Publications by authors named "Jeffrey A Gusenoff"

71 Publications

Patient Selection for Pedal Soft Tissue Augmentation.

Aesthet Surg J Open Forum 2020 Sep 24;2(3):ojaa031. Epub 2020 Jun 24.

School of Medicine and the Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA.

Background: Pedal fat grafting has been shown to improve pain and functional impairment from forefoot fat pad atrophy.

Objectives: The authors aimed to determine if patient demographics and foot characteristics play a role in the level of impact that is achieved following surgery.

Methods: The authors performed a retrospective review of patients who received forefoot autologous fat injections for the treatment of pedal fat pad atrophy. Patient improvement of pain and functional impairment were evaluated for correlation with patient characteristics, including gender, age, BMI, unilateral vs bilateral injections, flexible vs rigid arch, previous foot deformity or surgery, and presence of callus.

Results: Forty-four patients received fat injections into the ball of their foot; 73% of them were women; their mean age was 61 years, and mean BMI was 26.6 kg/m; 75% had injections performed bilaterally; 41% had a flexible arch, 73% had a past history of pedal deformity or surgery, and 43% had callus. Only female gender was found to correlate with an improvement in pain from the time of surgery to 12 months later ( = 0.02).

Conclusions: Bilateral rigid, high arched foot type is a risk factor for foot pain and disproportionately represented among these patients. The only patient characteristic found to be correlated with improvement in pain at 12 months post-surgery was female gender. BMI and laterality of injections impacted the course of improvement after surgery. Given current data, all patients with suspected pedal fat pad atrophy should be considered for soft tissue augmentation.

Level Of Evidence 4:
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http://dx.doi.org/10.1093/asjof/ojaa031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7671290PMC
September 2020

Update on Liposuction: What All Plastic Surgeons Should Know.

Plast Reconstr Surg 2021 Apr;147(4):658e-668e

From the Orlando Health Aesthetic and Reconstructive Surgery Institute; and the Department of Plastic Surgery, University of Pittsburgh.

Learning Objectives: After studying this article, the participant should be able to: 1. Understand the types of tumescence available for liposuction. 2. Explain the various modalities available for liposuction. 3. Describe the patient selection, staging, and complications associated with debulking liposuction. 4. Describe ways to optimize outpatient liposuction.

Summary: Liposuction is one of the most common procedures performed by board-certified plastic surgeons and is likely greatly underestimated, given underreporting of office procedures and the number of non-plastic surgeons performing these operations. With the ever-increasing popularity of liposuction, various methodologies and technology have been designed to make this task simpler and faster for the surgeon and hasten the recovery for the patient. In the past 10 years, over 50 devices or techniques have been released to assist, refine, or altogether replace liposuction. With the advent of these newer tools, a thorough Continuing Medical Education study was performed to review the available literature.
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http://dx.doi.org/10.1097/PRS.0000000000007419DOI Listing
April 2021

A Step in the Right Direction: A Prospective Randomized, Controlled Crossover Trial of Autologous Fat Grafting For Rejuvenation of the Heel.

Aesthet Surg J 2021 Feb 22. Epub 2021 Feb 22.

Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.

Background: The shock-absorbing soft tissues of the heel are composed of dermis and specialized fat pads. Heel fat pad atrophy (FPA) is common and can be painful and debilitating. In our previous work, autologous fat grafting (AFG) was effective for treating pain from forefoot FPA.

Objectives: We hypothesized that AFG to the heel would relieve pain and improve function in patients with heel FPA.

Methods: Patients with heel FPA and associated pain were recruited and randomized into two groups. Group 1 received AFG upon enrollment and was followed for 2yrs. Group 2 received offloading and activity modification for 1yr, then crossed over, underwent AFG, and was followed for 1yr afterward. Outcome measures included ultrasound-measured fat pad and dermal thickness, pedobarograph-measured foot pressures and forces, and patient-reported outcomes as measured by the Manchester Foot Pain and Disability Index (MFPDI).

Results: Thirteen subjects met inclusion criteria and completed the study. Seven (12 affected feet) were randomized into Group 1, and six (9 affected feet) were randomized into Group 2. Average age was 55yrs and BMI was 30.5kg/m 2. Demographics were not significantly different between groups. Heel fat pad thickness increased after AFG but returned to baseline at 6mo. However, AFG increased dermal thickness significantly and increased fat pad thickness under compressive load compared to controls at 6-12mo. Foot pain, function, and appearance were also significantly improved compared to controls at 6-12mo.

Conclusions: AFG improved patient-reported foot pain, function, and appearance and may rejuvenate local soft tissues in patients with heel FPA.
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http://dx.doi.org/10.1093/asj/sjab095DOI Listing
February 2021

A New Device for Autologous Small Volume Fat Grafting.

