Board-certified Plastic Surgeon Research Articles

Gynecomastia Surgery Patient Education: An Information Quality Assessment of YouTube Videos.

YouTube is a platform for many topics, including plastic surgery. Previous studies have shown poor educational value in YouTube videos of plastic surgery procedures. The purpose of this study was to evaluate the quality and accuracy of YouTube videos concerning gynecomastia surgery (GS). The phrases "gynecomastia surgery" (GS) and "man boobs surgery" (MB) were queried on YouTube. The first 50 videos for each search term were examined. The videos were rated using our novel Gynecomastia Surgery Specific Score to measure gynecomastia-specific information, the Patient Education Materials Assessment Tool (PEMAT) to measure understandability and actionability, and the Global Quality Scale to measure general quality. The most common upload source was a board-certified plastic surgeon (35%), and content category was surgery techniques and consultations (51%). Average scores for the Global Quality Scale (x̄ = 2.25), Gynecomastia Surgery Specific Score (x̄ = 3.50), and PEMAT Actionability (x̄ = 44.8%) were low, whereas PEMAT Understandability (x̄ = 77.4%) was moderate to high. There was no difference in all scoring modalities between the GS and MB groups. Internationally uploaded MB videos tended to originate from Asian countries, whereas GS videos tended to originate from non-US Western countries. Patient uploaders had higher PEMAT Actionability scores than plastic surgeon uploaders. The quality and amount of gynecomastia-specific information in GS videos on YouTube are low and contain few practical, take-home points for patients. However, understandability is adequate. Plastic surgeons and professional societies should strive to create high-quality medical media on platforms such as YouTube.

Anatomical Breast Implant Assessment Using Ultrasound: A Case Series from the International Breast Implant Check Clinic.

Breast augmentation with anatomic implants can achieve a natural look, but over time, implant-related complications can occur. This includes a risk of potential rotation, which can cause a change in breast shape. Reported rates of rotation vary widely (0%-42%). Implant rotation is often detected by physical examination only or as a perioperative finding. Change in breast shape after augmentation requires clinical evaluation. In-office ultrasound allows for detailed assessment of implants for rotation and other complications. Women with anatomical breast implants seeking follow-up at the International Breast Implant Check Clinic in Stockholm, Sweden, from April 2020 to July 2022 were included in the study. Using a standardized protocol, subjective symptoms were recorded, and a physical examination followed by an ultrasound assessment was performed by a single board-certified plastic surgeon (M.J.) trained in implant assessment via ultrasound. Rotation was defined as an implant rotated past 30 degrees off the breast midline at 6 o'clock. The study included 308 women (mean age 40.1, range 20-78) with bilateral anatomical implants. Overall, 40 women (13.0%) reported a change in breast shape; 35 had one or more implant-related complications, including five with rotation on ultrasound. Of the 308 women, 11 (3.6%) had rotations upon physical examination, and an additional 10 cases were identified using ultrasound. Rotation is a potential complication of anatomical breast implants. However, in this study, change in breast shape was more commonly caused by other implant-related complications. Ultrasound is a valuable tool in evaluating causes of change in breast shape.

The Brazilian Butt Lift Remains the Deadliest Aesthetic Surgery Procedure: Are Plastic Surgeons Adjusting Their Surgical Practice to Promote Safety?

The number of Brazilian butt lift (BBL) fatalities remains high in the United States despite numerous practice advisories geared towards patient safety and reducing the incidence of fatal pulmonary fat emboli. This study aimed to evaluate US board-certified plastic surgeons' opinions, understanding of BBL-related mortality, and current risk-reducing surgical practices for BBL procedures. An online 18-question survey was distributed via email by the Aesthetic Surgery Education and Research Foundation to national board-certified plastic surgeon members of the The Aesthetic Society. Survey responses were collected over 21 days on the Qualtrics platform. The survey response rate was 10% (n = 178). Of the 77% who performed BBL procedures, 48% (n = 80) did not use ultrasound. Approximately 60% (n = 102) of all respondents disagreed with imposing regulations to require ultrasound, with the most frequent reason being that it was unnecessary with adequate surgeon experience (45%). Plastic surgeons thought that high-volume budget clinics (n = 64) and a lack of regulations imposed on individual surgeons by boards of medicine (n = 31) were the greatest contributors to BBL mortality. Most US plastic surgeons did not use ultrasound for BBL procedures and did not agree that ultrasound should be required, which may partially be the result of unsuccessful educational outreach for risk-reducing practices and training for ultrasound. Regulations by the boards of medicine imposed on individual surgeons, in combination with new legislation targeted at ownership of high-volume clinics, are strongly backed by surgeon respondents as measures that may improve patient safety.

Aesthetic Surgery Before-and-After Photography Bias on Instagram.

