficacy of surgical interventions in improving tip plunging.

Methods This is a retrospective study of patients who underwent primary rhinoplasty at a single private practice with standardized preoperative and postoperative profile view photographs with and without smiling. The nasolabial angle (NLA) was defined as the angle formed by the intersection of the long axis of the nostril and a line drawn perpendicular to the Frankfort horizontal. The columellar-labial angle (CLA) was defined as the angle between the inferior border of the columella and a line from subnasale to labrale superius. Tip plunging was quantified as the differences in NLAs and CLAs with and without smiling. Matched-pairs analyses were used to assess changes in tip plunging both within and between preoperative and postoperative photographs. Analysis of variance was employed to detect intraoperative maneuvers with significant effects on tip plunging.

Results Forty-seven patients were analyzed [72.3% female, mean age: 34.68±12.98 years, median follow-up time: 406 days (IQR:359-531)]. Preoperatively, both NLAs (without smiling: 98.7°±9.0°, smiling: 84.4°±10.3°, p<0.0001), and CLAs (without smiling: 87.1°±11.2°, smiling: 83.1°±15.2°, p<0.0001) decreased significantly upon smiling. Postoperatively, the NLA was also significantly narrower upon smiling (without smiling: 100.5°±6.4°, smiling: 90.5°±8.4°, p<0.0001), while the CLA increased upon smiling (without smiling: 91.4°±9.5°, smiling: 93.4°±12.6°, p<0.0001). Tip plunging was significantly reduced postoperatively compared to preoperatively as measured by both the NLA (p=0.003) and the CLA (p=0.0008). For both preoperative and postoperative assessments of tip plunging using the NLA, 100% of patients exhibited some degree of decrease in the NLA upon smiling. In contrast, preoperative tip plunging assessed with CLA demonstrated plunging in only 66% of patients. Postoperatively, most patients demonstrated a widened CLA upon smiling (55%). Widening of the CLA upon smiling was attributed to concomitant retraction of the upper lip; tip plunging was still appreciated on visual analysis. Significantly reduced plunging as assessed by the NLA was noted with nasal spine grafts (p=0.004) and tip cartilage onlay grafts (p=0.02). Reduced plunging assessed by the CLA was demonstrated with tip suspension sutures (p=0.03) and lateral crural struts (p=0.03). The columellar strut, deployed in approximately 89% of patients, was associated with significantly decreased plunging as assessed by both the CLA (p<0.0001) and the NLA (p<0.0001).

Conclusions The NLA is a more reliable measure of tip plunging than the CLA, as it is less influenced by non-nasal landmarks. Nasal spine grafts, tip cartilage onlay grafts, tip suspension sutures, and lateral crural struts were associated with reduced tip plunging. This study was limited by an inability to analyze septal extension grafting, caudal septum resection, and release of the depressor septi nasi due to their rarity or absence in this sample.

PURPOSE: Nasal osteotomies are integral to rhinoplasty, often used to modify the nasal bony framework for aesthetic and structural refinement. However, lateral osteotomies may cause medialization of the nasal turbinates and narrowing of the bony vault, potentially compromising nasal aerodynamics postoperatively (1). This study employs Computational Fluid Dynamics (CFD) modeling to simulate airflow changes following different degrees of lateral osteotomy infracturing in rhinoplasty patients.

METHODS: Open-source midface skull and airflow cavity models were volume-rendered using 3D Slicer© (version 5.6.2) and exported for further refinement (2-4). ANSYS SpaceClaim (v2024R2) was used to create 1mm, 2mm, and 3mm lateral osteotomies via a high-low-high trajectory outlined in previous literature and airflow volume changes were noted (5). Using ANSYS Fluent (v2024R2), CFD was conducted using the Finite Volume Method (FVM) with continuity and Navier-Stokes equations for steady-state, incompressible, laminar air flow to obtain velocity changes. Nasal cavity material properties were set based on prior literature and inlet velocity and outlet pressures were set based on physiological inspiratory conditions.

RESULTS: Compared to the control model, the 1mm, 2mm, and 3mm infracturing lateral osteotomies exhibited airflow volume decreases of 1.2%, 2.5%, and 4.3% respectively. All models exhibited decreases in velocity at the airway-bone interfaces compared to control models. The 2mm model demonstrated velocity decreases along the full perimeter of the airflow cavity and the 3mm model exhibited significant decreases in airflow velocity throughout the full airflow cavity suggesting significant impacts on overall nasal airflow.