Aesthet Surg J 2020 Dec 18. Epub 2020 Dec 18.

Department of Plastic Surgery; University of Pittsburgh School of Medicine;Pittsburgh, PA USA.

Background: Many techniques and devices have been developed to improve small volume fat grafting efficiency and consistency for use in the operating room and outpatient procedure room. These methods require cumbersome or messy processing to remove excess oil and fluid from adipose graft.

Objectives: The aim of this study was to compare fat processing efficiency of a novel hand-held device, the Push-to-Spin (P2S™) system, to other common processing techniques and validate tissue quality after lipoaspirate processing.

Methods: Human lipoaspirate samples were processed using one of three experimental methods, including cotton gauze (Telfa) rolling, centrifugation (Coleman technique), or using the P2S™ system. Efficiency of fat processing was evaluated by total processing time, fat harvest ratio, and fat processed ratio. Histological examination and immunohistochemical staining were used to compare tissue morphology and adipocyte viability, respectively. Experimental samples were compared to unprocessed lipoaspirate controls.

Results: Lipoaspirate processing was significantly faster using the P2S™ device compared with other techniques. All three methods achieved similar fat harvest and fat processing ratios. Additionally, the P2S™, Telfa, and Coleman techniques yielded grafts with similar cellularity, and perilipin and GPDH expression. Measured differences between experimental and control samples were statistically significant.

Conclusions: The P2S™ device is an easy, efficient, and potentially cost-effective handheld device that can be used for lipoaspirate harvest, processing, and grafting in any procedural setting. The resulting adipocytes have similar morphology, viability, and function to those yielded by techniques. This handheld technology decreases procedure time, thereby improving surgeon efficiency and patient experience.
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http://dx.doi.org/10.1093/asj/sjaa385DOI Listing
December 2020

Discussion: Anatomy of the Dorsum of the Foot and Its Relevance for Nonsurgical Cosmetic Procedures.

Plast Reconstr Surg 2020 07;146(1):73-74

From the Department of Plastic Surgery, University of Pittsburgh School of Medicine.

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http://dx.doi.org/10.1097/PRS.0000000000006950DOI Listing
July 2020

Commentary on: Combination of Lipofilling With Liposuction in the Correction of Pseudo Genu Varus Deformity.

Aesthet Surg J 2020 02;40(3):NP101-NP102

Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA.

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http://dx.doi.org/10.1093/asj/sjz337DOI Listing
February 2020

Molecular Mechanisms of Adipose Tissue Survival during Severe Hypoxia: Implications for Autologous Fat Graft Performance.

Plast Reconstr Surg Glob Open 2019 Jun 27;7(6):e2275. Epub 2019 Jun 27.

Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pa.

Background: Variable retention outcomes remain a significant issue in autologous fat grafting procedures. Among seemingly similar patients, using identical harvesting procedures, variability in graft retention is noted. Recent data suggest that the inherent characteristics of donor adipose tissue dictate graft healing outcomes. The goal of this study was to elucidate intrinsic qualities of human adipose tissue that confer resistance to ischemic stress to therapeutically target such mechanisms and improve overall results of fat grafts.

Methods: Whole fat from 5 female patients was cultured in vitro under severe (1% O) and mild (8% O) hypoxic conditions. Microarray analysis of 44 hypoxia-related genes was performed. Perilipin was used to visualize viable adipocytes. Macrophage phenotypes were identified using PCR.

Results: Analysis of adipocyte survival with perilipin suggested improved viability for tissue obtained from high BMI donors. Microarray data revealed a significant positive correlation for induced expression of ANGPTL4, a survival gene, and subject BMI ( = 0.0313) during hypoxic conditions whereas HIF1α and HIF2α genes were negatively correlated with donor BMI ( = 0.0003 and 0.0303). Interestingly, induced differentiation of proinflammatory M1 macrophages was negatively correlated with BMI under hypoxia ( = 0.0177).

Conclusions: The innate resilience of adipocytes to hypoxia and relative macrophage activation play a crucial role in fat graft retention. This study suggests that adipose tissue from high BMI donors demonstrates greater resistance to hypoxia-induced apoptosis associated with an increased expression of ANGPTL4. Therefore, therapeutic interventions that target this factor may improve clinical adipose graft survival.
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http://dx.doi.org/10.1097/GOX.0000000000002275DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6635216PMC
June 2019

The Impact of Massive Weight Loss on Psychological Comorbidities: A Large, Retrospective Database Review.

Aesthetic Plast Surg 2019 12 9;43(6):1570-1574. Epub 2019 Oct 9.

University of Pittsburgh, 3550 Terrace Street, Pittsburgh, PA, USA.

