Publications by authors named "Elbert E Vaca"

39 Publications

Creating Harmonious Arcs: The Importance of Brow Shape in Determining Upper Lid Aesthetics.

Clin Plast Surg 2022 Jul;49(3):389-397

Private Practice, 660 Glades Road, Suite 210, Boca Raton, FL 33431, USA.

Brow lifting, when indicated, can significantly improve upper eyelid aesthetics. Brow lifting is a powerful maneuver to shape and lateralize the curvature of the brow arc and directly influences the upper eyelid fold height and the curvature of the upper eyelid crease. This article reviews the importance of upper periorbital aesthetic assessment because it lays the foundation to tailor the appropriate operative intervention. Highlighted are the authors' preferred approach to aesthetically shape the brow along with other complimentary upper eyelid aesthetic procedures including upper blepharoplasty, blepharoptosis repair, fat grafting, and upper periorbital fat shifting to optimize brow lifting outcomes.
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http://dx.doi.org/10.1016/j.cps.2022.01.006DOI Listing
July 2022

The Influence of Sagittal Head Tilt on Periorbital Appearance: Implications for Clinical Photography and the Evaluation of Postoperative Results.

Aesthet Surg J Open Forum 2022 30;4:ojab043. Epub 2021 Oct 30.

Background: Consistency in standardized periorbital photography-specifically, controlling for sagittal head tilt-is challenging yet critical for accurate assessment of preoperative and postoperative images.

Objectives: To systematically assess differences in topographic measurements and perceived periorbital attractiveness at varying degrees of sagittal head tilt.

Methods: Standardized frontal photographs were obtained from 12 female volunteers (mean age 27.5 years) with the Frankfort plane between -15° and +15°. Unilateral periorbital areas were cropped, and topographic measurements were obtained. The images of each individual eye, at varying head tilt, were ranked in order of attractiveness by 11 blinded evaluators.

Results: Inter-rater and intra-rater reliability was excellent (intraclass correlation > 0.9). Downward sagittal head tilt was linearly associated with an improved aesthetic rating (Spearman's correlation; ρ = 0.901, < 0.001). However, on subgroup analysis, eyes with lower lid bags received the highest aesthetic score at neutral head tilt. Pretarsal show and upper lid fold heights progressively decreased ( < 0.001), positive intercanthal tilt became more pronounced ( < 0.001), and the apex of the brow ( < 0.001) and lid crease ( = 0.036) arcs lateralized with downward sagittal head tilt, contributing to a more angular appearance of the eye. Marginal reflex distance (MRD) 1 was maintained, while MRD2 progressively increased ( < 0.001) with downward head tilt.

Conclusions: Negative sagittal head tilt significantly improves periorbital aesthetics; however, in the presence of lower eyelid bags, this also increases demarcation of the eyelid cheek junction which may be aesthetically detrimental. Controlling for sagittal head tilt is critical to reliably compare preoperative and postoperative clinical photographs.
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http://dx.doi.org/10.1093/asjof/ojab043DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8830303PMC
October 2021

Langerhans cells and SFRP2/Wnt/beta-catenin signalling control adaptation of skin epidermis to mechanical stretching.

J Cell Mol Med 2022 02 12;26(3):764-775. Epub 2022 Jan 12.

Department of Surgery, Plastic Surgery Division, Northwestern University Feinberg School of Medicine, Stanley Manne Children's Research Institute, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.

Skin can be mechanically stimulated to grow through a clinical procedure called tissue expansion (TE). Using a porcine TE model, we determined that expansion promptly activates transcription of SFRP2 in skin and we revealed that in the epidermis, this protein is secreted by Langerhans cells (LCs). Similar to well-known mechanosensitive genes, the increase in SFRP2 expression was proportional to the magnitude of tension, showing a spike at the apex of the expanded skin. This implies that SFRP2 might be a newly discovered effector of mechanotransduction pathways. In addition, we found that acute stretching induces accumulation of b-catenin in the nuclei of basal keratinocytes (KCs) and LCs, indicating Wnt signalling activation, followed by cell proliferation. Moreover, TE-activated LCs proliferate and migrate into the suprabasal layer of skin, suggesting that LCs rebuild their steady network within the growing epidermis. We demonstrated that in vitro hrSFRP2 treatment on KCs inhibits Wnt/b-catenin signalling and stimulates KC differentiation. In parallel, we observed an accumulation of KRT10 in vivo in the expanded skin, pointing to TE-induced, SFRP2-augmented KC maturation. Overall, our results reveal that a network of LCs delivers SFRP2 across the epidermis to fine-tune Wnt/b-catenin signalling to restore epidermal homeostasis disrupted by TE.
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http://dx.doi.org/10.1111/jcmm.17111DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8817127PMC
February 2022

Do Dedicated Research Years during Medical School Predict Academic Productivity during Residency?

Plast Reconstr Surg Glob Open 2021 Oct 19;9(10):e3849. Epub 2021 Oct 19.

Division of Pediatric Plastic and Reconstructive Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Ill.

Background: Evidence regarding whether medical school research portends resident research is limited. This information will provide program directors with data that may be useful for selecting applicants with a commitment to continued academic productivity.

Methods: A questionnaire distributed via the American Society of Plastic Surgeons Resident Council to residents in 44 plastic surgery training programs in May 2020 assessed participation in dedicated research years during medical school, the number of publications completed before residency, and the total number of publications by each resident at the time of the survey. One-way ANOVA and post hoc analysis determined significant associations between publication count and number of research years.

Results: Of the 256 included respondents, 203 did not complete a research year during medical school, 44 completed 1 research year, and nine completed 2 research years. Mean publications before residency were higher for participants who took 1 or 2 research years (9.88 and 27.60, respectively) compared with those who did not (4.83, < 0.001). A comparison of total publications during residency similarly revealed increased productivity by individuals who took 1 or more research years; however, there was no difference between the number of publications completed during residency for individuals who took 1 versus 2 years ( = 0.23).

