Publications by authors named "Sammy Sinno"

59 Publications

How to Approach Secondary Breast Reduction: International Trends and a Systematic Review of the Literature.

Aesthetic Plast Surg 2021 12 5;45(6):2555-2567. Epub 2021 Apr 5.

Centre of Plastic, Aesthetic, Hand and Reconstructive Surgery, University of Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.

Background: Secondary breast reduction is complex and poses significant challenges to surgeons. Complication rates exceed those of primary reduction, commonly caused by impaired vascular supply of the nipple-areolar complex (NAC). Literature on the topic is scare and provides contradicting recommendations, especially with regard to pedicle choice in cases with unknown primary reduction technique. Aim of this study was to investigate international trends and to compare findings with literature.

Methods: A large-scale web-based questionnaire on international trends in mammaplasty (mastopexy and breast reduction) was designed and distributed to over five thousand surgeons in eight geographic regions. The presented manuscript evaluated information regarding pedicle choice in secondary breast reduction and compared data to literature identified in a systematic review.

Results: The survey was completed by 1431 participants. Overall, secondary procedures were performed in less than 5% or in 5 to 10% of cases. The preferred pedicle for secondary reductions differed significantly between geographic regions (p<0.001). The majority of respondents reported to use a superior or supero-medial pedicle (34.8% and 32.2%, respectively). Residual analysis revealed a strong association between the use of an inferior pedicle and procedures performed in North America.

Conclusions: Secondary breast reduction is challenging and there remains international disparity with regard to pedicle choice for secondary procedures. Studies investigating outcome when the primary pedicle is unknown are scarce and provide incoherent recommendations. High-quality data is needed to provide evidence-based practice guidelines.

Level Of Evidence Iii: 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/s00266-021-02243-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8677686PMC
December 2021

Evidence-Based Performance Measures for Rhinoplasty: A Multidisciplinary Performance Measure Set.

Plast Reconstr Surg 2021 02;147(2):222e-230e

From the Johns Hopkins Hospital; Fedok Plastic Surgery and Laser Center; the American Society of Plastic Surgeons; The Plastic Surgery Clinic; Westlake Dermatology and Cosmetic Surgery; The Center for Facial Restoration; the University of Pennsylvania; the University of Michigan; the University of Southern California; Beth Israel Deaconess Medical Center/Harvard Medical School; the University of Wisconsin; private practice; Stanford University; Case Western Reserve University; TLKM Plastic Surgery; Yale School of Medicine; the University of California, Davis; and the Dallas Plastic Surgery Institute.

Summary: The American Society of Plastic Surgeons, the American Academy of Otolaryngology-Head and Neck Surgery, and the American Academy of Facial Plastic and Reconstructive Surgery commissioned the multidisciplinary Rhinoplasty Performance Measure Development Work Group to identify and draft quality measures for the care of patients undergoing both functional and aesthetic rhinoplasty. One outcome measure and three process measures were identified. The outcome looked at patient satisfaction with rhinoplasty procedures. The process measures look at motivations and expectations of the procedure, airway assessment, and nonnarcotic shared decision-making strategies for pain management. All measures in this report were approved by the American Society of Plastic Surgeons Quality and Performance Measures Work Group and Executive Committee, and the American Academy of Otolaryngology-Head and Neck Surgery Foundation, the American Academy of Facial Plastic and Reconstructive Surgery, The Rhinoplasty Society, and the American Association of Oral and Maxillofacial Surgeons. The Work Group recommends the use of these measures for quality initiatives, Continuing Medical Education, Maintenance of Certification, Qualified Clinical Data Registry reporting, and national quality reporting programs.
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http://dx.doi.org/10.1097/PRS.0000000000007598DOI Listing
February 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

Allogeneic and Alloplastic Augmentation Grafts in Nipple-Areola Complex Reconstruction: A Systematic Review and Pooled Outcomes Analysis of Complications and Aesthetic Outcomes.

Aesthetic Plast Surg 2020 04 13;44(2):308-314. Epub 2019 Nov 13.

TLKM Plastic Surgery, Private Practice, Chicago, IL, USA.

Background: With advancements in materials engineering, many plastic surgeons have looked to allogeneic tissue and alloplastic materials as a possible source of structure for long-lasting nipple-areola complex reconstruction. Furthermore, in light of the recent mandate from the Food and Drug Administration restricting the marketing and direct indication of acellular dermal matrices (ADMs) in breast reconstruction, we sought to highlight the overall safety and efficacy demonstrated in the existing literature surrounding all alloplastic materials in nipple-areola complex reconstruction. In this study, the authors conduct a systematic review and pooled outcomes analysis on allogenic and alloplastic implant materials utilized to achieve long-lasting nipple projection stratified by specific material used and respective outcomes.

Methods: A comprehensive systematic review on allogenic and synthetic materials data utilized in nipple reconstruction was conducted utilizing Medline/PubMed database. Articles were stratified by (1) alloplastic material, as well as (2) objective and patient-reported outcomes.