Background: The obese population has a higher incidence of mood disorders compared to individuals with normal body mass index (BMI). A better understanding of the unique psychosocial challenges faced by this patient population will allow physicians to better optimize patient psychosocial support systems perioperatively, as well as help the patient to maintain appropriate expectations.

Methods: A large, retrospective database of 1135 patients with greater than 50 pounds of weight loss was reviewed. Data were analyzed using a multinomial regression model to determine the influence of psychosocial factors on the incidence of depression and anxiety.

Results: Prior to massive weight loss, patients reported an overall incidence of depression and anxiety of 42.5% and 26.3%, respectively. Following massive weight loss, the incidence of depression decreased to 32.3% and the incidence of anxiety decreased to 22.0%. Patients with spousal support and with positive self-image were more likely to experience resolution of depression. Patients with positive self-image were likely to experience resolution of anxiety. Resolution of medical comorbidities correlated with a decrease in the rate of depression.

Conclusion: Depression and anxiety are prevalent in the massive weight loss patient population undergoing body contouring surgery. Support systems are a vital resource for patients with psychological comorbidities undergoing massive weight loss. Patients who have a positive self-image of themselves are more likely to experience resolution of psychological comorbidities. Physicians should consider recommending support groups and/or counseling in patients who have poor support and negative self-image.

Level Of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
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http://dx.doi.org/10.1007/s00266-019-01444-zDOI Listing
December 2019

Volumetric Analysis in Autologous Fat Grafting to the Foot.

Plast Reconstr Surg 2019 09;144(3):463e-470e

Pittsburgh, Pa.

Background: Pedal fat grafting is a safe, minimally invasive approach to treat pedal fat pad atrophy. Prior randomized controlled trials demonstrate that the fat as measured directly under the metatarsal heads disappears between 2 and 6 months after fat grafting, despite patients having relief for 2 years. The authors aim to use magnetic resonance imaging to further assess three-dimensional volume of fat in the foot after autologous fat grafting to help explain the mechanism for improved pain.

Methods: A prospective study was performed using magnetic resonance imaging before and at 6 months after pedal fat grafting to assess changes in the three-dimensional morphology of the fat.

Results: Seventeen patients (six men and 11 women) underwent injections with a mean volume of 5.8 cc per foot. At 6 months, patients demonstrated increased tissue thickness (p = 0.008) and volume (p = 0.04). Improvements were seen in pain (p < 0.05) and activity (p < 0.05). Foot pressures and forces were significantly decreased and positively correlated with increased fat pad volume (p < 0.05).

Conclusions: Pedal fat grafting significantly increases metatarsal fat pad volume. The distribution of the fat may contribute to lasting clinical relief in these patients.

Clinical Question/level Of Evidence: Therapeutic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000005956DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6716614PMC
September 2019

Fat Grafting for Improved Ileostomy Ostomy Device Fit: A Case Report.

Wound Manag Prev 2019 03;65(3):38-44

University of Pittsburgh Medical Center, Pittsburgh, PA.

For patients with an ostomy, a poor fitting appliance may cause leakage, peristomal dermatitis, and frequent appliance changes.

Purpose: The purpose of this case study was to report the outcome of fat grafting to augment peristomal soft tissue and improve appliance fit.

Case Study: A 57-year-old woman with a history of Crohn's disease presented with soft-tissue deficiency and uneven contour around her ileostomy site. She was unable to properly fit an ostomy appliance, which resulted in leakage, chronic skin irritation, and frequent appliance changes. The patient underwent 2 rounds of fat grafting using fat harvested from her medial thighs and knees infused with dilute lidocaine with epinephrine. The patient noted immediate improvement after 34 cc of processed fat was injected in the first round. Appliance change frequency decreased from daily to every 3 to 4 days. A second graft of 32 cc provided 3 months later further improved appliance fit, reducing appliance change frequency to every 5 to 7 days and obviating the need to use adjustment rings and glue. Pre- and postoperative computed tomography showed increased thickness of abdominal wall subcutaneous tissues.

Conclusion: Fat grafting around an ostomy site presents a viable option to improve contour and appliance fit with reduced skin irritation and leakage.
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March 2019

Discussion: Abdominoplasty in the Obese Patient: Risk versus Reward.

Plast Reconstr Surg 2019 04;143(4):727e-728e

From the Department of Plastic Surgery, University of Pittsburgh.

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http://dx.doi.org/10.1097/PRS.0000000000005414DOI Listing
April 2019

Deep and Superficial Closure.

Aesthet Surg J 2019 03;39(Suppl_2):S85-S93

Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, PA.