Conclusions: Residents with research experience during medical school continue to produce an increased number of publications during residency compared with those without, suggesting dedicated research years taken during medical school serve as a predictor of academic productivity in plastic surgery residents.
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http://dx.doi.org/10.1097/GOX.0000000000003849DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8604020PMC
October 2021

Photographic Misrepresentation on Instagram After Facial Cosmetic Surgery: Is Increased Photography Bias Associated With Greater User Engagement?

Aesthet Surg J 2021 10;41(11):NP1778-NP1785

Division of Plastic and Reconstructive Surgery, Northwestern Feinberg School of Medicine, Chicago, IL, USA.

Background: Before-and-after images are commonly used on Instagram (Menlo Park, CA) to advertise aesthetic surgical treatments and are a powerful means of engaging prospective patients. Consistency between before-and-after images accurately demonstrating the postoperative result on Instagram, however, has not been systematically assessed.

Objectives: The aim of this study was to systematically assess facial cosmetic surgery before-and-after photography bias on Instagram.

Methods: The authors queried 19 Instagram facial aesthetic surgery-related hashtags on 3 dates in May 2020. The "top" 9 posts associated with each hashtag (291 posts) were analyzed by 3 plastic surgeons by means of a 5-item rubric quantifying photographic discrepancies between preoperative and postoperative images. Duplicate posts and those that did not include before-and-after images of facial aesthetic surgery procedures were excluded.

Results: A total of 3,477,178 posts were queried. Photography conditions were observed to favor visual enhancement of the postoperative result in 282/291 analyzed top posts, with an average bias score of 1.71 [1.01] out of 5. Plastic surgeons accounted for only 27.5% of top posts. Physicians practicing outside their scope of practice accounted for 2.8% of top posts. Accounts with a greater number of followers (P = 0.017) and posts originating from Asia (P = 0.013) were significantly associated with a higher postoperative photography bias score.

Conclusions: Photographic misrepresentation, with photography conditions biased towards enhancing the appearance of the postoperative result, is pervasive on Instagram. This pattern was observed across all physician specialties and raises significant concerns. Accounts with a greater number of followers demonstrated significantly greater postoperative photography bias, suggesting photographic misrepresentation is rewarded by greater user engagement.
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http://dx.doi.org/10.1093/asj/sjab203DOI Listing
October 2021

Current Upper Blepharoplasty and Ptosis Management Practice Patterns Among The Aesthetic Society Members.

Aesthet Surg J 2021 04;41(5):NP198-NP209

Division of Plastic & Reconstructive Surgery, Northwestern Feinberg School of Medicine, Chicago, IL, USA.

Background: Patients presenting for upper blepharoplasty can exhibit different aging patterns and we have anecdotally observed wide variability in upper blepharoplasty approaches among surgeons. However, upper blepharoplasty practice patterns have not been systematically analyzed among members of The Aesthetic Society.

Objectives: The aim of this study was to report upper blepharoplasty practice patterns, the recognition of different patient presenting features, and to assess the incidence and management of ptosis as reported by members of The Aesthetic Society.

Methods: A 29-item electronic questionnaire was distributed to 1729 Aesthetic Society members with available email addresses.

Results: In total, 214 Aesthetic Society members submitted the questionnaire, for a response rate of 12.4%. There was a significantly increased rate of volume preservation among surgeons with greater experience (≥10 years in practice) and a high-volume (≥100 cases in past 12 months) of upper blepharoplasty cases. Furthermore, high-volume upper blepharoplasty surgeons were significantly more likely to perform concomitant upper lid fat grafting (P = 0.03), browlift (P = 0.02), and ptosis repair (P = 0.01). Ninety-five percent of respondents reported a mild/moderate ptosis (MRD1 2 to <4mm) incidence of <25%. Among surgeons who perform ptosis repair, 97.4% utilize levator advancement or plication as their most commonly used technique.

Conclusions: High-volume upper blepharoplasty surgeons are more likely to preserve upper lid volume and perform concomitant browlift and ptosis repair. Our data suggest that different upper eyelid aging patterns and mild/moderate ptosis are underrecognized.
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http://dx.doi.org/10.1093/asj/sjaa369DOI Listing
April 2021

Rethinking Upper Blepharoplasty: The Impact of Pretarsal Show.

Plast Reconstr Surg 2020 12;146(6):1239-1247

From the Division of Plastic and Reconstructive Surgery, Northwestern Feinberg School of Medicine; and private practice.

Background: Conventional upper blepharoplasty relies on skin, muscle, and fat excision to restore ideal pretarsal space-to-upper lid fold ratios. The purpose of this study was to identify presenting topographic features of upper blepharoplasty patients and their effect on cosmetic outcomes.

Methods: This is a retrospective review of patients who underwent upper blepharoplasty at the authors' institution from 1997 to 2017. Preoperative and postoperative photographs were standardized using Adobe Illustrator to an iris diameter of 11.5 mm. Pretarsal and upper lid fold heights were measured at five locations. Patients were classified into three groups based on preoperative pretarsal show: none, partial, or complete. Photographs were randomized in PowerPoint and given a cosmetic score of 0 to 5 by four independent reviewers.

Results: Three hundred sixteen patients were included, 42 men (13 percent) and 274 women (87 percent). Group 1 included 101 eyes (16 percent), group 2 had 159 eyes (25 percent), and group 3 had 372 eyes (59 percent). Mean cosmetic score increased from 1.75 to 2.38 postoperatively (p < 0.001), with a significantly lower improvement in scores in group 3 compared to groups 2 and 1 for both sexes (p < 0.01). For group 3, those with midpupil pretarsal heights greater than 4 mm had a significantly lower postoperative aesthetic score (1.95) compared with those less than or equal to 4 mm (2.50) (p < 0.001).