Results: A total of 592 nipple-areola complexes on 482 patients were featured in 15 case series. In all studies, alloplastic or allograft material was utilized to achieve and maintain nipple projection. Subjective measurements revealed a patient satisfaction rate of 93.3% or higher with the majority of patients being very satisfied with their reconstruction. The alloplastic and allograft implants analyzed had an overall complication rate of 5.3% across all materials used. The most common complication reported was flap or graft necrosis with a pooled rate of 2.5%. Overall, the Ceratite implant presented with the highest complication rate (18%) including flap/graft necrosis (13%) and extrusion of the artificial bone (5%). Other rigid implants such as the biodesign nipple reconstruction cylinder reported complications of extrusion (3.6%), projection loss requiring revision (2.5%), wound dehiscence/drainage (1.5%), flap or graft necrosis (1.0%) and excessive bleeding (0.5%). ADM implants had reported complications of both insufficient projection (0.8%) and excessive projection (1.6%), which required surgical revision. Injectable materials had minimal reported complications of pain during injection (0.8%) with Radiesse and a false-positive PET scan result (0.8%) with DermaLive.

Conclusions: Allogeneic and alloplastic grafts are a reliable means of achieving satisfactory nipple projection, with a relatively low overall complication profile. The use of Ceratite (artificial bone) led to the highest complication rates. Further clinical studies are necessary to better understand the feasibility and longer-term outcomes of the use of allogeneic and synthetic augmentation grafts to improve nipple projection.

Level Of Evidence Iii: 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/s00266-019-01539-7DOI Listing
April 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

Matching into Integrated Plastic Surgery: The Value of Research Fellowships.

Plast Reconstr Surg 2019 02;143(2):640-645

From the Division of Plastic Surgery, Montefiore Medical Center; the Hansjorg Wyss Department of Plastic Surgery, New York University Medical Center; the Department of Plastic Surgery, The Ohio State University Wexner Medical Center; and the Division of Plastic Surgery, Albany Medical Center.

Background: Integrated plastic surgery residency applicants sometimes complete research fellowships before residency. The average productivity and the impact of these fellowships on subsequent application to residency are unknown. The purpose of this study was to provide objective data to better understand the utility and productivity of a research fellowship.

Methods: A national survey was conducted in which integrated plastic surgery residency applicants from 2013 to 2016 were surveyed regarding their experiences with research fellowships. American Council of Academic Plastic Surgeons members were also surveyed to elicit their perspectives on the value of these fellowships.

Results: Six hundred twenty-one integrated plastic surgery applicants from 2013 to 2016 were included in the study. Twenty-five percent of applicants participated in a research fellowship. Applicants who completed research fellowships were more likely to match into plastic surgery compared to those who did not (97 percent versus 81 percent, respectively; p < 0.05). Fellows were highly satisfied with their fellowship experience and produced an average of five publications and presentations per fellowship year. Sixty-three percent of research fellowships were performed to strengthen applications to categorical integrated plastic surgery residency. American Council of Academic Plastic Surgeons members considered three or four publications/presentations productive. Most do not recommend research fellowships to all medical students.

Conclusions: Research fellowships can effectively prepare for categorical plastic surgery by improving publication and presentation experience. This is the first study to show that applicants who completed research fellowships were highly satisfied with their experience, accomplished higher than expected levels of productivity, and statistically significantly matched into an integrated plastic surgery residency more often than applicants without research fellowships.
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http://dx.doi.org/10.1097/PRS.0000000000005212DOI Listing
February 2019

Cervical Branch of Facial Nerve: An Explanation for Recurrent Platysma Bands Following Necklift and Platysmaplasty.

Aesthet Surg J 2019 01;39(1):1-7

Department of Plastic Surgery, Lenox Hill Hospital and Manhattan Eye, Ear and Throat Hospital, New York, NY.

Background: Recurrent platysma bands remain a common problem in neck rejuvenation.

Objectives: The goals of this cadaver study were to document the course of the cervical branches of the facial nerve and investigate the pattern of platysma muscle innervation before and after various platysmaplasty maneuvers.

Methods: A total of 8 fresh cadaver specimens were dissected for a total of 16 hemifaces/necks. After subcutaneous undermining and identification of the main trunk of the facial nerve, the cervical branch was dissected as distally/anteriorly as possible under loupe magnification. The following 4 platysmaplasty maneuvers were each performed on 4 hemifaces/necks: platysma window, extended SMAS with platysma flap, full width platysma transection, and lateral skin-platysma displacement (LSD). Upon completion of the techniques, the integrity of the cervical branches was evaluated.

Results: Contrary to some reports, all specimens in this study had only 1 main cervical branch. There were no branches detectable under 3.2× magnification until branches were given off to the platysma muscle at approximately the location of the facial vessels. The main cervical branch continued distally/anteriorly to the medial edge of the muscle below the thyroid cartilage. After performing the various platysma techniques, all cervical branches were in continuity in all specimens. Specifically, the main cervical branch was in continuity to the medial border of the muscle caudal to all platysmaplasty maneuvers.