This study aims to systematically assess body and facial aesthetic surgery before-and-after photography bias on Instagram. An Instagram search using the term "plastic surgeon" was conducted on October 2020. The top 11 plastic surgeons' accounts were selected, and the first 15 images were selected from these profiles pertaining to different anatomical locations. Each photo was analyzed by a blinded board-certified plastic surgeon utilizing a 5-domain clinical photography bias score. The domains covered: (1) photo quality; (2) photo background; (3) position; (4) exposure/coverage; (5) bias. The search strategy identified a total of 161 sets of before and after. The most common anatomical site posted was the nose (n=47), followed by breasts (n=37). The most common angles posted were anterior-posterior view (n=61). The majority of images showed bias toward the post-operative image (70.8%). The main culprit with photo characteristics occurred due to there being a different post-operative background which was more flattering for the post-operative result (n=46, p=0.006) and a different view or angle, which again, flattered the post-operative image (n=36, p=0.02). Other factors that influenced the post-operative bias included photos of the patient covered with clothing (n=15, p=0.014) or standing (n=20, p=0.001), compared to a supine pre-operative image. Before-and-after photography conditions in aesthetic surgery is biased toward the post-operative result on Instagram. This observation was noticed across all surgical anatomical areas. Accounts photographer tends to misrepresent the photo background, view of angle, patients pose or position, or covering certain body parts. 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 .

Breast Implant Rupture: Causes, Diagnosis and Treatment

Breast implant rupture is a rare event that can occur at any time after breast augmentation surgery. The most common causes of rupture are natural aging of the implant, traumatic injury, and failure of the implant material. Symptoms of breast implant rupture can range from mild discomfort to total loss of breast shape and size. Diagnosing a ruptured breast implant can be challenging, as the condition can be asymptomatic in some cases. However, imaging tests such as MRI and ultrasound can help detect the presence of ruptured implants. Treatment options for ruptured breast implants vary depending on the type of implant, the duration of rupture and the presence of symptoms. In general, treatment involves surgical removal of the ruptured implant and replacement with a new one or complete removal of the implant and surrounding silicone material. Regular checkups with a board-certified plastic surgeon and being aware of any changes in the shape or feel of the breasts are crucial for early detection and treatment of breast implant rupture. Women considering breast augmentation surgery should carefully weigh the potential risks and benefits of the procedure before undergoing surgery. Breast implant rupture is a rare but important complication that requires prompt diagnosis and treatment to avoid potential complications. Understanding the causes, symptoms, diagnosis and treatment options for breast implant rupture can help women make informed decisions about breast augmentation surgery and maintain the health of their breasts.

Knowledge and Practice of Burn Management Among Physicians Using Burn Manikin in Ha'il, Kingdom of Saudi Arabia.

Background Burn is a skin injury that results in the death of the impacted cells. Burn injuries are frequently unintentional and very avoidable. With proper management, the outcome is improved, and the need for surgical intervention is reduced. This article discusses healthcare providers' knowledge and practice of burn first aid and management to highlight the need for the enhanced practice of burn management and first-aid skills. Objective This study aims to assess the knowledge and practice of burn injuries management among healthcare workers in different specialties in Hail city. Methods A cross-sectional study was conducted via an interviewer-administrated face-to-face questionnaire and video recording of a simulated case of burn injury collected from our skill lab at Hail University and evaluated by a board-certified plastic surgeon. Result The study analyzed 119 physicians (mean age = 36.3 years, SD = 6.7) managing burn cases. Of these, 59.7% were male, and 40.3% were female. The mean evaluation score was 7.71 (SD = 2.84). None of the factors studied, including gender (p = 0.353), age (p = 0.970), education level (p = 0.127), specialty (p = 0.871), professional experience (p = 0.118), working sector (p = 0.178), nationality (p = 0.742), or participation in burn management course (p = 0.131), had a significant effect on burn management skills of physicians. However, some groups had higher mean evaluation scores than others. Further research is needed to explore potential reasons for the observed differences in mean evaluation scores among different groups of physicians. Conclusion We discovered that most physicians were found to have poor practical knowledge of proper burn management, and most of them had not engaged in a burn first aid training, therefore more courses targeting physicians who may meet burn patients are required.

Suprapubic Cholecystectomy Improves Cosmetic Outcome Compared to Classic Cholecystectomy.