Conclusions: Many patients presenting for upper blepharoplasty have complete pretarsal show and are at risk for worse cosmetic outcomes using conventional skin excision techniques. Adjunctive procedures such as fat grafting and ptosis repair should be considered in this group.

Clinical Question/level Of Evidence: Risk, II.
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http://dx.doi.org/10.1097/PRS.0000000000007330DOI Listing
December 2020

Upper Blepharoplasty with Endoscopically Assisted Brow Lift to Restore Harmonious Upper Lid Arc Curvatures.

Plast Reconstr Surg 2020 11;146(5):565e-568e

From the Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine.

Background: Achieving excellent results in upper lid rejuvenation requires a balanced approach to address skin, muscle, fat, upper lid margin position, and brow aging changes. In the appropriately selected patient, brow lifting plays an essential complement to upper blepharoplasty to restore more youthful upper lid fold-to-pretarsal ratios. The goal of this study is to describe a safe and reproducible method to perform brow lifting and upper blepharoplasty.

Methods: Medial to the temporal line of fusion, in-line with the brow peak, a 2-cm scalp incision is oriented parallel to the course of the deep branch of the supraorbital nerve to minimize the risk of nerve injury. The brow vector of pull is maximal in this location and secured to a monocortical bone channel with 3-0 polydioxanone. Lateral to the temporal line of fusion, an ellipse of scalp tissue is excised to gently elevate the brow tail. Upper blepharoplasty is performed in an individualized fashion to achieve a youthful contour of the upper lid fold.

Results: The endoscopically assisted technique is designed to achieve tissue release under direct visualization. The brow-lift maximal vector of pull is centered over the brow peak and, to a lesser extent, at the brow tail to improve lateral upper lid fold height and a smooth contour of the pretarsal space. Muscle shaping sutures improve convexity of the lateral upper lid fold.

Conclusion: In the appropriately selected patient, combined brow lift and upper blepharoplasty with muscle contouring are safe and effective techniques that help improve aesthetic upper lid topographic proportions.
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http://dx.doi.org/10.1097/PRS.0000000000007285DOI Listing
November 2020

Transcriptomic analysis reveals dynamic molecular changes in skin induced by mechanical forces secondary to tissue expansion.

Sci Rep 2020 09 29;10(1):15991. Epub 2020 Sep 29.

Division of Plastic Surgery, Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Chicago, IL, 60611, USA.

Tissue expansion procedures (TE) utilize mechanical forces to induce skin growth and regeneration. While the impact of quick mechanical stimulation on molecular changes in cells has been studied extensively, there is a clear gap in knowledge about sequential biological processes activated during long-term stimulation of skin in vivo. Here, we present the first genome-wide study of transcriptional changes in skin during TE, starting from 1 h to 7 days of expansion. Our results indicate that mechanical forces from a tissue expander induce broad molecular changes in gene expression, and that these changes are time-dependent. We revealed hierarchical changes in skin cell biology, including activation of an immune response, a switch in cell metabolism and processes related to muscle contraction and cytoskeleton organization. In addition to known mechanoresponsive genes (TNC, MMPs), we have identified novel candidate genes (SFRP2, SPP1, CCR1, C2, MSR1, C4A, PLA2G2F, HBB), which might play crucial roles in stretched-induced skin growth. Understanding which biological processes are affected by mechanical forces in TE is important for the development of skin treatments to maximize the efficacy and minimize the risk of complications during expansion procedures.
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http://dx.doi.org/10.1038/s41598-020-71823-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7524724PMC
September 2020

Modeling Tissue Expansion with Isogeometric Analysis: Skin Growth and Tissue Level Changes in the Porcine Model.

Plast Reconstr Surg 2020 10;146(4):792-798

From Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Plastic and Reconstructive Surgery, Stanley Manne Children's Research Institute; and the School of Mechanical Engineering, Purdue University.

Background: Tissue expansion relies on the ability of skin to grow in response to sustained mechanical strain. This study focuses on correlation of cellular and histologic changes with skin growth and deformation during tissue expansion.

Methods: Tissue expanders were placed underneath the skin of five Yucatan minipigs and inflated with one fill of 60 cc of saline 1 hour, 24 hours, 3 days, and 7 days before the animals were killed, or two fills of either 30 cc or 60 cc at 10 and 3 days or 14 and 7 days before the animals were killed. Skin biopsy specimens and three-dimensional photographs were used to calculate skin growth and stretch according to the authors' novel finite element analysis model.

Results: The mitotic index of keratinocytes in the basal layer increased 1 hour after stimulus was applied (4 percent) (p = 0.022), peaked at approximately day 3 (26 percent) (p < 0.0001), and tapered by day 7 (12.5 percent) (p = 0.012) after tissue expansion. The authors demonstrated that it is the volume per fill rather than the total volume in the expander that scales the magnitude of response. Lastly, the authors demonstrated that the ratio of deformation attributable to growth versus stretch (Fgrowth/Fstretch) after 60 cc of tissue expansion fill was 1.03 at 1 hour, 0.82 at 1 day, 0.85 at day 3, and 0.95 at 7 days.

Conclusions: Peak cell proliferation occurred 3 days after tissue expansion fill and is scaled in response to stimulus magnitude. The growth component of deformation equilibrates to the stretch component at day 7, as cell proliferation has started to translate to skin growth.
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http://dx.doi.org/10.1097/PRS.0000000000007153DOI Listing
October 2020

Enhancing the Lateral Orbital "C-Angle" With Calcium Hydroxylapatite: An Anatomic and Clinical Study.

Aesthet Surg J 2021 07;41(8):952-966

Northwestern Feinberg School of Medicine Plastic Surgery Program, Chicago, IL, USA.

Background: Deliberate injection of specific facial subunits may improve aesthetic outcomes in facial rejuvenation. We contend that the lateral orbital area (LOA) is a key anatomic subunit in the perception of eye attractiveness, with a C-shaped distribution of fat contributing to the formation of a distinct angle in the lateral orbit.

