Eyebrow Height Changes with Aging: A Systematic Review and Meta-analysis Background: The eyebrows play an important role in emotional facial expressions, nonverbal communication, and facial esthetics. A comprehensive understanding of the mechanisms underlying eyebrow aging is vital in allowing plastic surgeons to appropriately address these age-related changes and to recreate an aesthetically desirable outcome for patients seeking brow rejuvenation. The aim of this study is to summarize the current literature on eyebrow height changes with aging. Methods: A comprehensive search was conducted across several databases to identify all published studies that reported changes of eyebrow position or height with aging, from 1946 to January 2019. Studies that reported eyebrow position at the level of medial canthus, mid-pupil, and lateral canthus were included in a meta-analysis. Results: A total of 346 articles were initially identified, of which 19 met our inclusion criteria. Of 3,634 patients who were identified, 2,237 (64%) were females and 1,274 (36%) were males. Eyebrow height showed significant increase with aging at the level of medial canthus (mean difference 1.4 mm; 95% CI: 0.22–2.59; P = 0.02), and the level of mid-pupil (mean difference 1.17 mm; 95% CI: 0.54–1.8; P = 0.0002). However, no significant difference was found at the level of lateral canthus (mean difference 0.19 mm; 95% CI: −0.87 to 1.25; P = 0.72). Conclusions: Based on the reviewed literature to date, the medial eyebrow height increases with age, whereas it remains stable at the level of the lateral canthus. These results should be considered when considering eyebrow rejuvenation.

Assessment of Rhinoplasty Outcomes with FACE-Q Rhinoplasty Module: Norwegian Linguistic Validation and Clinical Application in 243 Patients Background: Patient satisfaction after rhinoplasty is a growing area of research. The FACE-Q Rhinoplasty Module, used to assess these values, requires translation to national languages. Methods: Fourteen questions assessing the Satisfaction with Nose Scale and Adverse Effects Checklist of FACE-Q Rhinoplasty Module were translated to Norwegian with adherence to the Mapi Research Trust guidelines. Answers were processed by QuestBack anonymously. Of the 243 patients undergoing rhinoplasty at Oslo Plastic Surgery Clinic, 214 patients were reachable by e-mail. Results: Response rates to the pre- and postoperative questionnaire were 23% and 32%, respectively. Responses for somewhat or very satisfied with the nose (pre- versus postoperative) were: overall size of the nose (16.3% versus 61.7%); how straight the nose looks (22.4% versus. 58.3%); how well the nose suits the face (12.2% versus 60%); length of the nose (20.4% versus 68.4%); width of the nose at the bottom (26.6% versus 55%); bridge of the nose (14.3% versus 55%); how the nose looks in photographs (10.2% versus 50%), and tip of the nose (16.3% versus 48.3%). Adverse effects (pre- versus postoperative) were moderate or extreme difficulty breathing through the nose (28.6% versus 35%); tenderness (6.1% versus 23.7%); skin of the nose looking thick or swollen (14.6% versus 30.5%); and unnatural bumps or hollows on the nose (55.1% versus 53.3%). Conclusions: Satisfaction levels in rhinoplasty patients are not as high as in other cosmetic surgery procedures, such as breast augmentation. However, compared with baseline, satisfaction levels showed great improvement postoperatively. The Rhinoplasty Module seems useful in evaluating outcome of rhinoplasty. We encourage application of this clinical outcome of rhinoplasty in and among centers.