All operative interventions in plastic surgery have one thing in common: closure of an incision or wound at the conclusion of the procedure. For many years, the only option to accomplish this task was the use of sutures. Today's surgeon, however, has many more options available, ranging from smooth to barbed suture, external to internal staples, internal to external adhesive glues, and incisional negative-pressure wound therapy. These devices are designed with the goal of making wound closure more rapid and secure, and decreasing postoperative sequelae. This paper reviews methods available to perform incisional closure and the published clinical data regarding their use.
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http://dx.doi.org/10.1093/asj/sjy208DOI Listing
March 2019

Quick Calculation of Breast Resection Mass Using the Schnur Scale.

Ann Plast Surg 2019 03;82(3):316-319

From the Department of Plastic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA.

In 1991, Dr Paul Schnur and his colleagues published an article correlating the weight of breast tissue to be removed in a breast reduction operation with the total body surface area (BSA) of the patient. They presented a very cogent argument for selecting three groups of patients: those with medical indications for operation, those who merit review, and those whose operation could be considered cosmetic. The Schnur Sliding Scale is widely used by insurance companies in the western United States in the process of preauthorizing breast reduction operations, and its use may be spreading eastward. The Schnur group presented a nomogram for calculating BSA and a scale in the form of a table for guiding a determination of whether the patient is a reconstructive patient as opposed to an aesthetic patient. We have combined the scale and the BSA nomogram for a simplified nomogram calculator that facilitates rapid determination of anticipated tissue weight of resection for a patient of a given size. This calculator yields the required weight of tissue to remove with just knowledge of the patient's height and weight and the use of a straight edge. We demonstrate and compare performance of this calculation by hand and by nomogram. There is ample evidence that the practice of applying the Schnur Sliding Scale may be prohibitive to symptomatic patients seeking reduction mammaplasty and should be abandoned. While this practice continues, our simplified Schnur Sliding Scale nomogram is meant to help easily determine the insurer-required minimum breast resection weight and thereby both improve patient counseling prior to planning surgery and assist the surgeon with achieving insurer reimbursement for the procedure while avoiding rejected claims.
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http://dx.doi.org/10.1097/SAP.0000000000001643DOI Listing
March 2019

Milestones in Plastic Surgery: Attending Assessment versus Resident Assessment.

Plast Reconstr Surg 2019 02;143(2):425e-432e

From the Department of Plastic Surgery, University of Pittsburgh; and the University of Pittsburgh School of Medicine.

Background: The Plastic Surgery Milestones Project was jointly conceived by the Accreditation Council for Graduate Medical Education and the American Board of Plastic Surgery as a tool to improve granularity in resident feedback. Resident self-evaluations were compared to attending clinical competency committee evaluations to gauge resident self-perceptions and understanding of the milestones framework.

Methods: Semiannual evaluations from June of 2014 to 2017 were analyzed and compared with corresponding resident self-evaluations from the 2015 to 2017 academic year at the University of Pittsburgh Medical Center. Evaluations were analyzed for overall trends in performance. The presence of systemic differences between each type of evaluation were determined using Student's t tests. Subgroup analysis using the chi-square test was performed to determine factors that may contribute to major assessment disparity (≥1).

Results: Six thousand two hundred seven milestones across 187 faculty evaluations and 3139 milestones across 106 resident self-evaluations were available for review. With the exception of postgraduate year-2 residents, residents rated themselves at a significantly lower level in the competencies of medical education and patient care. Postgraduate year, academic year timing, and Accreditation Council for Graduate Medical Education competency were associated with major assessment discrepancies.

Conclusions: Overall, resident and faculty evaluations at the authors' program were concordant, which demonstrates that residents are capable of accurately assessing their own abilities and understanding the milestones framework. Areas of discordance between resident and faculty evaluations fostered discussion between residents and faculty and have led to multiple changes in the authors' program. The introduction of self-evaluation tools at other programs may provide them with similar benefits.
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http://dx.doi.org/10.1097/PRS.0000000000005214DOI Listing
February 2019

The Architecture of Fat Grafting II: Impact of Cannula Diameter.

Plast Reconstr Surg 2018 11;142(5):1219-1225

From the Department of Plastic Surgery, University of Pittsburgh Medical Center.

Background: Fat grafting has emerged as the treatment of choice for soft-tissue augmentation and reconstruction. Variability of volume retention remains the greatest challenge for this technique, often requiring multiple operations to achieve the desired volume. Graft that is placed greater than 2 mm from the recipient bed will undergo necrosis. Improved understanding of the architecture of fat within the recipient bed is paramount to improving outcomes. The impact of cannula diameter on graft architecture is unknown.

Methods: Fat was harvested by liposuction and stained with methylene blue. Stained fat was grafted into 4 × 2 × 1-cm sections of excised abdominal tissue with 12-, 14-, 16-, and 19-gauge Coleman cannulas at three different volumes: 0.1, 0.5, and 1.0 cc. Each tissue block was sectioned for stained graft visualization. The diameter of each deposit and percentage with a radius greater than 2 mm were recorded.