Objectives: The aim of this study was to describe the anatomy of the LOA that constitutes the C-shaped angle and to investigate the safety and cosmetic outcomes of nonsurgical enhancement of that area with calcium hydroxylapatite (CaHA).

Methods: Four injected fresh-frozen cadaver heads were dissected. Twenty patients were enrolled in a prospective clinical study. Participants were seen on the day of injection, and at 2 weeks and 3 months postinjection. Two-dimensional and 3D photographs were analyzed to quantify the volumetric changes between pretreatment and postinjection time points. Secondary outcomes included Global Aesthetic Improvement Scale score and subject satisfaction at 3 months.

Results: Cadaver dissections revealed distinct fat compartments and a zone of adhesion forming the C-shaped area around the lateral orbit. In the clinical study, a mean of 1.88 mL of CaHA was injected into each lateral periorbital region. There was 97% and 76% volume retention at 2 weeks and 3 months, respectively, with 70% of patients being "very satisfied" at 3 months. The average Global Aesthetic Improvement Scale rating at 3 months was 3.95. There were no complications.

Conclusions: The LOA is a distinct facial subunit that can be enhanced safely by CaHA injection with good cosmetic outcomes. Focusing on the C-angle can improve periorbital aesthetics.

Level Of Evidence: 4:
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http://dx.doi.org/10.1093/asj/sjaa218DOI Listing
July 2021

Getting Good Results in Cosmetic Blepharoplasty.

Plast Reconstr Surg 2020 07;146(1):71e-82e

From the Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine.

Learning Objectives: After studying this article, the participant should be able to: 1. Accurately diagnose the cosmetic deformity and thoroughly understand the periorbital surface topography. 2. Develop a preoperative plan and pick the right operation. 3. Master technical tips. 4. Rejuvenate the lateral orbital area. 5. Manage complications.

Summary: Getting good results in blepharoplasty requires understanding ideal surface topography, accurate diagnosis of the cosmetic deformity, thorough knowledge of anatomy, and careful technique to change the anatomy. Several approaches have been described; however, the procedure continues to have its shortcomings and share of complications that have both functional and cosmetic consequences. This continuing medical education article focuses on getting good results and maximizing success in upper and lower blepharoplasty through the discussion of five major components: diagnosis and understanding of the cosmetic deformity; preoperative planning; technical tips; rejuvenation of the lateral orbital area; and management of complications.
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http://dx.doi.org/10.1097/PRS.0000000000006953DOI Listing
July 2020

Reply: Lower Eyelid Reconstruction: A New Classification Incorporating the Vertical Dimension.

Plast Reconstr Surg 2020 04;145(4):878e-879e

Division of Plastic and Reconstructive, and Cosmetic Surgery, University of Illinois, Chicago Shriners Hospitals for Children, Chicago, Ill.

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http://dx.doi.org/10.1097/PRS.0000000000006666DOI Listing
April 2020

The Functional Anatomy of the Deep Facial Fat Compartments: A Detailed Imaging-Based Investigation.

Plast Reconstr Surg 2020 04;145(4):870e-871e

Department of Plastic and Reconstructive Surgery, Cleveland Clinic, Cleveland, Ohio.

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http://dx.doi.org/10.1097/PRS.0000000000006706DOI Listing
April 2020

Neurotized Free Platysma Flap for Functional Eyelid Reconstruction: A Cadaveric Study of Anatomical Feasibility.

Plast Reconstr Surg 2020 04;145(4):1049-1057

From the Division of Plastic and Reconstructive Surgery, Northwestern Feinberg School of Medicine; and the Department of Plastic Surgery, Cleveland Clinic.

Background: Conventional reconstructive options for large full-thickness eyelid defects are limited to static local flaps without replacing the missing orbicularis. The authors' aim is to delineate the platysma neurovascular anatomy for innervated functional eyelid reconstruction.

Methods: Fourteen fresh latex-injected heminecks were dissected. The locations where neurovascular structures entered the platysma muscles were expressed as the percentage distance ± SD from the sternocleidomastoid muscle mastoid insertion to manubrium origin.

Results: The superior thyroid, facial, and lingual vessels were the major pedicles in eight of 14 (57.1 percent), four of 14 (28.6 percent), and one of 14 specimens (7.1 percent), respectively. In one specimen (7.1 percent), both the superior thyroid and facial vessels supplied a major pedicle. Venous drainage generally mirrored arterial inflow but was redundant, with 43 percent and 14 percent of flaps also with major contributions from the external jugular and anterior jugular veins, respectively. Neurovascular pedicles entered the platysma 28 to 57 percent caudal to the sternocleidomastoid muscle mastoid insertion, between 0.5 and 4.8 cm anterior to the medial sternocleidomastoid muscle border.

Conclusion: Although variability exists, platysma neurovascular pedicles enter at predictable locations between 28 and 57 percent of the distance from the mastoid insertion of the sternocleidomastoid muscle, therefore making free platysma transfer a feasible option for eyelid reconstruction.
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http://dx.doi.org/10.1097/PRS.0000000000006648DOI Listing
April 2020

Secondary Suture Fusion after Primary Correction of Nonsyndromic Craniosynostosis: Recognition of the Problem and Identification of Risk Factors.

Plast Reconstr Surg 2020 Feb;145(2):493-503

From the Division of Plastic and Reconstructive Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago.

Background: Secondary fusion of initially patent cranial sutures after primary correction of nonsyndromic craniosynostosis is rarely reported. This study's aim is to report the incidence and analyze whether there are variables that may predispose to such fusion.

Methods: A single-institution, retrospective, case-control study was conducted of all nonsyndromic patients who underwent operative treatment for craniosynostosis from April of 2008 to May of 2017. Patients with less than 1 year of follow-up and/or without a 1-year postoperative computed tomographic scan were excluded. Preoperative, intraoperative, and postoperative variables were analyzed using univariate and multivariate analyses.