Currently, cholecystectomy is performed laparoscopically. While the conventional approach (CA) with four access ports persists, other methods seek to reduce trauma or to optimize cosmetic results. In this study, the safety and cosmetic outcome of a suprapubic approach (SA) were evaluated. Between 2015 and 2016, patients undergoing elective cholecystectomy either by CA or by a suprapubic approach (SA) at our institution were included. The cosmetic outcome, postoperative morbidity, operative time and length of stay were evaluated. Pictures of the site of intervention were taken 6–12 months postoperatively and rated on a scale from 1 (unsatisfying aesthetic result) to 5 (excellent aesthetic result). Five “non-medical” and five “medical” raters as well as one board-certified plastic surgeon performed the ratings. A total of 70 patients were included (n = 28 SA, n = 42 CA). The two groups did not differ in baseline characteristics (age, gender, BMI). The SA group showed a significantly better aesthetic outcome compared to the CA group 4.8 (4.8–4.9) vs. 4.2 (3.8–4.4), (p > 0.001). Medical raters: 4.0 (3.8–4.2) vs. 4.8 (4.6–5.0), (p < 0.001); non-medical raters: 4.2 (3.8–4.6) vs. 5.0 (4.8–5.0), (p < 0.001); plastic surgeon: 4.0 (4.0–4.0) vs. 5.0 (5.0–5.0), (p < 0.001). Fair interrater consistency was demonstrated with an ICC of 0.47 (95% CI = 0.38–0.57). No significant difference in the complication rate (1 (3.5%) in SA vs. 6 (14%) in CA, (p = 0.3)), or the operating time 66 (50–86) vs. 70 (65–82) min, (p = 0.3), were observed. Patients stayed for a median of three (3–3) days in the SA group and 3 (3–4) days in the CA group (p = 0.08). This study demonstrated that the suprapubic approach is an appropriate alternative to conventional laparoscopic cholecystectomy, presenting a better cosmetic outcome with a similar complication rate.

Patient Understanding of Provider Credentials and Selection of Plastic Surgery Providers.

Many physicians who are not board-certified plastic surgeons have started performing aesthetic procedures, leading to unsafe practices that jeopardize patients' health. Patients of a cosmetic and reconstructive private plastic surgery practice were asked to complete a survey that assessed their understanding of plastic surgeon credentials and advertising practices, and what influences their choice of a plastic surgeon. Eighty-five patients completed the survey, with 37.2% reporting prior aesthetic surgery; 84.9% were unaware of the lack of legal regulations governing the advertising practices of physicians. When asked if a doctor can perform surgery to improve their appearance without being a board-certified plastic surgeon, 22.1% responded "yes," 50% responded "no," and 27.9% responded "I don't know;" 98.8% reported a sense of comfort knowing their provider is board-certified in plastic surgery. When asked what factors help them decide if a surgeon is knowledgeable and trustworthy, the overwhelming majority reported referral from patients and providers as the most important factor, followed by online ratings and reviews. When deciding whether to recommend a plastic surgeon, personal experience was the most important factor. When deciding who should perform their cosmetic procedure, the most important factor was experience, followed by plastic surgery board certification. Current physician advertising practices lack strict guidelines and are often misleading. Patients would benefit from more thorough education on these practices. Of the various plastic surgeon assessment factors, most patients rely heavily on feedback obtained from patients and providers.

Assessing the quality and reliability of patient information regarding aesthetic fat grafting on YouTube

PurposePatients increasingly consult social media regarding aesthetic surgery. Given the popularity of fat transfer operations, this study assesses the quality and reliability of patient information available on YouTube regarding aesthetic fat grafting. MethodsThe terms “fat grafting” and “fat transfer” were searched on YouTube with respect to the terms “face”, “breast”, “buttock”, and “Brazilian butt lift”. Filtered by view count, the top 20 unique, English language, aesthetic surgery-related videos for each search combination were reviewed by three independent reviewers for demographic and descriptive characteristics. Videos were rated for information reliability and quality using the modified DISCERN (MD) tool (1 = low, 5 = high) and global quality scale (GQS) (1 = poor, 5 = excellent). ResultsOut of 80 total videos, 76% were authored by physicians and 24% by laypersons. The overall mean MD score was 1.5 and the mean GQS was 2.6. Videos authored by physicians outscored those by non-medical authors (MD: 1.6 vs. 1.3; GQS 2.7 vs. 2.2). Board-certified plastic surgeon videos (N = 30) scored higher on both the MD (1.7 vs 1.3) and GQS (3.1 vs 2.2) than those of non-medical authors. On the contrary, videos by laypersons and non-plastic surgeons had 40% more views, twice as many “likes” and nearly double as many subscribers. ConclusionThe overall quality of information presented in aesthetic fat grafting procedures videos on YouTube is low and from unreliable sources. Surgeons should educate patients regarding potentially inaccurate information, and professional societies should disseminate high-quality media.

A Single-Center Study Evaluating the Effects of a Novel Retinol and Cannabidiol Combination Topical on Facial Skin.