CONCLUSION: Utilizing computational simulations, we evaluated changes in nasal airflow with 1mm, 2mm, and 3mm infractured lateral osteotomies. Volumetric measurements revealed progressive decreases in airflow volume capacity compared to control models. Corresponding fluid flow analyses suggest that the measured volume changes from 2mm and 3mm osteotomies impact airflow velocity throughout the nasal airflow cavity, ultimately affecting breathing outcomes.

REFERENCES: 1. Guyuron, B. Nasal osteotomy and airway changes. Plast Reconstr Surg, 1998:856-860. doi:10.1097/00006534-199809030-00017 2. Fedorov, A., Beichel, R., Kalpathy-Cramer, J., et al. 3D Slicer as an image computing platform for the Quantitative Imaging Network. Magn Reson Imaging. 2012;30(9):1323-1341. doi:10.1016/j.mri.2012.05.001 3. Banoub, RG.; Gill, KS.; Karp, AR, et al. 3D Printed Midface Models for Percutaneous Nasal Osteotomy Surgical Education. Department of Otolaryngology Data Sets. 2021;(1). https://jdc.jefferson.edu/otodata/1 4. Brüning J, Hildebrandt T, Heppt W, et al. Characterization of the Airflow within an Average Geometry of the Healthy Human Nasal Cavity. Sci Rep. Feb 28 2020;10(1):3755. doi:10.1038/s41598-020-60755-3 5. Locketz GD, Lozada KN, Becker DG. Osteotomies-When, Why, and How? Facial Plast Surg. Feb 2020;36(1):57-65. doi:10.1055/s-0040-1701478

Background The nasolabial angle is a common metric used to assess nasal appearance. However, definitions of the nasolabial angle are variable, and at present, no single definition is universally accepted. Given the relative ubiquity of the nasolabial angle in aesthetic evaluation, it is necessary to assess the reliability of the various definitions and examine how they correlate with one another. To that end, this study aims to evaluate and compare the four most common definitions of the nasolabial angle.

Methods Patients undergoing primary rhinoplasty at a single private practice from 2000-2024 were analyzed. Nasolabial angles were measured on preoperative profile-view photographs. Four different definitions of the nasolabial angle were used: (1) the angle formed by the long axis of the nostril aperture and a line perpendicular to the Frankfort horizontal (N-FH), (2) the angle formed by the long axis of the nostril and a line drawn from glabella to pogonion (N-GP), (3) the angle formed by a line from subnasale along the inferior columellar border and a line from subnasale to labrale superius (C-LS), and (4) the angle formed by a line from subnasale along the inferior columellar border and a line tangent to the cutaneous upper lip proper (C-UL). The appearance of subnasale was categorized as either distinct or indistinct. Within each measurement, skewness was calculated and goodness-of-fit was assessed with the Shapiro-Wilk test. Measurements were compared using bivariate analysis.

Results One-hundred patients (84 female, 16 male) were included in the analysis. Mean N-FH was 96.9±6.2°, mean N-GP was 104.2±6.3°, mean C-LS was 109.6±7.8°, and mean C-UL was 132.4±12.5°. N-FH was the least skewed measurement (skewness: -0.2), followed by C-UL (skewness: -0.4) and C-LS (skewness: 0.5), with N-GP being the most skewed (skewness: -0.6). N-FH was the most normally distributed measurement (W=0.99, p=0.4), followed by C-LS (W=0.98; p=0.1) and C-LS (W=0.98; p=0.08). N-FH, C-LS, and C-UL were found to be normally distributed, while N-GP was not (p=0.03). N-FH values correlated significantly with N-GP (p<0.0001) and C-LS values (p=0.03). N-GP was also significantly correlated with C-LS (p=0.003). Neither N-FH nor N-GP correlated with C-UL (p=0.2 and p=0.9, respectively). C-UL correlated only with C-LS (p<0.0001). C-LS was the only measurement that correlated significantly with all three corresponding measurements (N-FH: p=0.03, N-GP: p=0.003, C-UL: p<0.0001). Subnasale was easily distinguishable in only 14 patients; it was not readily discernible in the remaining 86.

Conclusions In our cohort, the most reliable metric for assessing nasolabial angle was N-FH. Despite its reliability, N-FH lacks a true "labial" component, raising an important question regarding the accuracy and utility of current nomenclature. Additionally, the nasolabial angle depends on the Frankfort horizontal, which is a radiographic line whose position can only be estimated on visual analysis, thereby reducing the objective nature of the metric. Variability in the relationship between glabella and pogonion undermines the interpretability of N-GP. Though C-LS was most associated with various nasolabial measurements, C-LS and C-UL rely on the distinctiveness of subnasale and values may be disproportionately driven by anterior nasal spine prominence or maxillary morphology.