Results: Sixty-six patients were included in the study, with a mean 2.57-year postoperative follow-up. Six patients (8.8 percent) were found to have secondary craniosynostosis, all of whom had fusion of sutures that were initially patent and refusion of the primary pathologic suture(s). Fifty percent of secondary fusions presented as pansynostosis. On univariate analysis, suturectomy with barrel staving (p < 0.01) was significantly associated with secondary suture fusion. On multivariate analysis, bilambdoid suture involvement (p = 0.03) and suturectomy with barrel staving (p = 0.01) were significantly associated with secondary suture fusion.

Conclusions: Secondary cranial suture fusion may be a relatively common complication after primary craniosynostosis correction. Suturectomy with barrel staving was independently associated with secondary craniosynostosis. Wide surgical separation of the dura from the cranium and osteotomies across patent sutures may predispose to secondary craniosynostosis.

Clinical Question/level Of Evidence: Risk, III.
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http://dx.doi.org/10.1097/PRS.0000000000006491DOI Listing
February 2020

Getting Better Results in Facelifting.

Plast Reconstr Surg Glob Open 2019 Jun 27;7(6):e2270. Epub 2019 Jun 27.

Division of Plastic and Reconstructive Surgery, Northwestern Feinberg School of Medicine, Chicago, Ill.

The facelift has significantly evolved over the past several decades. What was once considered a skin only operation is now a sophisticated, elegant procedure that requires meticulous preoperative analysis, understanding of underlying anatomically based aging changes, and extreme attention to detail. According to the American Society of Plastic Surgeons, 125,697 facelifts were performed in 2017. It is not surprising that given these advances that facial rejuvenation surgery is still a very common procedure with a high degree of patient satisfaction despite the increase in nonsurgical facial aging treatments. With an improved understanding of facial anatomy including the facial retaining ligaments and intervening superficial and deep fat compartments, the modern facelift requires an anatomically targeted approach. Furthermore, the modern facelift surgeon must achieve consistently excellent results with reasonably little downtime while being aware of methods to improve the safety of this popular elective procedure. Hematoma is the most common complication after rhytidectomy with an incidence between 0.9% and 9%, with a higher incidence in males. Other potential complications include seroma, nerve injury, skin flap necrosis, siaolocele as a consequence of submandibular gland debulking, and skin flap rhytid and hairline distortion. This review aims to discuss safe, consistent, and reproducible methods to achieve success with facelift.
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http://dx.doi.org/10.1097/GOX.0000000000002270DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6635200PMC
June 2019

Simplified Lateral Brow Lift under Local Anesthesia for Correction of Lateral Hooding.

Plast Reconstr Surg Glob Open 2019 Jun 12;7(6):e2098. Epub 2019 Jun 12.

Northwestern University Feinberg School of Medicine, Division of Plastic and Reconstructive Surgery, Chicago, Ill.

Background: A limited incision lateral brow lift has been described as an alternative to the endoscopic or the bicoronal approaches. The senior author has developed a safe and effective lateral brow lift technique that can be performed in an office setting under local anesthesia.

Methods: We retrospectively reviewed 150 consecutive patients who underwent a brow lift by the senior author (TAM). The technique begins with an upper blepharoplasty incision which is used to divide the corrugator under direct vision, followed by a release of the periorbital retaining ligaments. The lateral temporal incision is the access point for dissection above the deep temporal fascia then connecting to the subperiosteal plane, allowing full mobility of the brow. Galea is advanced with sutures and redundant skin is excised.

Results: All patients treated with this technique had resolution of lateral brow hooding. Two temporary neuropraxias of the frontal branch of the facial nerve were observed with full resolution and no permanent nerve injuries occurred. The revision rate was 7% and there was a 3% incidence of delayed wound healing at the temporal incision with no infections. One hundred forty-two patients (97%) underwent this procedure with sedation, 52 of which (35%) were in the office with light oral sedation.

Conclusions: The limited incision lateral brow lift as described allows for safe elevation of the lateral brow. When complemented by upper blepharoplasty, this technique provides excellent and natural-appearing rejuvenation of the upper face.
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http://dx.doi.org/10.1097/GOX.0000000000002098DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6635213PMC
June 2019

Mechanical stretching stimulates growth of the basal layer and rete ridges in the epidermis.

J Tissue Eng Regen Med 2019 11 5;13(11):2121-2125. Epub 2019 Sep 5.

Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

We have developed four experimental models of mechanical stimulation applied to the back skin using tissue expansion (TE) procedure performed on minipigs. The technique is used by plastic surgeons for decades, to amend the congenital or accidental skin defects, though underlying changes in epidermis are not well understood. We found that the initial stretching increased proliferation of basal keratinocytes leading to elongation of the basal layer, and increased cellular density. The increased number of the rete ridges, suggests that they absorbed the impact of excessive proliferation, preserving layered organization of epidermis. We found β1 integrin to be a very sensitive responder to stimulation instigated by TE procedure, able to dynamically relocate to adjust the basal cell against external force. Repeated mechanical stimulation with a seven-day interval generated healthy tissue without detrimental effects. Given the similarities between the structure of the porcine and human epidermis, we speculate that a similar mechanism functions in human skin. A better understanding of the underlying process could help improve medical care and outcomes for patients undergoing surgical reconstruction.
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http://dx.doi.org/10.1002/term.2952DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6872913PMC
November 2019

Lower Eyelid Reconstruction: A New Classification Incorporating the Vertical Dimension.

Plast Reconstr Surg 2019 08;144(2):443-455

From the Division of Plastic and Reconstructive Surgery, Northwestern Memorial Hospital.

Background: Lower eyelid defects are traditionally classified based on depth and 25 percent increments in defect width. The authors propose a new classification system that includes the vertical defect component to predict functional and aesthetic outcomes.