Conclusions: Undermining the platysma muscle results in no injury to platysmal innervation unless continued beyond the facial vessels. Recurrent bands are likely related to persistent innervation of the medial platysma, which remains intact cranial and caudal to any described platysmal transection maneuvers.
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http://dx.doi.org/10.1093/asj/sjy150DOI Listing
January 2019

Platelet rich plasma for photodamaged skin: A pilot study.

J Cosmet Dermatol 2019 Feb 31;18(1):77-83. Epub 2018 May 31.

Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY, USA.

Introduction: Despite increasing popularity of platelet-rich plasma (PRP) in treating aging facial skin, the quality of evidence supporting its use is poor due to the lack of consistent methods of its preparation and application.

Objective: This study was conducted to assess treatment efficacy and patient satisfaction with a single PRP treatment prepared with a simplified preparation and application technique.

Methods: Four millilitre of PRP were injected into 6 standardized points on each side of the face. Outcomes were assessed by independent physician evaluation of pretreatment and posttreatment photographs using the Wrinkle Severity Rating Scale (WSRS) and Global Aesthetic Improvement Scale (GAIS). In addition, patient-reported outcomes were evaluated using the FACE-Q.

Results: Thirty-one participants ranging from 27 to 71 years of age (median, 38; IQR 32-58) were recruited for this study. Posttreatment WSRS scores improved in only 1 patient; the GAIS scores of 14 patients indicated aesthetic improvement. Analysis of FACE-Q scores revealed statistically significant increases in participant satisfaction with overall facial appearance and cheeks. The most frequently reported adverse effects were tenderness (23.4%; 7 of 31), facial tightness (20.0%; 6 of 31), and swelling (20.0%; 6 of 31).

Conclusions: A simple method of PRP preparation offers modest benefit in treating the effects of skin aging and photodamage. Future research studies should alter our methods using a stepwise approach to optimize the treatment of aging facial skin with PRP.
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http://dx.doi.org/10.1111/jocd.12676DOI Listing
February 2019

Assessing the Value of a Multimedia-Based Aesthetic Curriculum in Plastic Surgery Residency: A Single-Center Pilot Study.

Aesthet Surg J 2018 Nov;38(12):NP216-NP224

Plastic surgeon in private practice in Chicago, IL.

Background: Although global demand for cosmetic surgery continues to rise, plastic surgery residents feel that current models of aesthetic training are inadequate in preparing them for future practice. Digital learning resources offer promising educational possibilities, yet there are no formal studies investigating the integration of these technologies into the aesthetic curriculum.

Objectives: Here, we review the current state of aesthetic training for plastic surgery residents and present a pilot study investigating the value of a dedicated multimedia-based aesthetic curriculum at a single, large academic program.

Methods: Twenty plastic surgery residents participated in an 8-week curriculum consisting of weekly multimedia-based modules covering a specific aesthetic topic. Participants completed pre- and post-intervention surveys at 0 and 10 weeks, respectively. Surveys evaluated resident perspectives of the current state of aesthetic training, confidence in performing surgical and non-surgical aesthetic procedures, perceived efficacy of multimedia interventions for learning, and preferences for inclusion of such approaches in future curricula.

Results: 16.7% of participants planned on entering an aesthetic fellowship following residency. The mean number of months of dedicated cosmetic surgery rotations was 1.65 months. Resident confidence level in performing a particular aesthetic procedure significantly increased in 6/14 modules. More than 90% of residents were interested in incorporating the modules into residency.

Conclusions: Technology-based aesthetic training is critical for producing the finest future practitioners and leaders of this specialty. Here, we show that plastic surgery residents can benefit from a multimedia-based aesthetic curriculum, even if they do not plan on pursuing a career devoted to cosmetic surgery.
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http://dx.doi.org/10.1093/asj/sjy110DOI Listing
November 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

Evaluating Platelet-Rich Therapy for Facial Aesthetics and Alopecia: A Critical Review of the Literature.

Plast Reconstr Surg 2018 05;141(5):1115-1123

New York, N.Y.

Background: Despite the growing popularity of platelet-rich plasma, existing evidence supporting its efficacy remains controversial due to the lack of large-scale studies and standardized protocols for preparation and application. This article reviews its use in facial rejuvenation, fat grafting, acne scarring, and androgenic alopecia. Emphasis is placed on comparing methods of platelet-rich plasma preparation and application across studies.

Methods: A systematic review was performed for articles published between 2006 and 2015. All clinical studies and case reports that addressed platelet-rich plasma alone and/or in combination with fat grafting for facial rejuvenation, acne scarring, or androgenic alopecia were included.

Results: Of the 22 articles included in the analysis, seven studies used platelet-rich plasma alone for facial rejuvenation, seven in combination with fat grafting, two for treatment of acne scarring, and six for treatment of androgenic alopecia. Individual study procedures, means of evaluation, and significant results are summarized. Although the majority of studies in this review report positive results, significant variation exists in preparation protocols and in the number and frequency of clinical treatments.