Results: With an injection volume of 0.1 cc, no fat deposits had a radius greater than 2 mm, regardless of cannula size. A graft volume of 0.5 cc created globules greater than 2 mm with larger cannulas (0 percent with 19-gauge, 2.9 percent with 16-gauge, 6.1 percent with 14-gauge, and 4.3 percent with 12-gauge). Injecting 1.0 cc resulted in a significant increase in the percentage of fat parcels expected to undergo central necrosis (16 percent with 19-gauge, 21 percent with 16-gauge, 26 percent with 14-gauge, and 44 percent with 12-gauge).

Conclusions: Injection cannulas of 14-gauge or larger are more likely to create deposits with dimensions that may be susceptible to central necrosis when injecting 1.0 cc per pass. Smaller cannula sizes or lower volumes per pass should be considered.

Clinical Question/level Of Evidence: Therapeutic, V.
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http://dx.doi.org/10.1097/PRS.0000000000004837DOI Listing
November 2018

Body Contouring After Massive Weight Loss.

Clin Plast Surg 2019 01 1;46(1):xi. Epub 2018 Oct 1.

University of Pittsburgh, 3380 Boulevard of the Allies, Suite 180, Pittsburgh, PA 15213, USA. Electronic address:

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http://dx.doi.org/10.1016/j.cps.2018.09.001DOI Listing
January 2019

Common Complications and Management After Massive Weight Loss Patient Safety in Plastic Surgery.

Clin Plast Surg 2019 Jan 22;46(1):115-122. Epub 2018 Oct 22.

Department of Plastic Surgery, University of Pittsburgh, 3380 Boulevard of the Allies, Suite 180, Pittsburgh, PA 15213, USA. Electronic address:

This article discusses strategies to prevent and manage the most common complications seen in body contouring surgery. General approaches to avoidance and treatment of these complications are addressed, including wound dehiscence, delayed wound healing, seroma, hematoma, infections of the surgical or remote sites, lymphedema, suture extrusion, and fat necrosis. Procedure-specific complications and pearls to avoiding complications in these cases are presented. Difficult problems, such as management of the disappointed patient, also are discussed.
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http://dx.doi.org/10.1016/j.cps.2018.08.013DOI Listing
January 2019

The Obesity Epidemic and Bariatric Trends.

Clin Plast Surg 2019 Jan;46(1):1-7

Department of Plastic Surgery, University of Pittsburgh, 3380 Boulevard of the Allies, Suite 180, Pittsburgh, PA 15213, USA. Electronic address:

The United States has experienced a significant increase in obesity over the past several decades, including a substantial increase in obesity-related comorbidities, such as type 2 diabetes, hypertension, heart disease, and obstructive sleep apnea. With obesity reaching epidemic proportions, there has been an increasing need for surgical intervention as a treatment option. Bariatric procedures have not only contributed to the significant weight loss a patient may experience but they have also had a profound effect on the decrease of weight-related comorbidities.
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http://dx.doi.org/10.1016/j.cps.2018.08.001DOI Listing
January 2019

Discussion: Defining the Aesthetic Units of the Male Chest and How They Relate to Gynecomastia Based on 635 Patients.

Plast Reconstr Surg 2018 10;142(4):908-909

From the Department of Plastic Surgery, University of Pittsburgh Medical Center.

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http://dx.doi.org/10.1097/PRS.0000000000004808DOI Listing
October 2018

Fat Grafting for Pedal Fat Pad Atrophy in a 2-Year, Prospective, Randomized, Crossover, Single-Center Clinical Trial.

Plast Reconstr Surg 2018 12;142(6):862e-871e

From the Department of Plastic Surgery, University of Pittsburgh.

Background: By age 60, 30 percent of Americans suffer from fat pad atrophy of the foot. Forefoot fat pad atrophy results from long-term aggressive activity, genetically dictated foot type, multiple forefoot steroid injections, surgery, and foot trauma.

Methods: The authors present data from a 2-year, prospective, randomized crossover study performed to assess pain and disability indexes, fat pad thickness, forces, and pressures of stance and gait. Group 1 underwent fat grafting with 2 years of follow-up, and group 2 underwent conservative management for 1 year, then underwent fat grafting with 1 year of follow-up.

Results: Eighteen subjects (14 women and four men) constituted group 1. Thirteen subjects (nine women and four men) constituted group 2. Group 1 reported the worst pain at baseline and group 2 experienced the worst pain at 6- and 12-month standard-of-care visits; pain for both groups improved immediately following fat grafting and lasted through study follow-up (p < 0.05). Group 1 demonstrated functional improvements at 12, 18, and 24 months postoperatively (p < 0.05), whereas group 2 demonstrated the highest function at 12 months postoperatively (p < 0.05). Pedal fat pad thickness of subjects in group 1 increased postoperatively and returned to baseline thickness at 2 months postoperatively; subjects in group 2 experienced return to baseline thickness at 6 months postoperatively (p < 0.01). Forces and pressures of stance and gait increased over the 2 years of follow-up for group 1 (p < 0.05).