Methods: A retrospective review of patients who underwent lower lid reconstruction performed by a single surgeon was performed. Defects were classified into four categories based on the vertical component: (1) pretarsal; (2) preseptal; (3) eyelid-cheek junction; and (4) complex pretarsal/preseptal. Preoperative and postoperative central and lateral marginal reflex distance-2 values were obtained. Aesthetic outcomes were evaluated by three blinded reviewers. Outcomes were compared using one-way analysis of variance and analysis of covariance with Bonferroni corrected post hoc comparisons to control for defect area and width.

Results: Thirty-four patients underwent reconstruction of lower eyelid defects. There were 12 pretarsal defects (type I), nine preseptal defects (type II), nine eyelid-cheek defects (type III), and four complex pretarsal/preseptal defects (type IV). Postoperative retraction was highest in the complex pretarsal/preseptal group at 75 percent, with a significantly greater change from preoperative to postoperative central and lateral marginal reflex distance-2 compared with the other groups (p < 0.01) and worse postoperative mean aesthetic scores (p < 0.001). Type IV patients had significantly more revision operations (mean, 5.5) compared with the other groups (p < 0.001).

Conclusions: The vertical dimension of lower eyelid defects is an important variable. A new classification system is proposed that supplements width-based methods for improved surgical planning and prediction of postoperative outcomes in lower eyelid reconstruction.

Clinical Question/leevl Of Evidence: Therapeutic, IV.
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August 2019

Identifying Aesthetically Appealing Upper Eyelid Topographic Proportions.

Aesthet Surg J 2019 07;39(8):824-834

Division of Plastic and Reconstructive Surgery, Northwestern Feinberg School of Medicine, Chicago, IL.

Background: The goal of upper eyelid procedures is to restore or create the ideal proportions between the pretarsal space and the upper lid fold.

Objectives: The aim of this study was to define the topographic features of the attractive upper lid.

Methods: Caucasian female frontal facial photographs were obtained from public media and periorbital areas were cropped. A total of 294 photographs of eyes were rated by 6 evaluators using a 4-point Likert scale. Eyes rating an average ≥3.5 were defined as "attractive," whereas those rated ≤2.0 were defined as "unattractive" and analyzed using Adobe Illustrator.

Results: Fifty-one and 19 eyes were included in the attractive and unattractive cohorts, respectively. (Upper lid foldPretarsal) shows ratios averaged between 1.8 and 3.0 among attractive eyes, and larger ratios were observed laterally. These ratios were significantly larger laterally among attractive vs unattractive eyes (P ≤ 0.003). The lash line peak (P < 10-4), lid crease peak (P < 10-3), and brow peak (P < 0.05) were significantly more lateralized in attractive eyes.

Conclusions: Attractive eyes tend to exhibit decreased pretarsal show. However, there is pronounced variability in these ratios among attractive eyes, suggesting the importance of other features. Interestingly, progressive lateralization of the lash line, lid crease, and brow peaks appears to be an undescribed feature common to attractive eyes. Knowledge of attractive eyelid features may be an important consideration for planning and optimization of upper lid rejuvenation procedures.
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http://dx.doi.org/10.1093/asj/sjz014DOI Listing
July 2019

Eleven-Year Follow-Up of Craniopagus Twins After Unsuccessful Attempt at Separation: Are They Better Off?

Cleft Palate Craniofac J 2019 07 3;56(6):817-822. Epub 2019 Jan 3.

4 Division of Pediatric Plastic Surgery, Lurie Children's Hospital, Chicago, IL, USA.

Craniopagus twins are a rare phenomenon and present numerous challenges in separation. Due to the paucity of data, it is paramount to evaluate outcomes based on case studies to continue improving medical and surgical management of these patients. We present a case report of craniopagus twins cared for by the senior author (A.K.G.). The patients underwent extensive surgical planning and 2 attempts at cerebroendovascular embolization to reroute shared venous sinus drainage. After the 2 endovascular procedures, attempted separation at age 41 months was aborted due to intraoperative hemodynamic instability. Eleven-year follow-up shows the twins to be developing well in regard to social and cognitive development. Nonetheless, they have had numerous physical challenges including a fall in 2016 resulting in C1-C2 subluxation in twin B leading to partial spinal cord ischemia and left-sided weakness. The separation of craniopagus twins is fraught with technical, medical, and ethical challenges. Surgical separation of the twins is not always possible without significant risk of devastating consequences to one or both twins. Follow-up of the twins 11 years later raises the question: are some craniopagus twins better off without separation?
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http://dx.doi.org/10.1177/1055665618811534DOI Listing
July 2019

Major Complications and 30-Day Morbidity for Single Jaw Versus Bimaxillary Orthognathic Surgery as Reported by NSQIP.

Cleft Palate Craniofac J 2019 07 29;56(6):705-710. Epub 2018 Nov 29.

1 Division of Plastic and Reconstructive Surgery, Lurie Children's Hospital of Chicago, Northwestern Feinberg School of Medicine, Chicago, IL, USA.

Objective: Acute complications in orthognathic surgery are reported in single-institution studies with small sample sizes. We aimed to analyze risk factors for acute complications using a national data set to better inform surgical decision-making.

Methods: 2005-2015 National Surgical Quality Improvement Program (NSQIP) data sets were analyzed for patients undergoing Le Fort 1 and/or bilateral sagittal split osteotomies (BSSO) for nontraumatic indications. Demographics, comorbidities, medical, and surgical 30-day complications were tabulated. A logistic regression model was used to determine predictors of complications.

Results: Five hundred eight patients met the inclusion criteria: 228 underwent Le Fort I osteotomies, 152 BSSO, and 128 patients underwent both during a single surgical encounter. Overall complication rate was 4.5% (23/508). Superficial infection was the most common complication (11 in BSSO and 2 in Le Fort I cohorts). Increasing age and undergoing BSSO alone were associated with higher overall complication rates ( < .05) and surgical complications specifically ( < .05). Patients undergoing the combined procedure had shorter operative time (208 minutes) than the times for Le Fort I osteotomies alone (177 minutes) and BSSO alone (155 minutes) added together and did not have a longer hospital stay ( = .608) or increased need for transfusion ( = 1.0) compared to the surgeries being done separately.