Nasal Skin Thickness Measurements Using Computed Tomography in an Adult Saudi Population Background: Rhinoplasty is one of the most challenging operations in plastic surgery, and nasal skin thickness is a significant factor in determining rhinoplasty success. Only a few studies have measured nasal skin thickness before rhinoplasty. The present study was designed to measure nasal skin thickness to shed light on its importance to successful rhinoplasty. Methods: Altogether, 60 patients underwent measurements of nasal skin thickness at 4 aesthetic points: nasion, rhinion, nasal tip, columella. The thickness was measured using computed tomography (CT), an objective, reliable tool for this purpose. Universally adopted Hounsfield unit measurement using in house software (Consultant Radiology Center, Riyadh, Saudi Arabia) was performed using CT scan. Results: The study group included 32 women and 28 men. Age range was 18–68 years, but most of the patients (53.3%) were within the 20–30-year age range. CT results showed that the mean nasal skin thickness was 3.96 ± 1.08 mm at the nasion, 1.86 ± 0.62 mm at the rhinion, 3.32 ± 0.78 mm at the nasal tip, and 3.32 ± 0.73 mm at the columella. When the nasal skin thicknesses were compared between men and women, a significant difference was observed only at the columella (P = 0.016). Conclusions: The nasal skin is thickest at the nasion, thinner at the rhinion, and again thicker at the nasal tip and columella. Our data could be useful for plastic surgeons who could take the patient’s own nasal area thickness into consideration when planning his or her rhinoplasty.

Translucent and Ultrasonographic Studies of the Inferior Labial Artery for Improvement of Filler Injection Techniques Background: Lower lip augmentation by filler injection is an aesthetic procedure essential for achieving a feminine look and to enhance attractiveness. Complications as a result of injury to the inferior labial artery can result in undesirable outcomes. Methods: The translucent technique was used to study the origin of the inferior labial artery in 11 cadavers. Ultrasonography of the inferior labial artery was also performed in 20 volunteers, which provided supplemental data to this study, in relation to establishing recommendations for filler injection. Results: Five different types of inferior labial artery were described. These types were found in various combination patterns. Types 2, 4, and 5 are more vulnerable to arterial injury during filler injection. Ultrasonography revealed a depth of 6 mm and an arterial position at the vermillion border as the dangerous injection plane. Conclusion: The origins and courses of the inferior labial artery are classified into 5 types. These types are often found in combination with each other in different faces, resulting in large anatomical variation between people. Types of combination influence severity of lower lip necrosis when arterial injury occurs. The physician should be aware of these anatomical variations during aesthetic treatments and reconstructive procedures to avoid the dangers of accidental arterial injury.

An Ideal Female Breast Shape in Balance with the Body Proportions of Asians Background: Defining an ideal breast shape is one of the most fundamental and essential parts for a breast surgery. To propose a set of criteria for determining an ideal breast shape of Asians, the authors performed a survey using a questionnaire based on important esthetic elements of a breast. Methods: The authors created a 11-item questionnaire, asking breast shape preference in the frontal and the lateral views. Each question had multiple options, each of which was accompanied by adequate illustrations. Results: A total of 1,012 Asian responses were collected. In the frontal view, preferences converged for position of the nipple to be at 45% of the SU (distance from the sternal notch to the umbilicus) and the inframammary fold at 60% of the SU. For lateral bulging of the breast, the respondents preferred it to be 100% of the upper buttock, and 100% of the interacromion width. As for the lower pole height, breast width ratio of 50% was the most preferred. In the lateral view, straight slope of the upper breast was the most preferred, along with a 1.0 projection ratio and a front-facing nipple. The most ideal vertical proportion of the breast footprint was selected as 65:35, and for the anterior breast as 55:45. Conclusion: The authors used a questionnaire analysis, which considers a proportional balance between the breast and the whole body shape, and proposed that an ideal breast shape can be used effectively in planning for and assessing the outcomes of breast surgery

