Downward Rotation of the Capsulopalpebral Fascia, Orbital Septum, and Orbital Fat Complex: A New Technique for Lower Eyelid Rejuvenation Background: Filling of the orbitomalar sulcus through fat conservation and relocation is important for the lower eyelid rejuvenation procedure and has been reported on extensively. This study aimed to introduce a new technique—downward rotation of the capsulopalpebral fascia, septum, and fat complex in lower eyelid blepharoplasty to correct orbitomalar sulcus depression. Methods: Eighty-six patients who underwent transcutaneous lower eyelid blepharoplasty for cosmetic purposes from March 2015 to March 2016 were included in this study. The results were evaluated based on pre- and postoperative photographs, surgical records, and questionnaires. Results: The patients had no permanent or major complications. There were no fat hernia recurrences, diplopia, fat granulomas, or soft tissue irregularities. Approximately 98% of the patients were satisfied with the outcome. Conclusions: This technique more completely fills the orbitomalar sulcus and reinforces the anterior wall of the lower lid septum with capsulopalpebral fascia by rotating the orbital fat downward with the septum and capsulopalpebral fascia. Thus, it lowers the recurrence rate of the lower lid fat hernia and does not require fat removal. In particular, it has a distinct advantage in terms of the correction of the orbitomalar sulcus depression in reoperation cases, especially in patients who undergo fat removal or those with excessive fat removal.

Influence of Social Media on the Decision to Undergo a Cosmetic Procedure Background: There is a rise of cosmetic procedures in Saudi Arabia. Social media have become a popular means of advertisements for cosmetic professional providers. There are currently no studies that determine the relationship between viewing cosmetic surgery advertisements and considering undergoing cosmetic procedures in female university students in Saudi Arabia. Methods: A cross-sectional study was conducted using an online survey. This survey determined the use of social media, cosmetic-related accounts followed by the respondent, and attitudes toward advertising for cosmetic treatments on social media. It also determines the influence of these accounts on female university students to consider undergoing cosmetic treatments in the future. The survey was distributed on multiple social media platforms and by Email. Results: Out of 816 completed questionnaires, 48.5% reported being influenced by social media to consider undergoing cosmetic procedures. Respondents (51.4%) follow plastic surgeons on social media (P < 0.001). The most common reported number of hours of social media use per day was >5 hours per day (53.2%; P < 0.026). Statistical significance was considered in relation to reporting being influenced by social media to consider undergoing cosmetic procedures in the future. Conclusions: Our findings revealed that viewing cosmetic surgery–related material on social media, spending longer hours on social media platforms, and having negative self-views when viewing social media are associated with an increased likelihood of considering undergoing cosmetic procedures in the future. Future studies using a validated questionnaire that assesses the likelihood of being influenced by social media to undergo cosmetic treatments are encouraged.

Skin Protein Profile after Major Weight Loss and Its Role in Body Contouring Surgery Background: Chronic inflammation during morbid obesity significantly alters cutaneous tissue. Large weight loss achieved after bariatric surgery minimizes or halts damage caused by metabolic syndrome, but further deteriorates the clinical condition of skin. Postbariatric skin flaccidity produces major difficulties to plastic surgery. In this study, we analyzed differences in protein composition of the skin between patients with morbid obesity and those after large weight loss and established correlations between differentially expressed proteins and clinical characteristics of postbariatric skin tissue, to improve body contouring surgery techniques. Methods: Skin fragments were removed from the abdomen of 32 patients, who were allocated into 3 groups: morbidly obese, large weight loss without surgery, and postbariatric surgery. Samples were subjected to proteomic analysis, and the protein profiles of the groups were compared. Six differentially expressed proteins of clinical interest were validated by immunohistochemistry and statistical analysis. Results: Comparative analyses confirmed differences in protein profile of the skin between morbidly obese and large weight loss groups. A persistent increase in inflammatory markers such as haptoglobin was observed in all groups and decrease in the expression of collagen XIV, which regulates the physical properties of cutaneous tissue, was observed in the postbariatric group. Conclusions: High expression of haptoglobin associated with the decrease of Collagen XIV, vinculin, and periplakin in the groups after major weight losses, mainly postbariatric, confirm that the inflammatory lesion remains active in the skin and causes changes in its structural organization, with serious repercussions on its clinical characteristics and physical properties.