Conclusion: This is the first complication risk factor analysis for Le Fort I osteotomy and BSSO using the multi-institutional NSQIP data set. Combining BSSO and Le Fort I osteotomy leads to a shorter overall operative time and does not increase hospital stay duration or 30-day complication rate when compared to the 2 procedures being done separately.
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http://dx.doi.org/10.1177/1055665618814402DOI Listing
July 2019

Google Ranking of Plastic Surgeons Values Social Media Presence Over Academic Pedigree and Experience.

Aesthet Surg J 2019 03;39(4):447-451

Division of Plastic and Reconstructive Surgery, Northwestern Memorial Hospital, Chicago, IL.

Background: Patients increasingly rely on online resources to make healthcare decisions. Google dominates the search engine market; first-page results receive most of the web traffic and therefore serve as an important indicator of consumer reach.

Objectives: Our objective was to analyze the respective importance of physician academic pedigree, experience, and social media presence on plastic surgeon Google first-page search result placement.

Methods: A Google.com search was conducted in the top 25 United States metropolitan areas to identify the top 20 websites of board-certified plastic surgeons. Social media presence was quantified by tracking the number of followers on Facebook, Twitter, and Instagram for every surgeon as well as medical school and year of graduation. The primary outcome was website ranking in the first page of Google search results. To identify the independent predictors of presence on the front page, we performed a multivariate logistic regression.

Results: Total number of social medial followers was associated with Google front-page placement (P < 0.001), whereas medical school ranking and years in practice were not (P = 0.17 and 0.39, respectively). A total 19.6% of plastic surgeon practices in our study cohort still had no social media accounts whatsoever.

Conclusions: For the past few decades, plastic surgery practices relied on referrals, word of mouth, and the surgeon's reputation and academic pedigree to attract new patients. It is now clear that this practice-building model is being rapidly supplanted by a new paradigm based on social media presence to reach potential patients.
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http://dx.doi.org/10.1093/asj/sjy285DOI Listing
March 2019

Nitroglycerin Ointment for Reducing the Rate of Mastectomy Flap Necrosis in Immediate Implant-Based Breast Reconstruction.

Plast Reconstr Surg 2018 09;142(3):264e-270e

From the Division of Plastic and Reconstructive Surgery, Northwestern University Feinberg School of Medicine.

Background: Mastectomy flap necrosis remains a challenging complication in immediate tissue expander breast reconstruction. Nitroglycerin ointment has been shown to reduce the incidence of mastectomy flap necrosis in a randomized controlled study, using 45 g per breast and treating one side only in bilateral cases. This study was conducted to determine the efficacy of 15 g of nitroglycerin ointment per breast, therefore permitting application to both breasts in cases of bilateral mastectomy.

Methods: A retrospective cohort study of patients undergoing immediate tissue expander breast reconstruction performed by a single reconstructive surgeon was conducted. The intervention cohort consisted of all patients between June 10, 2015, and June 9, 2016 (94 patients, 158 breasts), where 15 g of nitroglycerin ointment was routinely applied per breast. The control cohort consisted of all patients from June 10, 2014, to June 9, 2015 (107 patients, 170 breasts), where nitroglycerin was not applied. All complications were tracked, including minor wound healing problems.

Results: There was an overall 22 percent decreased incidence of mastectomy flap necrosis in the nitroglycerin ointment cohort (47.5 percent versus 60.6 percent; p = 0.002), with a 44 percent reduction in full-thickness mastectomy flap necrosis that trended toward statistical significance (9.5 percent versus 16.5 percent; p = 0.06). On multivariate analysis, nitroglycerin application was independently associated with a decrease in mastectomy flap necrosis or need for mastectomy flap débridement. There was no significant difference in the incidence of postoperative hypotension (3.8 percent versus 2.9 percent) or headache among cohorts.

Conclusion: Topical nitroglycerin ointment application to mastectomy skin flaps at 15 g per breast is a cost-effective means of decreasing the incidence of mastectomy flap necrosis in unilateral and bilateral immediate tissue expander breast reconstruction.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000004633DOI Listing
September 2018

Management of High-energy Avulsive Ballistic Facial Injury: A Review of the Literature and Algorithmic Approach.

Plast Reconstr Surg Glob Open 2018 Mar 19;6(3):e1693. Epub 2018 Mar 19.

Department of Surgery, Division of Plastic and Reconstructive Surgery, Northwestern Memorial Hospital, Chicago, Ill.; Wyss Department of Plastic Surgery, New York University Langone Medical Center, New York, N.Y.; and Private Practice, TLKM Plastic Surgery, Chicago, Ill.

Background: High-energy avulsive ballistic facial injuries pose one of the most significant reconstructive challenges. We conducted a systematic review of the literature to evaluate management trends and outcomes for the treatment of devastating ballistic facial trauma. Furthermore, we describe the senior author's early and definitive staged reconstructive approach to these challenging patients.

Methods: A Medline search was conducted to include studies that described timing of treatment, interventions, complications, and/or aesthetic outcomes.

Results: Initial query revealed 41 articles, of which 17 articles met inclusion criteria. A single comparative study revealed that early versus delayed management resulted in a decreased incidence of soft-tissue contracture, required fewer total procedures, and resulted in shorter hospitalizations (level 3 evidence). Seven of the 9 studies (78%) that advocated delayed reconstruction were from the Middle East, whereas 5 of the 6 studies (83%) advocating immediate or early definitive reconstruction were from the United States. No study compared debridement timing directly in a head-to-head fashion, nor described flap selection based on defect characteristics.