Conclusion: Pedal fat grafting provides long-lasting improvements in pain and function, and prevents against worsening from conservative management.

Clinical Question/level Of Evidence: Therapeutic, I.
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http://dx.doi.org/10.1097/PRS.0000000000005006DOI Listing
December 2018

The Constriction Arm Band Deformity in Brachioplasty Patients: Characterization and Incidence Using a Prospective Registry.

Plast Reconstr Surg 2018 12;142(6):856e-861e

From the Department of Plastic Surgery, University of Pittsburgh Medical Center.

Background: Demand for brachioplasty in the United States has seen a dramatic increase, from 338 procedures in 2000 to 17,860 in 2016. In this article, the authors present their series of arm band deformities not yet described in the literature.

Methods: This is a retrospective review of massive weight loss patients undergoing brachioplasty at their institution from 2000 to 2016. Preoperative and postoperative photographs were reviewed. Descriptive statistics and t test were used.

Results: One hundred seventy-two patients underwent brachioplasty, and 25 patients (15 percent) were identified with the deformity. Twenty-four (96 percent) were women, with an average age of 60 years (range, 36 to 85 years) and a mean body mass index of 34 kg/m at the time of surgery (average, 2 years since gastric bypass; mean delta body mass index, 22 kg/m). The bands were generally single bands (100 percent) found bilaterally (68 percent) in the distal third (74 percent) of the upper arm and exacerbated (50 percent) by brachioplasty. The average specimen weighed 1005 g. The authors found that arm banding was associated with a higher current body mass index, but not with a maximum body mass index or delta body mass index.

Conclusions: For massive weight loss patients, arm band deformity is a challenging problem that can be exacerbated by brachioplasty. It can be identified preoperatively to aid in counseling. The authors found patients with a higher current body mass index to be at a higher risk for the arm band deformity after brachioplasty.

Clinical Question/level Of Evidence: Risk, IV.
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http://dx.doi.org/10.1097/PRS.0000000000004979DOI Listing
December 2018

The Influence of Fat Grafting on Skin Quality in Cosmetic Foot Grafting: A Randomized, Cross-Over Clinical Trial.

Aesthet Surg J 2019 03;39(4):405-412

Department of Plastic Surgery at the University of Pittsburgh Medical Center, Pittsburgh, PA.

Background: Pedal fat grafting is a cosmetic procedure to treat the functional and aesthetic sequelae of pedal fat pad atrophy. Fat grafting has been found to mitigate these symptoms, but the exact mechanism is unknown.

Objectives: The authors hypothesized that pedal fat grafting may improve skin quality, accounting for prolonged symptomatic improvement despite loss of grafted fat.

Methods: Patients with pedal atrophy were enrolled in a randomized crossover clinical trial. Group 1 underwent fat grafting upon enrollment with 2-year follow-up. Group 2 was managed conservatively for 1 year then placed into the fat grafting group with 1-year follow-up. Patients underwent pedal ultrasounds to determine thicknesses of the fat pad and dermis, and photographs were taken to assess skin quality.

Results: Three men and 20 women with an average age of 63 ± 6 years and an average BMI of 26.0 ± 4.6 kg/m2 were enrolled in the study. Twenty-six feet were injected in Group 1 and 17 were injected in Group 2. Group 1 dermal thickness increased at 6 months post-injection (P < 0.05). This increase persisted through 24 months. Group 2 dermal thickness decreased prior to injection (P < 0.05) but returned to baseline after injection and through 12-month follow-up (P < 0.05). Fat pad thickness returned to baseline by study completion in both groups (P < 0.05).

Conclusions: Pedal fat grafting yielded a significant, sustained increase in dermal thickness, though grafted fat was not retained. Fat grafting may improve skin quality, which could contribute to improved clinical outcomes despite loss of grafted fat.

Level Of Evidence: 2:
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http://dx.doi.org/10.1093/asj/sjy168DOI Listing
March 2019

Characterizing the Saddlebag Deformity After Lower Body Lift.

Aesthet Surg J 2018 Sep;38(10):1115-1123

Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.

Background: One of the commonly cited sequelae of lower body lift is recurrence of the saddlebag deformity. However, there are currently no data that characterize the evolution of the saddlebag following lower body lift, nor is there a classification scheme to objectively quantify the severity of the deformity.

Objectives: The authors aimed to develop a grading scale to score the severity of the saddlebag deformity and, using this, determine the short- and long-term changes in the saddlebag following lower body lift.