Background: Scarring is a common consequence of tissue injury, often causing both physical discomfort and emotional distress. While fractional CO2 laser (FCL) and pulsed dye laser (PDL) have both shown promise in treating scars individually, there is limited research exploring their combined use. This systematic review aims to evaluate the effectiveness and safety of combining FCL and PDL for scar management, following the PRISMA guidelines.

Methods: We conducted a thorough search of several databases, including PubMed, Cochrane, MEDLINE, and ScienceDirect, up until December 2024. The studies included in this review assessed the combined use of FCL and PDL in patients with scars from various causes, focusing on outcomes like scar size, thickness, redness, and pliability. To be included, studies had to have a control group. We independently extracted data and assessed the quality of the studies using standardized tools, with the risk of bias evaluated through the Cochrane Risk of Bias tool for randomized controlled trials (RCTs) and the Newcastle-Ottawa Scale for non-randomized studies.

Results: A total of nine studies, involving 247 patients, were included in the review. The combination of FCL and PDL was found to significantly improve scar appearance, reducing scar thickness, pigmentation, and vascularity. Overall, the aesthetic outcomes were enhanced, as reflected in improvements in Vancouver Scar Scale (VSS) and Patient and Observer Scar Assessment Scale (POSAS) scores. Patient satisfaction rates were high, reaching up to 96.67%. Adverse effects were minimal and manageable, with erythema and hyperpigmentation being the most common, but none of these were long-lasting. Compared to monotherapy, the combined therapy showed superior results, especially in treating hypertrophic and keloid scars.

Conclusion: The combination of FCL and PDL significantly improves scar remodeling and delivers better clinical outcomes than either laser alone. This approach is especially effective for hypertrophic and keloid scars, with high patient satisfaction and minimal side effects. However, more research with standardized treatment protocols and longer follow-up is needed to confirm the long-term benefits and safety of this dual-laser approach.

References: 1. Butzelaar L, Ulrich MM, Mink van der Molen AB, Niessen FB. Currently known risk factors for hypertrophic skin scarring: a review. J Plast Reconstr Aesthet Surg. 2016.

2. Lawrence JW, Mason ST, Schomer K, Klein MB. Epidemiology and impact of scarring after burn injury: a systematic review of the literature. J Burn Care Res. 2012;33:136–46. doi:10.1097/BCR.0b013e3182374452.

3. Wolfram D, Tzankov A, Pülzl P, Piza-Katzer H. Hypertrophic scars and keloids: a review of their pathophysiology, risk factors, and therapeutic management. Dermatol Surg. 2009;35:171–81. doi:10.1111/j.1524-4725.2008.34406.x.

4. Zhang C, Zhu K, Li Y, Zhang X, He J. Efficacy of fractional carbon dioxide laser therapy for burn scars: a meta-analysis. J Dermatol Treat. 2019;30(4):382–7.

5. Tiwari VK. Burn wound: How it differs from other wounds? Indian J Plast Surg. 2012;45:364–73. doi:10.4103/0970-0358.101319.

Introduction:

Postoperative opioid prescriptions can vary significantly, impacting patient recovery and the risk of opioid-related complications. This study aims to identify the factors that influence the total daily opioid dose prescribed postoperatively, measured in morphine milligram equivalents (MME). By examining demographic, procedural, and clinical factors, we seek to uncover patterns that may contribute to variations in opioid prescribing. Understanding these factors is crucial for optimizing pain management and reducing the risk of opioid misuse and complications.

Methods:
A retrospective review of panniculectomy patients from 2022-2024 was conducted. Demographic/clinical data and postoperative opioid prescriptions were recorded. For standardized comparison, the total daily MME dose prescribed was calculated by multiplying the dosage, frequency, and the corresponding MME multiplier. Multivariate linear regression was performed to calculate regression coefficients (β) for variables that influence the total daily opioid dose prescribed postoperatively, controlling for potential confounding demographic, clinical, and procedural variables. Statistical significance was alpha = 0.05.

Results:

172 panniculectomy patients were included, with 87% female, 71% White, at an average age of 47 years. The average procedure time was 135 minutes, and patients had 2 drains placed, on average. The most common opioid prescribed was oxycodone (87%) and the average period of opioid therapy was 4 days. On average, the total daily MME dose prescribed was 33.