The Posterior Arm Flap for Reshaping the Postbariatric Breast Background: Postbariatric surgery, either by itself or in association with other procedures, tries to correct physical defects and body deformities. Because of the intrinsic complexity of massive weight loss (MWL) patients, more than a single procedure is, most of the time, required. We report a combined surgical method able to improve arms’ and breasts’ contour that aims to obtain a satisfying functional and aesthetic result by reducing surgical times and costs. Methods: A female MWL patient with proper body mass index was clinically evaluated and considered suitable for surgery. While authors performed a modified Pascal-Le Louarn brachioplasty for the upper arm, a standard McKissock mastopexy followed by a Wise pattern skin closure was selected to obtain the breast lift. By sparing the proximal pedicle, the fasciocutaneous flaps were harvested on both posteromedial sides of the arms. The posterior arm flaps (PAF) were tunneled and transposed below the subcutaneous skin bridge across the axilla and finally used to increase the breast mound. Results: In the immediate postoperative follow-up, no complications were reported. After the 6-month and 1-year follow-up, both arms’ silhouette was documented as healthy and symmetric. Breasts were soft, without any signs of ptosis and/or contracture. No skin disorders or scar hypertrophy or lymphedema were reported. Conclusions: PAF in breast contouring procedures is an interesting surgical option, but more patients need to be treated to validate the effectiveness of the procedure. This technique should be considered when there is a need for simultaneously improving arm’s contour and breast’s volume and shape.

Acellular Dermal Matrix Performance Compared with Latissimus Dorsi Myocutaneous Flap in Expander-Based Breast Reconstruction Background: Latissimus dorsi myocutaneous flap (LDMF) with tissue expander provides excellent results in breast reconstruction. Acellular dermal matrix (ADM) has been used in expander-based reconstruction (EBR) with good results. This study assesses how ADM compares to LDMF in EBR. Methods: The cohorts comprised 124 patients (218 breasts) who had EBR using ADM between 2006 and 2012, and 242 patients (266 breasts) who had EBR using LDMF between 1994 and 2012. Postoperative complications, reoperations, Breast-Q scores, and objectively assessed aesthetic outcomes were compared. Results: Median age was 55 years for both ADM (range 23–84) and LDMF (range 26–88) groups. No statistically significant differences were noted between the groups in the rates of major postoperative complications (P > 0.3). Forty-nine of the 218 (22.5%) in the ADM group and 67 of 266 (25.2%) in the LDMF group had a total of 63 and 84 reoperations, respectively (P = 0.52), with no significant differences in the reoperations rate (P > 0.3). No significant differences were observed in the Breast-Q scores. Some categorical differences were noted in the aesthetic outcomes; however, the difference between the overall outcomes was not significant (P = 0.54). Conclusion: Our study revealed no statistically significant differences in the complications or reoperation rates, patient satisfaction, or overall aesthetic outcomes when comparing the use of ADM to LDMF in EBR. In conclusion, this study supports the hypothesis that ADM performs as well as LDMF in EBR.

Successful Immediate Staged Breast Reconstruction with Intermediary Autologous Lipotransfer in Irradiated Patients Background: As indications for radiotherapy in mastectomized patients grow, the need for greater reconstructive options is critical. Preliminary research suggests an ameliorating impact of lipotransfer on irradiated patients with expander-to-implant reconstruction. Herein, we present our technique using lipotransfer during the expansion stage to facilitate implant placement. Methods: A retrospective review of postmastectomy patients with expander-to-implant reconstruction by one reconstructive surgeon was performed. All patients were treated with immediate expander and ADM placement at the time of mastectomy. Irradiated patients underwent a separate lipotransfer procedure after completion of radiotherapy but prior to prosthesis exchange. Our study compared postoperative outcomes between non-radiated patients and irradiated patients who underwent this intermediary lipotransfer. Clinical endpoints of interest included: overall complications, infection, delayed wound healing, dehiscence, capsular contracture, implant failure, and reoperation. Results: One hundred and thirty-one breast reconstructions were performed; 18 (13.74%) were irradiated and 113 (86.26%) were not. Overall complication risk (infection, implant failure, or reoperation) was no higher in irradiated breasts treated with lipotransfer than non-irradiated breasts (p=0.387). Fifteen patients who had one radiated and one non-radiated breast were separately analyzed; no difference in complication by radiotherapy exposure (p=1) was found. Age, BMI, smoking status, and nipple-sparing versus skin-sparing mastectomy did not vary significantly between study groups (p=0.182, p=0.696, p=0.489, p=1 respectively). Conclusions: Comparable postoperative outcomes were found between non-radiated breasts and radiated breasts treated with intermediary lipotransfer. The ameliorating effects of autologous lipotransfer on radiotoxicity may therefore offer irradiated patients the option of expander-to-implant reconstruction with acceptable risk and cosmesis.