Treatment of Horizontal Neck Wrinkles with Hyaluronic Acid Filler: A Retrospective Case Series Background: Horizontal neck wrinkles are a common aesthetic deficiency but limited treatment options exist and none have been studied with follow-ups of over 2 months. Methods: This dual-center, retrospective case series (Apr 2016–Jan 2017) included adult patients receiving CPM-HA to treat horizontal neck wrinkles. Patients were followed up for 40 weeks. CPM-HA treatment efficacy was evaluated through the Horizontal Neck Wrinkle Severity Scale and Global Aesthetic Improvement Scale (GAIS). Adverse events (AEs) and pain on injection, as assessed on the visual analogue scale, were documented. Results: Sixty-four lateral neck halves from 32 women (23–61 years) were analyzed. Significant improvement in wrinkle intensity, as assessed by Horizontal Neck Wrinkle Severity Scale, was observed from the second week onwards (1.352 ± 0.682, P<0.05). This improvement was sustained throughout the study duration and remained statistically significant at week 36 (1.423 ± 0.796, P<0.05). Patient GAIS (92.3%–100% through 36 weeks) and physician GAIS (100% through 24 weeks) were both excellent. Visual analogue scale scores revealed more pain associated with blunt cannula use (2.72 ± 1.71) than with sharp needle use (1.75 ± 1.39). AEs included erythema (62.5%), pruritus (43.7%), ecchymosis (43.7%), and localized swelling (25%). Conclusions: Subdermal injection of CPM-HA is safe and effective for treating horizontal neck wrinkles. Sustained improvement of wrinkle intensity up to 36 weeks and minimal AEs with no Tyndall effect were observed.

Rhinoplasty and External Nasal Splinting: Is It Really a Must? Background: Rhinoplasty is a common and challenging procedure. Lateral osteotomy is routinely performed in most cases. Most of the surgeons have the habit of applying external nasal splints to stabilize the nasal tissues and bone in their new position postrhinoplasty. These splints are widely used despite the absence of any evidence supporting this practice. Moreover, these splints have a lot of disadvantages, so we conducted this study to evaluate the cosmetic result in their absence. Patients and Methods: A retrospective cross-sectional study was performed. Medical records of 211 patients operated on for rhinoplasty by the same surgeon from 2015 to 2017 were reviewed. All patients were operated using open technique. After surgery, a Steri-Strips dressing with an overlying layer of surgical tape was applied to the nose without the use of an external nasal splint. Most of the patients were followed up for 18 months. Complication rates, revision rates, and nasal bone widths were recorded. Results: Complication rates and revision rates were as follows: skin infection 0.99%, skin necrosis 0.99%, and secondary revision 3.48%. Finally 79.60% of patients had a decrease in their nasal bone width postsurgery. Conclusion: Based on the present study, external nasal splinting postrhinoplasty should not be routinely used. Satisfactory cosmetic results can be obtained while avoiding the complications, cost, and bulky dressings associated with external splints.

Multilevel Breast Reduction: A Retrospective Study of 338 Breast Reduction Surgeries Background: Aesthetic breast reduction is a common plastic surgery procedure with the potential for considerable improvement of the patient’s quality of life in addition to its aesthetic value. Many different approaches have been described for breast reduction to improve upon previous techniques in terms of scarring, nipple position, amount of breast tissue excised, shape, and longevity of the results. However, medium size resections in ptotic and wide breasts are difficult to treat using both the most common inferior pedicle wise procedure and the various vertical scar techniques. Methods: A retrospective study of 338 consecutive bilateral breast reduction patients between January of 2010 and January of 2018 at a single center by a single surgeon using a vertical scar technique. Demographic and postoperative outcome data were collected and evaluated. Results: Patient satisfaction with the results was high. Complication rates were comparable or lower than previously published series. Major complications requiring revision surgery: 3 (0.8%) hematomas; minor complications: 68 (20%) cases of superficial dehiscence; 12 (3.5%) superficial surgical site infections; 11 (3.2%) seromas; 4 (1.2%) fat necrosis; and 1 (0.2%) partial areola necrosis. Conclusion: The Borenstein Breast Reduction technique aims to recreate the breast mound support from the “bottom up” facilitating long-lasting results and high patient satisfaction rates. This approach can be helpful in all breast reductions and is most effective in wide ptotic breasts.

Anthropometric Breast Measurement: Analysis of the Average Breast in Young Nulliparous Saudi Female Population Background: Anthropometric measurements and proportions of the female body play a significant role in plastic and reconstructive surgery. This study is aimed to identify the descriptive measurements of the breast in a sample population of young nulliparous Saudi women. Methods: Fifty-four nulliparous Saudi women of 20–25 years old, with no physical or developmental deformity, and body mass index (BMI) of 20–25 kg/m2 were recruited. The following parameters were measured: body weight, height, BMI, sternal notch-nipple length for each breast (SN), internipple distance (IND), distance from nipple to inframammary fold (IMF), distance from edge of areola to the IMF, and areolar diameter (AD). Results: The mean values of age, BMI, height, and weight of the participants were 22.1 ± 1.2 years, 21.8 ± 3.1 kg/m2, 162.1 ± 5 cm, and 57.4 ± 8.6 kg, respectively. The mean values of the breast parameters were 19.8, 20.3, 7.7, 5.4, and 4.5 cm for SN, IND, distance from nipple to IMF, distance from lower end of the areola to IMF, and AD, respectively. Statistically significant difference was found only in the distance from edge of areola to IMF between the right and left breasts, with the parameter significantly higher in the left breast (P < 0.05, n = 54). A positive correlation between weight and BMI was found in SN, IND, distance from nipple to IMF, and AD. Conclusion: These study results will be useful for the comparison of anthropometric breast values of young Saudi women with those of women from other nationalities.