Conclusions: The majority of studies report positive results for all indications evaluated in this review, but the procedure is limited by the lack of a standardized method for preparation and application of platelet-rich plasma. The extent to which significant variability in platelet-rich plasma preparation and/or application methods may affect clinical outcomes is not completely clear. In the interim, we present a consolidation of platelet-rich plasma treatment techniques and outcomes currently in use to help guide physicians in their clinical practice.
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http://dx.doi.org/10.1097/PRS.0000000000004279DOI Listing
May 2018

The ideal ear position in Caucasian females.

J Craniomaxillofac Surg 2018 Mar 26;46(3):485-491. Epub 2017 Dec 26.

Department of Plastic, Hand, and Reconstructive Surgery, University Medical Center Regensburg, Regensburg, Germany. Electronic address:

Purpose: Ear position contributes significantly to facial appearance. However, while objective measurements remain the foundation for esthetic evaluations, little is known about how an ear should ideally be positioned regarding its rotational axis. This study aimed to further evaluate whether there exists a universally applicable ideal ear axis, and how sociodemographic factors impact such preferences.

Materials And Methods: An interactive online survey was designed, enabling participants to change the axis of a female model's ear in terms of its forward and backward rotation. The questionnaire was sent out internationally to plastic surgeons and the general public. Demographic data were collected and analysis of variance was used to investigate respective preferences.

Results: A total of 1016 responses from 35 different countries (response rate: 18.5%) were gathered. Overall, 60% of survey takers chose the minus 10 or 5° angles to be most attractive. Significant differences were found regarding sex, ethnicity, country of residence, profession and respective ear axis preferences.

Conclusion: Across multiple countries and ethnicities, an ear position in slight reclination of minus 5-10° is considered most pleasing in Caucasian females. However, sociodemographic factors significantly impact individual ear axis preferences and should be taken into consideration when performing reconstructive ear surgery.
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http://dx.doi.org/10.1016/j.jcms.2017.12.017DOI Listing
March 2018

Public Interest in Breast Augmentation: Analysis and Implications of Google Trends Data.

Aesthetic Plast Surg 2018 Jun 21;42(3):648-655. Epub 2017 Dec 21.

Private Practice, Baker Levine Plastic Surgery, 630 Park Avenue, New York, NY, 10065, USA.

Introduction: Breast augmentation is the most common aesthetic surgery performed in the United States (US) annually. Analysis of Google Trends (GT) data may give plastic surgeons useful information regarding worldwide, national, and regional interest for breast augmentation and other commonly performed aesthetic surgeries.

Methods: Data were collected using GT for breast augmentation and associated search terms from January 2004 to May 2017. Case volume was obtained from the American Society of Plastic Surgeons (ASPS) annual reports for the calendar year 2005-2016.

Results: Trend analysis showed that total search term volume for breast augmentation and breast implants gradually decreased worldwide and in the US over the study period while the search term boob job slowly increased. Univariate linear regression demonstrated a statistically significant positive correlation between average annual Google search volume of "breast augmentation" and the annual volume of breast augmentations performed in the US according to ASPS data (R  = 0.44, p = 0.018). There was no significant correlation between national volume of breast augmentations performed and search volume using the terms "breast implants" or "boob job" over time (p = 0.84 and p = 0.07, respectively). In addition, there appears to be country specific variation in interest based on time of year and peaks in interest following specific policies.

Conclusions: To our knowledge, this is the first and only analysis of GT data in the plastic surgery literature to date. To that end, this study highlights this large and potentially powerful data set for plastic surgeons both in the US and around the world.

Level Of Evidence V: 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/s00266-017-1038-1DOI Listing
June 2018

Is There a Limit? A Risk Assessment Model of Liposuction and Lipoaspirate Volume on Complications in Abdominoplasty.

Plast Reconstr Surg 2018 04;141(4):892-901

Chicago, Ill.; and Baltimore, Md.

Background: Combining liposuction and abdominoplasty is controversial because of concerns for increased complications and potential for vascular compromise of the abdominoplasty flap. Also, the lipoaspirate volume in abdominoplasty is regulated in some areas to as little as 500 ml when performed with abdominoplasty. This study measures abdominoplasty complication rates when performed with and without trunk liposuction, and evaluates the effect of lipoaspirate volume on complications.

Methods: Abdominoplasty and liposuction of the trunk procedures were identified in the Tracking Operations and Outcomes for Plastic Surgeons database. Multivariate regression models determined the effect of liposuction with abdominoplasty on complications compared with abdominoplasty alone and determined the effect of liposuction volume on complications.

Results: Eleven thousand one hundred ninety-one patients were identified: 9638 (86.1 percent) having abdominoplasty with truncal liposuction and 1553 (13.9 percent) having abdominoplasty alone. Overall complication rates were 10.5 percent and 13.0 percent, respectively. Combined liposuction and abdominoplasty was independently associated with a reduced risk of both overall complications (p = 0.046) and seroma (p = 0.030). Given existing laws limiting liposuction volume to 500 or 1000 ml in combination with abdominoplasty, each of these thresholds was evaluated, with no effect on complications. Surprisingly, increasing liposuction volume was not independently associated with an increased risk of any complication.