Several procedural factors were associated with variations in the total daily opioid dose prescribed. Patients who underwent liposuction were more likely to be prescribed higher amounts of daily opioids compared to those who did not undergo liposuction (β=12.69, p=0.001). Each additional minute of procedure duration was associated with a higher likelihood of receiving more opioids/day (β=0.002, p<0.001). Patients who had more drains placed were likely to be prescribed lower amounts of daily opioids (β=-6.60, p<0.001). Procedures ending in the afternoon were linked to a higher prescribed daily opioid dose (β= 3.24, p=0.04) compared to those ending in the morning (β= -4.30, p=0.009). Greater intraoperative patient body temperature variation was associated with a lower daily opioid dose prescription (β = -0.88, p = 0.02).

Demographic and clinical factors also played a role. Each additional year of age was linked to an increase in prescribed opioid dose/day (β= 0.16, p=0.049). Asian patients were likely to be prescribed lower amounts of daily opioids compared to White patients (β= -25.89, p=0.004). Higher preoperative BMI was associated with greater amounts of daily opioids prescribed (β = 0.16, p = 0.04). A longer time between bariatric surgery and panniculectomy was associated with lower amounts of daily opioids prescribed (β = -0.03, p = 0.04).

Conclusion:

This study identifies several factors-procedural, demographic, and clinical-that influence the total daily opioid dose prescribed after panniculectomy. Since all patients underwent a similar surgical procedure with controlled variables, the observed variations in opioid prescribing patterns are likely influenced by a combination of procedural factors, provider practices, and patient characteristics. Understanding these factors can help inform more objective, evidence-based approaches to opioid prescribing, ultimately optimizing pain management and reducing the risk of opioid-related complications.

Purpose: Arm aesthetics often receive insufficient attention in body rejuvenation, despite their role in overall body harmony. Loose arm skin is a noticeable change associated with aging and massive weight loss but is refractory to minimally invasive treatments such as radiofrequency microneedling or laser therapy. Traditional brachioplasty focuses on skin excision; however, elite arm rejuvenation extends beyond simple removal. By emphasizing gentle contours and underlying muscle definition, an aesthetic and youthful arm appearance can be achieved. This study evaluates a refined approach to brachioplasty using tumescent anesthesia, liposuction for contouring and pre-dissection, dart incisions for precise skin excision, and patient-assisted intraoperative muscle flexion to optimize outcomes.

Technique: A single-center retrospective chart review was conducted, analyzing patients who underwent brachioplasty with tumescent anesthesia between July 2020 and December 2023. Preoperative markings were made with the patient standing, beginning at the ulnar groove between the olecranon and medial epicondyle. Anterior markings were placed at the most inferior portion of the arm while retracting the skin posteriorly to create a convex contour from the elbow to the axilla. A Z-plasty pattern was incorporated into the axilla and, when necessary, extended onto the lateral chest wall for enhanced contouring. Posterior markings were placed similarly by retracting the skin anteriorly. Patients received oral pain medication, and tumescent anesthesia was infused into the soft tissue. The procedure was performed under awake anesthesia, allowing for repositioning and intraoperative muscle flexion to assess contouring and skin turgor. Liposuction was performed before skin excision to facilitate pre-dissection and sculpting. Skin was excised down to the fascial layer while preserving critical neurovascular structures, particularly the medial antebrachial cutaneous and ulnar nerves. Dart incisions and multiple crossing marks ensured precise alignment of tissue post-excision, achieving tensionless closure while maintaining smooth contours. At the axilla, maximal tissue excision was performed, with Z-plasty insetting to prevent scar shortening and contracture. Patient cooperation during the procedure further enhanced sculpting at the bicipital groove and triceps.

Results: A total of 54 patients underwent brachioplasty with liposuction under tumescent anesthesia. The majority (95%) were female, with a mean age of 50.7 years (range: 34–75) and a mean BMI of 29.07. Three male patients, with a mean age of 56.67 years (range: 55–59) and a mean BMI of 29.44, also underwent the procedure. Eight patients had concurrent surgeries, including neck lift with liposuction (n=2), bilateral breast reduction, mastopexy, back liposuction, trunk liposuction, and bilateral mastopexy with implant removal. One female patient developed deep vein thrombosis (DVT) and pulmonary embolism, later diagnosed with an undiagnosed antithrombin III deficiency. No nerve injuries were reported.