Triple-Plane Augmentation Mastopexy Background: Dual-plane augmentation mammaplasty has gained wide popularity in treating breast ptosis. However, in our experience, dual-plane augmentation mastopexy fails to treat severe cases of ptosis (grade 3) and glandular ptosis. Therefore, we conceived a method to manage these cases effectively. The aim was to achieve harmonious, natural fullness, better projection, and appropriate size with limited scarring. We named this technique triple-plane augmentation mastopexy as three planes are used: the first plane is the subfascial plane, the second is the subglandular plane, and the third is the subpectoral plane. Methods: A retrospective review was performed of 75 consecutive cases of grade 3 or glandular ptosis treated in a single clinic by three separate surgeons adopting the same technique from January 2010 to January 2017. Triple-plane augmentation mastopexy begins by undermining the breast tissue through a tunnel until the second rib is in the prepectoral plane. Then, the subpectoral pocket for the implant is dissected with release of the lower border of the pectoralis major and avoiding release of the sternal border. Subsequently, the breast tissue is suspended at the lower border of the second rib, followed by subpectoral insertion of the implant and skin envelope excision. Results: Surgical follow-up varied from a minimum of 6 months to a maximum of 6 years, with an average of 3 years. Among a total of 75 patients, 64 patients (85.3%) complied with follow-up and 49 (76.5%) of these patients were satisfied. Complications varied from early complications (14.6%) to late complications (21.5%). Conclusions: Grade 3 and glandular ptosis represent a challenge to plastic surgeons. Traditional techniques may fail to achieve optimized results. Triple-plane augmentation mastopexy is a safe, reliable procedure that ensures long-term desired aesthetic outcomes with limited scarring.

Antimicrobial Irrigation and Technique during Breast Augmentation: Survey of Current Practice Background: Breast augmentation is among the most common procedures performed in the United States. Though bacterial contamination of breast prostheses is associated with adverse sequelae, there are no universally accepted guidelines and limited best practice recommendations for antimicrobial breast pocket irrigation. We designed a survey to identify pocket irrigation preferences and antimicrobial techniques during implant-based breast augmentation among American Society of Plastic Surgeons (ASPS) members. Methods: In January 2018, a random cohort of 2,488 ASPS members was surveyed. Questions queried breast pocket irrigation methods and surgical techniques including implant placement, incision location, and implant soaking agents. An extensive literature review of breast pocket irrigation practices was completed and used as a basis for the survey. Results: The survey response rate was above the ASPS average at 16% (n = 407). Respondents preferred an inframammary incision (90%) and submuscular implant placement (92%). Triple antibiotic solution (TAS) and TAS + Betadine ± Bacitracin were preferred by 61% and Betadine variants by 11%. Preferred dwell times stratified to 30 seconds (39%), 1 minute (18%), 2–5 minutes (21%), and >5 minutes (22%). Among those employing a TAS variant, 53% preferred a suboptimal dwell time of ≤1 minute. Prostheses were soaked in TAS (42%), TAS + Betadine ± Bacitracin (15%), a Betadine variant (12%), or other (31%). Conclusions: Periprosthetic bacterial contamination leads to comorbidity following breast augmentation. Our results reveal significant variability regarding breast pocket irrigation techniques among ASPS members during cosmetic breast augmentation. These data suggest the need for best practice guidelines regarding breast pocket irrigation and implant soaking agents.

Defining Quality Indicators for Breast Device Surgery: Using Registries for Global Benchmarking Background: Breast device registries monitor devices encompassing breast implants, tissue expanders and dermal matrices, and the quality of care and patient outcomes for breast device surgery. Defining a standard set of quality indicators and risk adjustment factors will enable consistency and adjustment for case-mix in benchmarking quality of care across breast implant registries. This study aimed to develop a set of quality indicators to enable assessment and reporting of quality of care for breast device surgery which can be applied globally. Methods: A scoping literature review was undertaken, and potential quality indicators were identified. Consensus on the final list of quality indicators was obtained using a modified Delphi approach. This process involved a series of online surveys, and teleconferences over 6 months. The Delphi panel included participants from various countries and representation from surgical specialty groups including breast and general surgeons, plastic and reconstructive surgeons, cosmetic surgeons, a breast-care nurse, a consumer, a devices regulator (Therapeutic Goods Administration), and a biostatistician. A total of 12 candidate indicators were proposed: Intraoperative antibiotic wash, intraoperative antiseptic wash, preoperative antibiotics, nipple shields, surgical plane, volume of implant, funnels, immediate versus delayed reconstruction, time to revision, reoperation due to complications, patient satisfaction, and volume of activity. Results: Three of the 12 proposed indicators were endorsed by the panel: preoperative intravenous antibiotics, reoperation due to complication, and patient reported outcome measures. Conclusion: The 3 endorsed quality indicator measures will enable breast device registries to standardize benchmarking of care internationally for patients undergoing breast device surgery.