Conclusions: When done by board-certified plastic surgeons, abdominoplasty with truncal liposuction is safe, with fewer complications than abdominoplasty alone. Regulations governing liposuction volumes in abdominoplasty are arbitrary and do not reflect valid thresholds for increased complications.

Clinical Question/level Of Evidence: Therapeutic, III.
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http://dx.doi.org/10.1097/PRS.0000000000004212DOI Listing
April 2018

The Ideal Buttock Size: A Sociodemographic Morphometric Evaluation.

Plast Reconstr Surg 2017 Jul;140(1):20e-32e

Munich, Germany; New York, N.Y.; Houston, Texas; and New Haven, Conn.

Background: Perception of beauty is influenced by geographic, ethnic, cultural, and demographic factors. However, objective measurements remain the foundation for aesthetic evaluations. In the quest to better define the "ideal" female buttock, this study assumes interdependence among variables such as country of residence, sex, age, occupation, and aesthetic perception, yielding a waist-to-hip ratio that appears most pleasing across most cultures and geographic locations.

Methods: An online survey was designed. Modifiable ranges of buttock sizes were achieved by means of digital alteration, enabling participants to interactively change the size and waist-to-hip ratio of a single model's buttocks. The questionnaire was translated into multiple languages and sent to more than 9000 plastic surgeons and to the general public worldwide. Demographic data were collected, and analysis of variance was used to elucidate buttock shape preferences.

Results: A total of 1032 responses were gathered from over 40 different countries. Significant differences regarding preferences for buttock size were identified across the respondents. Overall, 404 of 1032 of survey takers (39 percent) chose the 0.7 waist-to-hip ratio to be their ideal. Significant relationships were distilled between sex, age, self-reported ethnicity, plastic surgeons' country of residence, and ethnic background. For example, surgeons in Latin America preferred the largest buttocks, followed by surgeons in Asia, North America, and Europe, with non-Caucasians preferring larger buttocks than Caucasians.

Conclusion: There seems to exist a global consensus regarding the ideal waist-to-hip ratio; however, multiple other factors impact the aesthetic perception of the buttocks significantly.
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http://dx.doi.org/10.1097/PRS.0000000000003439DOI Listing
July 2017

Current Trends in Breast Augmentation: An International Analysis.

Aesthet Surg J 2018 Feb;38(2):133-148

Attending, Department for Plastic, Reconstructive, Hand, and Burn Surgery, StKM - Klinikum Bogenhausen, Academic Teaching Hospital, Technical University Munich, Munich, Germany.

Background: Breast augmentation surgery remains the most frequently performed aesthetic surgical procedure worldwide. However, many variations exist regarding preoperative planning, surgical management, and postoperative care.

Objectives: The goal was to evaluate current trends and practices in breast augmentation, with a focus on international variability.

Methods: A questionnaire was sent to over 5000 active breast surgeons in 44 countries worldwide. The survey inquired about current controversies, new technologies, common practices, secondary procedures, and surgeon demographics. The findings and variations were evaluated and correlated to evidence-based literature.

Results: There were a total 628 respondents equaling a response rate of approximately 18%. While certain approaches and common practices prevail also on an international basis, there exist several geographic controversies. For example, while almost fifty percent of surgeons in the United States and Latin America never use anatomically shaped implants, in Europe and Oceania most surgeons use them. Similarly, in Latin America, Europe, Asia, and Oceania, over 80% of surgeons use silicone implants only, whereas in the United States only 20% use them - meanwhile US surgeons use the largest implants (78% > 300 cc). Internationally dominant practice preferences include preoperative sizing with silicone implants, as well as the use of inframammary incisions and partial submuscular pockets.

Conclusions: Significant differences exist when comparing most common surgical breast augmentation approaches on an international basis. While certain techniques seem to be universal standards, there still remain several controversies. Further standardizing this most common aesthetic surgical procedure according to evidence-based guidelines will help to improve outcomes.
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http://dx.doi.org/10.1093/asj/sjx104DOI Listing
February 2018

The Cosmetic Ladder: Familiar Structure, New Commitment.

Authors:
Sammy Sinno

Plast Reconstr Surg 2017 09;140(3):519e-520e

TLKM Plastic Surgery, 737 N. Michigan Avenue, Suite 1500, Chicago, Ill. 60611,

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http://dx.doi.org/10.1097/PRS.0000000000003639DOI Listing
September 2017

Selective Serotonin Reuptake Inhibitor-Induced Hyponatremia and the Plastic Surgery Patient.

Plast Reconstr Surg 2017 Jun;139(6):1481-1488

New York, N.Y.