Volumetric Symmetry after Unilateral Autologous Breast Reconstruction: A Reasonable Goal Background: With growing concerns about the overuse of contralateral prophylactic mastectomy, optimizing unilateral mastectomy reconstruction outcomes becomes a priority. However, there remains a paucity of objective data that describe volumetric symmetry between a natural and autologous-reconstructed breast. Methods: We evaluated patients who underwent unilateral mastectomy reconstruction with free-flap abdominal tissue transfer from 04/2006 to 01/2015, and had at least 2 postoperative magnetic resonance images (MRIs; n = 28). Using these MRI data, volumetric measurements of the reconstructed and natural breast were performed at the first postoperative MRI (after all revisions were complete) and the most recent MRI. Relationships were analyzed using Spearman correlation coefficients. A symmetry score (SS) was calculated such that values closer to 1.0 reflected volumetric symmetry. Results: The mean age (years) and BMI of the patients was 44.8 and 26.8, respectively. The mean interval time between the MRIs was 3.03 years (range 0.43–6.6). After surgical revisions were complete, volumetric symmetry between reconstructed and nonreconstructed breasts was typically achieved (mean SS 0.92). This symmetry was also retained at the end of follow-up (mean SS 0.96), despite a mean change in BMI of 3.9% (range 1.1–7.7). Additionally, the mean number of flap revisions was 0.75 (range 0–2), and 39% of patients had a procedure performed on the natural breast. Conclusion: In patients undergoing unilateral abdominal-based breast reconstruction, volumetric symmetry is attainable; however, it can require flap revisions and procedures to natural breast. Interestingly, this study does show that initial symmetry is retained postoperatively, regardless of changes in BMI.

Improvement in Sleep Architecture is associated with the Indication of Surgery in Syndromic Craniosynostosis Background: Children with syndromic craniosynostosis (sCS) often suffer from obstructive sleep apnea (OSA) and intracranial hypertension (ICH). Both OSA and ICH might disrupt sleep architecture. However, it is unclear how surgically treating OSA or ICH affects sleep architecture. The aim of this study was twofold: to explore the usefulness of sleep architecture analysis in detecting disturbed sleep and to determine whether surgical treatment can improve it. Methods: Eighty-three children with sCS and 35 control subjects, who had undergone a polysomnography (PSG), were included. Linear-mixed models showed the effects of OSA and ICH on sleep architecture parameters. In a subset of 19 patients, linear regression models illustrated the effects of OSA-indicated and ICH-indicated surgery on pre-to-postoperative changes. Results: An increase in obstructive-apnea/hypopnea index (oAHI) was significantly associated with an increase in N2-sleep, arousal index, and respiratory-arousal index and a decrease in REM-sleep, N3-sleep, sleep efficiency, and sleep quality. ICH and having sCS were not related to any change in sleep architecture. OSA-indicated surgery significantly increased the total sleep time and sleep efficiency and decreased the arousal index and respiratory-arousal index. ICH-indicated surgery significantly decreased REM-sleep, N1-sleep, sleep efficiency, and sleep quality. Conclusions: For routine detection of disturbed sleep in individual subjects, PSG-assessed sleep architecture is currently not useful. OSA does disrupt sleep architecture, but ICH does not. OSA-indicated surgery improves sleep architecture, which stresses the importance of treating OSA to assure adequate sleep. ICH-indicated surgery affects sleep architecture, although it is not clear whether this is a positive or negative effect.