Conclusions: Existing literature suggests that early and aggressive intervention improves outcomes following avulsive ballistic injuries. Further comparative studies are needed; however, although evidence is limited, the senior author presents a 3-stage reconstructive algorithm advocating early and definitive reconstruction with aesthetic free tissue transfer in an attempt to optimize reconstructive outcomes of these complex injuries.
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http://dx.doi.org/10.1097/GOX.0000000000001693DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5908512PMC
March 2018

Improving tissue expansion protocols through computational modeling.

J Mech Behav Biomed Mater 2018 06 29;82:224-234. Epub 2018 Mar 29.

School of Mechanical Engineering, Purdue University, West Lafayette, IN 47907, USA. Electronic address:

Tissue expansion is a common technique in reconstructive surgery used to grow skin in vivo for correction of large defects. Despite its popularity, there is a lack of quantitative understanding of how stretch leads to growth of new skin. This has resulted in several arbitrary expansion protocols that rely on the surgeon's personal training and experience rather than on accurate predictive models. For example, choosing between slow or rapid expansion, or small or large inflation volumes remains controversial. Here we explore four tissue expansion protocols by systematically varying the inflation volume and the protocol duration in a porcine model. The quantitative analysis combines three-dimensional photography, isogeometric kinematics, and finite growth theory. Strikingly, all four protocols generate similar peak stretches, but different growth patterns: Smaller filling volumes of 30 ml per inflation did not result in notable expander-induced growth neither for the short nor for the long protocol; larger filling volumes of 60 ml per inflation trigger skin adaptation, with larger expander-induced growth in regions of larger stretch, and more expander-induced growth for the 14-day compared to the 10-day expansion protocol. Our results suggest that expander-induced growth is not triggered by the local stretch alone. While stretch is clearly a driver for growth, the local stretch at a given point is not enough to predict the expander-induced growth at that location. From a clinical perspective, our study suggests that longer expansion protocols are needed to ensure sufficient growth of sizable skin patches.
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http://dx.doi.org/10.1016/j.jmbbm.2018.03.034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6028355PMC
June 2018

Orbital Fracture Reconstruction Using Prebent, Anatomic Titanium Plates: Technical Tips to Avoid Complications.

J Craniofac Surg 2018 Jul;29(5):e515-e517

Division of Plastic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL.

Orbital fractures are common. In patients where there is significant loss of the medial wall and orbital floor, anatomic prebent 3-dimensional plates allow efficacious restoration of orbital volume. However, the large size of these plates can result in technical difficulties with plate placement, especially in fractures with complete loss of 2 walls of the orbit. In this article, the authors review the pertinent anatomy of the bony orbit with respect to fracture and landmarks in fracture reduction. The authors also note the 3 most commonly encountered problems with the placement of anatomic plates: poor exposure, failure to identify the posterior ledge for the plate, and rotational issues with plate placement resulting in impingement. Technical tips are given to help overcome these issues intraoperatively.
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http://dx.doi.org/10.1097/SCS.0000000000004563DOI Listing
July 2018

Labial Incompetence in Mobius Syndrome: LeFort I Impaction Case Report and Review of Management Strategies.

Cleft Palate Craniofac J 2018 10 13;55(9):1313-1315. Epub 2018 Mar 13.

1 Lurie Children's Hospital of Chicago, Division of Plastic and Reconstructive Surgery, Northwestern Feinberg School of Medicine, Chicago, IL, USA.

Difficulty with speech intelligibility in Mobius syndrome patients due to bilabial incompetence is common yet rarely discussed. We present a patient with Mobius syndrome who underwent counterclockwise LeFort I impaction to improve her labial competence. In addition, we present a literature review of management strategies for labial incompetence correction in Mobius patients. At 7-year follow-up after LeFort 1 impaction, the patient reports improvement in speech intelligibility, specifically regarding the ability to pronounce bilabial consonants. This is the first published report of LeFort I impaction to improve labial competence and bilabial consonant pronunciation in a Mobius syndrome patient.
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http://dx.doi.org/10.1177/1055665618758540DOI Listing
October 2018

Plastic Surgery-Related Hashtag Utilization on Instagram: Implications for Education and Marketing.

Aesthet Surg J 2018 Feb;38(3):332-338

Division of Plastic and Reconstructive Surgery, Northwestern Memorial Hospital, Chicago, IL.

Background: Recent data suggest patients are seeking aesthetic surgery to improve their appearance on Instagram and other social media. Despite the rising influence of Instagram in plastic surgery, few academic publications address Instagram, let alone evaluate its utilization in plastic surgery.

Objectives: We set out to answer the following three questions: 1) what plastic surgery-related content is being posted to Instagram; 2) who is posting this content; and 3) what specific hashtags are they using?

Methods: Our study queried 21 Instagram plastic surgery-related hashtags. Content analysis was used to qualitatively evaluate each of the nine "top" posts associated with each hashtag (189 posts). Duplicate posts and those not relevant to plastic surgery were excluded.

Results: A total of 1,789,270 posts utilized the 21 hashtags sampled in this study. Of the top 189 posts for these 21 queried hashtags, 163 posts met inclusion criteria. Plastic surgeons eligible for membership in American Society for Aesthetic Plastic Surgery (ASAPS) accounted for only 17.8% of top posts, whereas noneligible physicians accounted for 26.4%. All nonplastic surgery trained physicians marketed themselves as "cosmetic surgeons." Nine top posts (5.5%) were by nonphysicians, including dentists, spas with no associated physician, and a hair salon. The majority of these posts were self-promotional (67.1%) as opposed to educational (32.9%). Board-certified plastic surgeons were significantly more likely to post educational content to Instagram as compared to nonplastic surgeons (62.1% vs 38.1%, P = 0.02).

Conclusions: ASAPS eligible board-certified plastic surgeons are underrepresented amongst physicians posting top plastic surgery-related content to Instagram.
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http://dx.doi.org/10.1093/asj/sjx120DOI Listing
February 2018
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