Cosmetic plastic surgery procedures continue to increase in frequency, and a greater number of them now occur outside of an acute-care hospital setting. In addition, antidepressant use is also rising, with a greater number of patients taking selective serotonin reuptake inhibitors to aid in a variety of mood and anxiety disorders. Americans spend more than $86 billion each year on antidepressants, as 34 million people in the United States are taking at least one of these medications. Many side effects of selective serotonin reuptake inhibitors are well known and not clinically relevant to practicing surgeons. Hyponatremia, however, is a well-documented side effect of these medications that has received relatively little attention in the surgical literature. Postoperative hyponatremia results because of a decrease of antidiuretic hormone suppression that occurs with selective serotonin reuptake inhibitor administration. Here, the authors first review the literature reporting hyponatremia with selective serotonin reuptake inhibitor use. The authors then present two cases of severe postoperative hyponatremia after plastic surgery operations. The authors propose that patients using selective serotonin reuptake inhibitors, especially elderly patients and those undergoing procedures with expected large fluid shifts, should be tested preoperatively and postoperatively for serum sodium levels so that a diagnosis of hyponatremia may be made early and treated before a catastrophic event.

Clinical Question/level Of Evidence: Therapeutic, V.
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http://dx.doi.org/10.1097/PRS.0000000000003329DOI Listing
June 2017

Chin Ups and Downs: Avoiding Bad Results in Chin Reoperation.

Aesthet Surg J 2017 03;37(3):257-263

Department of Plastic Surgery, New York University Medical Center, Department of Plastic Surgery, New York, NY, USA.

The senior author (B.M.Z.) has performed 512 chin reoperations over the last 30 years. This paper will describe the usual errors in surgical planning regarding what seems to be a relatively straightforward operation. We will focus on: (1) assessment of the chin; (2) pitfalls with surgical approaches; and (3) problem cases. This paper will not focus on the large chin, but rather on the chin that needs augmentation. Some chins will do well with an implant, others will need an osteotomy or ostectomy, and even others need both. The surgeon is responsible for selecting the correct operation. Thus, it remains incumbent on the surgeon to become diligent in diagnosis and delivery.
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http://dx.doi.org/10.1093/asj/sjw208DOI Listing
March 2017

Definitive Management of Persistent Frontal Sinus Infections and Mucocele with a Vascularized Free Fibula Flap.

Plast Reconstr Surg 2017 Jan;139(1):170-175

New York, N.Y.

Chronic frontal sinus infections in the setting of previous trauma or tumor removal are challenging clinical scenarios. To remove and débride all chronically infected tissue, obliterate dead space, and provide a stable reconstructive yet aesthetic contour are critical tasks in managing these patients. The vascularized free fibula is an ideal flap for this situation; in this article, the authors detail their technique in a patient with chronic frontal sinus infections complicated by mucocele formation.
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http://dx.doi.org/10.1097/PRS.0000000000002925DOI Listing
January 2017

The Need for Overcorrection When Using a Suborbital Cervicofacial Hike Flap.

J Craniofac Surg 2017 Jan;28(1):122-124

*Department of Plastic and Reconstructive Surgery, New York University †Division of Plastic and Reconstructive Surgery, Northwell Health, New York, NY.

Background: The senior author has previously described a deep-plane cervicofacial hike flap as a workhorse for reconstruction mid-cheek defects. One important modification commonly used involves overcorrection of the defect in order to reduce the incidence of ectropion. This report outlines the senior author's experience in surgical treating complex cheek defects with an overcorrected deep-plane cervicofacial hike flap.

Methods: The authors performed a retrospective review of the senior author's patients with cheek and eyelid reconstruction. The authors initially identified all patients who had undergone a deep-plane cervicofacial hike flap, then filtered those charts for patients who had overcorrection of their deformity in order to prevent ectropion.

Results: A total of 3 patients had an overcorrected flap. Overcorrection was accomplished either by cheek advancement with suture fixation to the deep temporal fascia, or by placement of drill holes and bone anchors. Lower eyelid malposition was avoided in all 3 patients. Patient satisfaction at long term follow-up was very high, and no revision surgery was needed.

Conclusion: If gravitational or cicatricial forces can potentially distort the eyelid in patients with cheek or eyelid reconstruction, it is necessary to overcorrect the cheek flap. This modification of the deep-plane cervicofacial flap is an important tool in reconstructing defects in this area.
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http://dx.doi.org/10.1097/SCS.0000000000003359DOI Listing
January 2017

Aesthetic Surgery in Patients with Lung Cancer: A Paradigm Shift.

Plast Reconstr Surg Glob Open 2016 Oct 24;4(10):e1086. Epub 2016 Oct 24.

Division of Plastic Surgery, Weill Cornell Medical College, New York, N.Y.; Lung Cancer Research Foundation, New York, N.Y.; and Hansjörg Wyss Department of Plastic Surgery, New York University Langone Medical Center, New York, N.Y.

Background: Lung cancer is the most common cancer worldwide and the leading cause of cancer death. With the development of targeted therapy against causative driver mutations, some patients have experienced dramatic responses that have converted their disease into a chronic, stable form. Shifting concerns away from survival and back to quality-of-life issues has led some of these patients to seek aesthetic surgery.

Methods: Three patient examples are presented to illustrate current lung cancer treatment modalities, disease responses, and subsequent experiences with aesthetic surgical procedures. Two patients presented for blepharoplasty and the third for revisional breast augmentation surgery.