Conclusion: Brachioplasty has evolved into an art form beyond excess skin removal. Optimizing results requires refined techniques, including strategic preoperative markings, liposuction-assisted contouring, dart incision-based excision, and awake tumescent anesthesia to facilitate intraoperative contour evaluation. This approach allows for concurrent procedures with favorable outcomes and minimal complications, enhancing arm aesthetics and patient satisfaction.

Background: The deep plane facelift is a procedure utilized to correct progressive soft tissue sagging and neck laxity associated with the aging process. Choosing to perform this procedure can improve aesthetic outcomes as well as decrease operative times. With patients requesting less procedures under general anesthetics, trends have turned towards performing minorly invasive procedures under tumescent anesthesia (1). Limited research has been done on the safety and efficacy of more invasive procedures, such as the deep plane facelift, under tumescent anesthesia (2). This study aims to illustrate the exceptional outcomes that can safely be obtained performing the deep plane facelift under tumescent anesthesia. Methods: This study is a retrospective chart review of 101 patients who underwent a deep plane facelift with tumescent anesthesia between March 2021 and September 2023. All procedures were performed in a Class A QUADA-accredited surgical facility by the senior author. Tumescent fluid containing lidocaine and epinephrine was used for local anesthesia, pain control, and hemostasis. Patients received oral diazepam and oxycodone preoperatively, along with intraoperative IV antibiotics. Patients remained awake throughout the procedure. No drains were used, and all patients were discharged home under the care of a family member. Results: A total of 101 deep plane facelifts were performed under tumescent anesthesia, with 91.1% (n=92) of patients being female and 8.9% (n=9) male. The average age of female patients was 61.96 years (range: 42–83) with a mean BMI of 24.05, while male patients had an average age of 65.11 years (range: 59–74) with a mean BMI of 28.51. Additionally, 33.6% (n=34) of patients underwent concurrent procedures, including blepharoplasty (n=17), lip lift (n=5), CO2 laser (n=3), facial fat grafting (n=2), and rhinoplasty (n=1). Seven patients, all female, experienced minor complications: skin eschar (n=2), hematoma (n=2), and seroma (n=3). No nerve injuries were reported. Conclusion: The deep plane facelift provides patients with excellent results compared to other methods of facial rejuvenation. This is an invasive operation that can be performed safely under tumescent anesthesia, providing patients with optimal outcomes and decreased risk of postoperative complications associated with prolonged anesthesia. As patient awareness of deep plane facelifts increases, there is growing demand for a more definitive procedure involving the release of retaining ligaments for optimal SMAS repositioning, As patients increasingly seek procedures with faster recovery times and reduced reliance on general anesthesia, this technique offers a durable, effective alternative that enhances patient comfort and surgical efficiency. (1): Plastic Surgery Statistics Report: ASPS National Clearinghouse of Plastic Surgery Procedural Statistics. 2019. (2): Frojo G, Dotson A, Christopher K, Kaswan S, Lund H. Facelift performed safely with local anesthesia and oral sedation: analysis of 174 patients. Aesthet Surg J. 2019;39(5):463-469.

Background: Conventional facelift surgery may fail to adequately address submandibular gland ptosis (SMGP), prompting recommendations for partial gland resection. Alternatively, the extended SMAS technique involves a more extensive SMAS-platysma dissection, providing lower facial and neck rejuvenation while preserving the submandibular glands. This study aims to quantify the effect of the extended SMAS technique on SMGP.

Methods: This retrospective cohort study analyzed 53 patients who underwent extended SMAS facelift surgery over a ten-year period in the senior author's practice (Table 1). Photographic analysis was used to quantify SMGP correction and cervicomental angle (CMA) improvement.

Results: All patients were available at a mean follow-up of 8.4 months (range: 1–34 months). Mean SMGP decreased from 8.9 mm preoperatively (range: 0–23 mm) to 0.1 mm postoperatively (range: 0–3.9 mm), with an average improvement of 8.01 mm (P < 0.001). Mean CMA improved from 152° (range: 100–180°) to 121° (range: 92–156°), with a mean change of 30.8° (P < 0.001), Table 2. Two patients (3.8%) were dissatisfied, and three (5.7%) required office revisions.

Conclusion: The extended SMAS facelift technique effectively controls SMGP, nearly eliminating submandibular gland visibility on postoperative photographic analysis while enhancing neck angularity. This improvement may result from the thorough release of the cervical and parotid retaining ligaments, as well as the platysma-auricular ligament. This level of SMAS-platysma flap mobilization may create a more effective sling-like effect on the contents of the digastric triangle, potentially obviating the need for submandibular gland resection.