Methods: Using the Pittsburgh Rating Scale, the Pittsburgh Saddlebag Rating Scale, a 4-point Likert scale, was developed to score the saddlebag deformity. Patients who underwent lower body lifts were parsed from a prospectively maintained database. Two educated observers independently reviewed both preoperative and postoperative photographs and graded the saddlebag deformity according to the Pittsburgh Saddlebag Rating Scale.

Results: Seventy-nine patients met inclusion criteria, including 5 males and 74 females. The average saddlebag score preoperatively was 1.34, while the average scores at short- and long-term follow up were 1.28 and 1.42, respectively. No significant differences in saddlebag severity scores were noted between preoperative and short- or long-term postoperative time points (P > 0.05).

Conclusions: This is the first study to objectively demonstrate the postoperative changes in the saddlebag following lower body lift. Results demonstrated that lower body lift does not effectively treat the saddlebag as the deformity only slightly improved in the short-term window but recurred within a year of surgery.

Level Of Evidence 4:
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http://dx.doi.org/10.1093/asj/sjy105DOI Listing
September 2018

Characterizing Breast Deformities After Massive Weight Loss: Utilizing the Pittsburgh Rating Scale to Examine Factors Affecting Severity Score and Surgical Decision Making in a Retrospective Series.

Ann Plast Surg 2018 Mar;80(3):207-211

Background And Objectives: Massive weight loss (MWL) can result in variable contour deformities of the breasts. The Pittsburgh Rating Scale (PRS) was designed to describe the multitude of deformities after MWL and recommends operations to consider for surgical improvement. We present the first comprehensive description of breast deformities in a large sample of MWL patients, examine factors affecting the severity of deformities, and report the correlation between PRS score and surgical decision making.

Methods: A retrospective review of all MWL patients presenting for breast surgery at our institution's Life After Weight Loss program from 2004 to 2015 was performed. Information including demographics, body mass indices (BMIs), method of weight loss, and type of surgical intervention was collected. Preoperative breast photographs were blinded and scored according to the PRS.

Results: A total of 204 MWL patients were identified; 26% (53) scored 1, 34% (69) scored 2, and 40% (82) scored 3 on the PRS. Greater deformities were seen after weight loss from bariatric surgery versus diet and exercise alone (P = 0.031), in mastopexy versus augmentation/mastopexy (P = 0.001), and in breast reduction versus augmentation/mastopexy patients (P > 0.0001). Patients who underwent reduction mammaplasty had the greatest maximum BMI compared with other procedures (P = 0.016). The PRS scores were positively correlated to maximum BMI (P < 0.001), delta BMI (P < 0.001), and current BMI (P < 0.001).

Conclusions: Massive weight loss patients have variable, and often severe, breast deformities, and the PRS remains a valuable classification tool. Severity scores correlate with BMI, procedure, and weight loss mechanism. Similar scores between mastopexy-only and reduction mammaplasty patients may reflect a composite of personal cosmetic expectations and cost. The PRS scale should also be expanded to include breast reduction as a surgical remedy for PRS grade 3 breast deformities. Understanding breast deformities in this unique population has applications in both preoperative planning and surgical expectations for this unique patient population.
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http://dx.doi.org/10.1097/SAP.0000000000001338DOI Listing
March 2018

Heterogeneity in Body Contouring Outcomes Based Research: The Pittsburgh Body Contouring Complication Reporting System.

Aesthet Surg J 2017 Dec;38(1):60-70

University of Pittsburgh School of Medicine and the Department of Plastic Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, PA.

Background: Body contouring complications after massive weight loss (MWL) vary significantly in frequency and type. Currently, no standardized recommendations exist regarding which complications are most important to report.

Objectives: We aim to provide a guideline for complication reporting in the body contouring literature. The Pittsburgh Body Contouring Complication Reporting System (PBCCRS) will aid in risk stratification of body contouring procedures and will decrease under-, over-, and nonreporting of complications.

Methods: The authors reviewed the literature for the terms "body contouring," "MWL," and "complications." Elimination criteria included: non-English language, case report, meta-analysis, outpatient, non-MWL, unclear demographics, N <30 and lack of numeric results. Data were analyzed in 2 groups: truncal contouring and extremity contouring.

Results: Eighty-nine papers were reviewed and 21 met inclusion criteria. The weighted mean rates as percentages for complications in the extremity group were: dehiscence (29.0), seroma (18.6), scarring (14.9), infection (8.8), lymphedema (7.8), hematoma (3.5), necrosis (1.9), deep venous thrombosis (DVT) or pulmonary embolism (PE) (0), and death (0). In the truncal group, weighted mean complication rates as percentages were: dehiscence (15.4), seroma (13.1), scarring (2.9), infection (9.4), lymphedema (1.3), hematoma (6.4), necrosis (7.2), DVT/PE (1.5), and death (0.6). Lymphedema was seldom reported, and suture extrusion was not reported in any selected papers. Weighted mean rates of DVT/PE in the extremity vs truncal contouring groups were significantly different. Differences in rates of scarring, lymphedema, and hematoma rates neared significance.