Results: Two patients were treated for lung cancer with targeted therapy and a third with more traditional chemotherapy before undergoing aesthetic surgery. All 3 patients experienced a normal recovery from surgery without any untoward results. Two remain free of disease and one has chronic stable disease. All have returned to normal, active lives.

Conclusions: Recent developments in lung cancer treatment are transforming this entity into a less formidable diagnosis for some patients, much like breast cancer and prostate cancer. Plastic surgeons should be aware of this paradigm shift. Successfully treated patients should be considered as reasonable candidates for aesthetic surgery, particularly when they have the full support of their oncologist. Beyond the typical psychological benefits that plastic surgery can produce, it also provides affirmation in this patient population of a return to normalcy, thereby imparting hope and optimism for the future.
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http://dx.doi.org/10.1097/GOX.0000000000001086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5096535PMC
October 2016

Inferior Turbinate Hypertrophy in Rhinoplasty: Systematic Review of Surgical Techniques.

Plast Reconstr Surg 2016 Sep;138(3):419e-429e

New York, N.Y.; and Shreveport, La.

Background: Inferior turbinate hypertrophy is often encountered by plastic surgeons who perform rhinoplasty. Many treatment options are available to treat the inferior turbinate. The objective of this study was to systematically review outcomes of available techniques and provide guidance to surgical turbinate management.

Methods: A MEDLINE search was performed for means of treating inferior turbinate hypertrophy. Studies selected focused on treatment of the inferior turbinate in isolation and excluding patients with refractory allergic rhinitis, vasomotor rhinitis, or hypertrophic rhinitis.

Results: Fifty-eight articles were identified, collectively including the following surgical treatments of inferior turbinate hypertrophy: total turbinectomy, partial turbinectomy, submucosal resection, laser surgery, cryotherapy, electrocautery, radiofrequency ablation, and turbinate outfracture. Outcomes and complications were collected from all studies. Procedures such as turbinectomy (partial/total) and submucosal resection showed crusting and epistaxis at comparatively higher rates, whereas more conservative treatments such as cryotherapy and submucous diathermy failed to provide long-term results. Submucosal resection and radiofrequency ablation were shown to decrease nasal resistance and preserve mucosal function. No literature exists to support the belief that turbinate outfracture alone is an effective treatment for turbinate hypertrophy.

Conclusions: Treatment of inferior turbinate hypertrophy is best accomplished with modalities that provide long-lasting results, preservation of turbinate function, and low complication rates. Submucosal resection and radiofrequency ablation appear to best fulfill these criteria. Turbinate outfracture should only be considered in combination with tissue-reduction procedures.
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http://dx.doi.org/10.1097/PRS.0000000000002433DOI Listing
September 2016

Utilizing the Power of Fat Grafting to Obtain a Naturally-Appearing Muscular "6-Pack" Abdomen.

Aesthet Surg J 2016 Oct 21;36(9):1085-8. Epub 2016 Jun 21.

Dr Steinbrech is a plastic surgeon in private practice in New York, NY, USA. Dr Sinno is a Resident, Department of Plastic Surgery, New York University Medical Center, New York, NY, USA.

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http://dx.doi.org/10.1093/asj/sjw072DOI Listing
October 2016

Management of Lower Extremity and Pelvic Tumors Using Computer Assisted Modeling (CAM) A Case Series.

Bull Hosp Jt Dis (2013) 2016 Jun;74(2):176-9

Computer assisted modeling (CAM) has become an important tool in surgical oncology and reconstructive surgery. The preservation of the limb is an important consideration when approaching the treatment of lower extremity and pelvic tumors. The use of cutting guides allows for optimal conservation of disease-free bone and maintenance of function. We present a small case series that illustrates the use of CAM in patients with lower extremity and pelvic bone tumors.
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June 2016

Reply: Face-Lift Satisfaction Using the FACE-Q.

Plast Reconstr Surg 2016 06;137(6):1051e

Hansjorg Wyss Department of Plastic Surgery, New York University, Department of Plastic Surgery, Lenox Hill Hospital, New York, NY.

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http://dx.doi.org/10.1097/PRS.0000000000002001DOI Listing
June 2016

Creating the Perfect Umbilicus: A Systematic Review of Recent Literature.

Aesthetic Plast Surg 2016 Jun 8;40(3):372-9. Epub 2016 Apr 8.

Institute for Reconstructive Plastic Surgery, New York University Langone Medical Center, New York, NY, 10016, USA.

Background: The aim of this study was to perform an updated systematic review of the literature over the last 10 years, analyzing and comparing the many published techniques with the hope of providing plastic surgeons with a new standard in creating the perfect umbilicus in the setting of both abdominoplasty and abdominally based free-flap breast reconstruction.

Methods: An initial search using the PubMed online database with the keyword "umbilicoplasty" was performed. These results were filtered to only include articles published within the last 10 years. The remaining articles were thoroughly reviewed by the authors and only those pertaining to techniques for umbilicoplasty in the setting of abdominoplasty and abdominally based free flap were included.