Background: Conventional facelift surgery may fail to adequately address submandibular gland ptosis (SMGP), prompting recommendations for partial gland resection. Alternatively, the extended SMAS technique involves a more extensive SMAS-platysma dissection, providing lower facial and neck rejuvenation while preserving the submandibular glands. This study aims to quantify the effect of the extended SMAS technique on SMGP.

Methods: This retrospective cohort study analyzed 53 patients who underwent extended SMAS facelift surgery over a ten-year period in the senior author's practice (Table 1). Photographic analysis was used to quantify SMGP correction and cervicomental angle (CMA) improvement.

Results: All patients were available at a mean follow-up of 8.4 months (range: 1–34 months). Mean SMGP decreased from 8.9 mm preoperatively (range: 0–23 mm) to 0.1 mm postoperatively (range: 0–3.9 mm), with an average improvement of 8.01 mm (P < 0.001). Mean CMA improved from 152° (range: 100–180°) to 121° (range: 92–156°), with a mean change of 30.8° (P < 0.001), Table 2. Two patients (3.8%) were dissatisfied, and three (5.7%) required office revisions.

Conclusion: The extended SMAS facelift technique effectively controls SMGP, nearly eliminating submandibular gland visibility on postoperative photographic analysis while enhancing neck angularity. This improvement may result from the thorough release of the cervical and parotid retaining ligaments, as well as the platysma-auricular ligament. This level of SMAS-platysma flap mobilization may create a more effective sling-like effect on the contents of the digastric triangle, potentially obviating the need for submandibular gland resection.

Purpose This study aims to provide a comprehensive quantitative analysis of aesthetic procedure trends worldwide compared to the US, providing a relatable benchmark for US-based plastic surgeons. Examining trends in aesthetic surgery across different regions and levels of economic development, this study also explores the relationship between socioeconomic factors and the prevalence of these procedures.

Methods & Materials Data were analyzed from the 2023 International Society of Aesthetic Plastic Surgery (ISAPS) Global Survey, encompassing over 21 million procedures reported by more than 1,600 board-certified plastic surgeons across 23 countries. To facilitate comparisons across countries with varying population sizes, procedure rates were calculated per 100,000 people. To focus on procedure rates among the aesthetic clientele in a given country, procedure rates were also calculated per 1,000 aesthetic procedures. Linear regression analysis was used to assess the correlation between GDP per capita and procedure prevalence. Chi-squared tests were employed to compare the proportion of surgical versus nonsurgical procedures between developed and developing countries. Finally, odds ratios (ORs) and their respective 95% confidence intervals (CIs) were calculated to compare procedure rates abroad with those in the US. To capture the full spectrum of variation in aesthetic procedures between the US and other regions, procedures with the five highest and lowest ORs were identified for each region. Conversely, those with ORs closest to 1 were also identified to determine procedures that have similar popularity in the US.

Results Developing countries demonstrate a preference for surgical procedures (55.4%), while nonsurgical procedures predominate in developed countries (66.8%) (p < 0.0001). A moderate positive correlation was found between GDP per capita and total aesthetic procedures (r = 0.49, p < 0.05). This correlation was more pronounced for nonsurgical procedures (r = 0.53, p < 0.05), with no significant correlation observed for surgical procedures (r = 0.23, p = 0.291). Latin America exhibits a significantly higher volume of buttock augmentation (OR = 13.71 [95% CI: 13.53-13.89], p < 0.0001), the Middle East shows a preference for rhinoplasty (OR = 10.36, [95% CI: 10.26-10.47], p < 0.0001), and eyelid surgery is more prevalent in Southeast Asia (OR = 8.83, [95% CI: 8.71-8.95], p < 0.0001) compared to the US. Europe mirrors the US with a strong preference for nonsurgical procedures (71.1% vs. 60.6%, respectively), and shares 9 out of the top 10 surgical procedures.

Conclusion While anecdotal evidence and qualitative observations have hinted at variations in surgical expertise and beauty standards across different countries, this study represents the first quantitative analysis to rigorously assess and measure these international trends. The higher prevalence of surgical aesthetic procedures in developing countries, where access to surgical care is often limited, presents a seeming paradox. This may be attributed to a prioritization of long-lasting results and a desire to avoid the ongoing maintenance associated with nonsurgical options. The complex relationship between GDP per capita and aesthetic procedure volume suggests an interplay of economic capacity and the cultural value a region places on aesthetic enhancements.