Conclusions: Heterogeneity amongst selected studies is explained by variability in how complications are defined. The Pittsburgh Body Contouring Complication Reporting System provides suggested recommendations on complication reporting in massive weight loss body contouring surgery.
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http://dx.doi.org/10.1093/asj/sjx081DOI Listing
December 2017

Commentary: Micro-Autologous Fat Transplantation (MAFT) for Forehead Volumizing and Contouring.

Aesthetic Plast Surg 2017 10 7;41(5):1093-1095. Epub 2017 Jun 7.

Department of Plastic Surgery, University of Pittsburgh School of Medicine, 3380 Boulevard of the Allies, Suite 180, Pittsburgh, PA, 15213, USA.

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http://dx.doi.org/10.1007/s00266-017-0897-9DOI Listing
October 2017

The Challenges of Augmentation Mastopexy in the Massive Weight Loss Patient: Technical Considerations.

Plast Reconstr Surg 2017 May;139(5):1090-1099

Pittsburgh, Pa.

Background: Augmentation mastopexy in the massive weight loss population is challenging because of poor skin elasticity and lack of inframammary support. Despite several large studies of augmentation mastopexy in the literature, few data exist regarding this unique patient population. The authors examine early postoperative ptosis, implant malposition, and strategies to optimize outcomes.

Methods: A retrospective review of massive weight loss patients who underwent augmentation mastopexy from 2003 to 2011 was performed to record age, body mass index, implant characteristics, postoperative ptosis, and implant malposition.

Results: Thirty patients were identified with a mean age of 44.8 ± 8.5 years, mean current body mass index of 26.1 ± 3.9 kg/m, and mean follow-up time of 283.5 days (range, 7 to 1095 days). Preoperatively, patients mostly presented with grade 3 ptosis (63.3 percent). Five patients (16.7 percent) developed postoperative ptosis within the first 3 months after surgery, with no increase after this time. Implant malposition increased significantly with time: 61.9 percent by 12 months (p = 0.006), with a median time for implant malposition of 160 days. Postoperative ptosis was significantly related to age (p = 0.039) and a larger left-side implant (p = 0.022). Implant malposition was significantly related to higher current body mass index (p = 0.047), but not to implant size. Two patients (6.6 percent) underwent revision procedures.

Conclusion: Massive weight loss patients have an increased risk of early postoperative ptosis or implant malposition, reinforcing the need for appropriate preoperative counseling to manage patient expectations.

Clinical Question/level Of Evidence: Therapeutic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000003294DOI Listing
May 2017

The Impact of Abdominal Contouring with Monsplasty on Sexual Function and Urogenital Distress in Women Following Massive Weight Loss.

Aesthet Surg J 2017 Jan 25;37(1):63-70. Epub 2016 Oct 25.

From the Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA. Dr Gusenoff is Body Contouring Section Co-editor for Aesthetic Surgery Journal

Background: Monsplasty treats massive weight loss (MWL) patients with redundant tissues in the mons region. Monsplasty, however, is not a routine component of abdominal contouring.

Objectives: The goal of this study was to evaluate the changes in urinary and sexual functioning in patients who undergo abdominal contouring with monsplasty vs non-operated controls.

Methods: A prospective study was performed of patients who underwent abdominal contouring + monsplasty or no surgery. The Urogenital Distress Inventory Short Form (UDI-6) and the Female Sexual Function Index (FSFI) questionnaires were administered to both groups at baseline and then three months later.

Results: The surgical (n = 20) and nonsurgical groups (n = 20) were similar related to patient demographics, body mass index after MWL, parity, relationship status, hormonal status, and baseline UDI-6/FSFI scores (all P values >0.05). After three months, there was a statistically significant decrease in the UDI-6 score for the surgical groups vs the nonsurgical group: median UDI-6 score = -0.01 (interquartile range [IQR], -7.65-5.55) vs 0 (IQR, 0-11.11) (P = .03). There was no change for the Female Sexual Function Index in the surgical vs nonsurgical groups: median FSFI = 0.20 (IQR, -1.20-1.58) vs 0.95 (IQR, 0.08-2.58) (P = .11).

Conclusions: Urinary dysfunction improved even at the early time point of three months following abdominal contouring procedures including monsplasty. At the early postoperative period of three months, however, there was no significant change in female sexual function. Monsplasty in conjunction with abdominal contouring is recommended in the MWL female patient.

Level Of Evidence: 2 Therapeutic.
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http://dx.doi.org/10.1093/asj/sjw144DOI Listing
January 2017