Results: Of the 10 unique techniques yielded by our search, 9/10 (90 %) initially incised the native umbilicus with a round, oval, or vertical ellipse pattern. Of the 9 techniques that initially perform a round incision, 4 of them (44.4 %) later modify the round umbilicus with either an inferior or superior excision to create either a "U"- or "inverted U"-shaped umbilicus. In terms of the shape of the incision made in the abdominal flap for umbilical reinsertion, the most common were either a round incision or an inverted "V" or "U," both of which accounted for 4/10 (40 %) and 3/10 (30 %), respectively. Almost all of the studies (8/10; 80 %) describe "defatting" or trimming of the subcutaneous adipose tissue around the incision to create a periumbilical concavity following inset of the umbilicus. 4/10 (40 %) of the techniques describe suturing the dermis of the umbilical skin to rectus fascia. Furthermore, 3/10 (30 %) advise that stalk plication is a necessary step to their technique. 7/9 techniques (77.8 %) preferred nondissolvable sutures for skin closure, with nylon being the most common suture material used. Only 2/9 (22.2 %) used dissolvable sutures.

Conclusion: Although future studies are necessary, it is our hope that this systematic review better elucidates the techniques and provides some guidance to both aesthetic and reconstructive plastic surgeons in the pursuit of creating the perfect umbilicus following abdominoplasty and TRAM/DIEP breast reconstruction.

No Level Assigned: 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/s00266-016-0633-xDOI Listing
June 2016

Determining the Safety and Efficacy of Gluteal Augmentation: A Systematic Review of Outcomes and Complications.

Plast Reconstr Surg 2016 Apr;137(4):1151-1156

New York, N.Y.; and Shreveport, La.

Background: Augmentation gluteoplasty has been performed more frequently in the past decade, with over 21,000 procedures performed in the past year alone. The most popular methods for buttock augmentation involve silicone prostheses and autologous fat grafting. A comparison of complications of these two techniques does not exist in our literature.

Methods: The PubMed, MEDLINE, and Cochrane databases were searched through April of 2015 for studies that achieved buttock augmentation through the use of silicone implant placement or autologous lipoinjection. Complication outcomes of interest included wound dehiscence, infection, seroma, hematoma, asymmetry, and capsular contracture.

Results: Forty-four articles met inclusion criteria. The most commonly reported complications in 2375 patients receiving silicone implants were wound dehiscence (9.6 percent), seroma (4.6 percent), infection (1.9 percent), and transient sciatic paresthesias (1.0 percent), with an overall complication rate of 21.6 percent (n = 512). The most commonly reported complications in 3567 patients receiving autologous fat injection were seroma (3.5 percent), undercorrection (2.2 percent), infection (2.0 percent), and pain or sciatalgia (1.7 percent), with an overall complication rate of 9.9 percent (n = 353). Patient satisfaction after surgery was assessed differently among studies and could not be compared quantitatively.

Conclusions: Although gluteal augmentation was once reported to have complication rates as high as 38.1 percent, a systematic review of the two most popular techniques demonstrated substantially lower overall complication rates. The overall complication rate with autologous fat grafting (9.9 percent) is lower than that with silicone buttock implants (21.6 percent). A standardized method of measuring patient satisfaction is necessary to fully understand outcomes of these increasingly popular procedures.
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http://dx.doi.org/10.1097/PRS.0000000000002005DOI Listing
April 2016

Current Trends and Controversies in Breast Augmentation.

Plast Reconstr Surg 2016 Apr;137(4):1142-1150

New York, N.Y.

Background: A survey was conducted to study current attitudes and common practices in breast augmentation.

Methods: A 35-item electronic questionnaire was sent to the entire active American Society of Plastic Surgeons membership. It was divided into current controversies, new technologies, common practices, secondary procedures, and member demographics.

Results: There were 1067 respondents. Fifty percent of surgeons never use anatomically shaped implants and another 42 percent do so less than half the time. Autologous fat is used infrequently as a primary technique but more often as a supplemental technique. Approximately 7 percent report a case of anaplastic large cell lymphoma. Eighty-five percent do not use preoperative three-dimensional imaging. More than half of surgeons use acellular dermal matrix in secondary procedures. Approximately half do not use insertion funnels. Preoperative sizing with silicone implants, inframammary incisions, partial submuscular pockets, and smooth silicone implants larger than 300 cc are dominant practice preferences. Postoperative massage is still popular with over half of respondents. Just over half do not use pharmacologic agents for capsular contracture. Capsular contracture and size change were the most frequent reasons for reoperation. Capsular contracture is typically treated with anterior capsulectomy the first time, and either total capsulectomy or anterior capsulectomy with acellular dermal matrix use when recurrent. Almost half of respondents perform fewer than 50 breast augmentations yearly.

Conclusions: There is an established most common approach to breast augmentation among respondents. Most surgeons are slow to embrace controversial practices and to adopt new technologies, although acellular dermal matrix use is becoming more popular. The 7 percent incidence of anaplastic large cell lymphoma was noteworthy.
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http://dx.doi.org/10.1097/01.prs.0000481110.31939.e4DOI Listing
April 2016
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