BackgroundWhile retinol is known to reduce the appearance of fine lines and wrinkles, it is associated with irritating effects. However, when combined with water soluble cannabidiol (CBD; CR Topical), CBD may act to reduce oxidative stress and inflammation, mitigating irritation from retinol and further improving the skin’s appearance through independent anti-aging mechanisms. ObjectivesTo assess the efficacy and tolerability of CR-Topical for improving facial skin.MethodsIn this prospective, single-center pilot study, 9 female patients and one male patient aged 20 to 53 years who presented with facial skin imperfections (visible pores, dehydration, roughness, and/or static/dynamic wrinkles) applied CR-Topical to the entire face once daily for 42 days. Outcomes were measured on days 1, 21, and 42 using the Global Ranking Scale (GRS) with Comprehensive Skin Analysis by the patient and senior investigator as well as by a blinded reviewer (board-certified plastic surgeon). Dynamic videos and static imagery were taken before and after treatment, and patient satisfaction surveys were completed.ResultsGlobal improvement across all 13 domains was observed, with the greatest mean differences for visible pores (2.0; 95% CI, 1.5-2.5), dehydration (2.0; 95% CI, 1.4-2.6), surface roughness (1.8; 95% CI, 1.2-2.4), static wrinkles (1.8; 95% CI, 1.1-2.5), and dynamic wrinkles (1.6; 95% CI, 0.8-2.3). Patient satisfaction (100%) and willingness to recommend the product to others (90%) were high, and tolerability of CR-Topical was excellent.ConclusionsCR-Topical is effective at improving global skin quality, including static and dynamic wrinkles. This study also used 4-dimensional analysis in the evaluation, a novel and developing method.Level of Evidence: 4

Basal Cell Carcinoma Destruction by a Concentrate of Proteolytic Enzymes Enriched in Bromelain: A Preliminary Report

Objectives: Basal Cell Carcinoma (BCC) is the most common skin cancer generally treated by a variety of surgical and non-surgical destructive therapies. A Concentrate of Proteolytic Enzymes Enriched in Bromelain (CPEEB) derived from the stems of pineapples is approved for use for debriding deep burns. Prior studies suggest that bromelain also has anti-tumor effects. We describe our preliminary off-label treatment experience using topical CPEEB for the destruction of six BCCs in three patients. Methods: CPEEB was self-applied by three patients on six different Morphea, nodular, and superficially invasive BCCs. The CPEEB was applied as a thin layer prior to bedtime and left for a period of 9-12 hours. The wound was then covered with a petrolatum-based ointment for the next 24 hours. Application of the CPEEB was repeated up to 5 times over the course of 10 days, during which the patients were monitored daily and reevaluated by a board-certified plastic surgeon. If necessary, the CPEEB was reapplied up to five additional times over the next 10-day period. If necessary, any remaining lesion was surgically excised (MOHS surgery). The patients were then followed for up to 1 year. Results: Six BCCs located on the face, neck, and extremities were self-treated by three patients with 2-6 CPEEB applications. All of the BCCs were completely removed after the CPEEB application. CPEEB application was associated with local irritation and mild itching pain which resolved untreated within hours. In one patient, two of the lesion’s sites were surgically excised after 6 months with no tumor cells noted on histopathology. None of the BCCs recurred over the next 1 year. Conclusion: Our preliminary findings are a proof-of-concept that a concentrate of proteolytic enzymes enriched in bromelain may be a safe and effective destructive treatment for basal cell carcinomas. Future studies on larger groups of BCC patients are necessary in order to elucidate the potential use of CPEEB for this indication.

Breast implant illness: a topic in review.

Recently, the term breast implant illness has become popularized in social media to describe a constellation of symptoms which have been attributed to a patient's breast implants. These symptoms include fatigue, chest pain, hair loss, headaches, chills, photosensitivity, rash, and chronic pain amongst others. While physicians aim to treat these physical symptoms, currently the evidence supports the safety of silicone breast implants. This article entitled "Breast implant illness: a topic in review" presents an up-to-date review focusing on the safety of silicone breast implants. Patients retain the right to decide to keep or remove their breast implants and for those who choose to pursue explantation, they should be advised to seek the care of a board-certified plastic surgeon. As a scientific community is our duty to continue to conduct well-designed scientific studies to gain more insight into the safety of breast implants as it related to cancer detection, autoimmune disease, and other health concerns to improve patient safety, awareness, and education. This review article aims to delineate both the content and timing of all research and evidence as it pertains to the newly coined phrase "breast implant illness". The authors of this study support that currently there have not been any concrete or evidence-based studies which support the formation of a new syndrome "silicone implant illness".

Silicone Implant Illness: Science versus Myth?

Summary: The purpose of this Special Topic article is to present the current state of scientific evidence related to the safety of silicone breast implants. There is presently overwhelming evidence to support the safety of silicone breast implants. Ultimately, the decision to obtain, keep, or remove breast implants is the choice of the patient. If a patient chooses to have her breast implants removed, it is important to find a board-certified plastic surgeon with expertise in breast surgery. Ongoing studies are strongly encouraged in all areas, from cancer detection to autoimmune disease, as we strive for improved patient safety, patient awareness, and patient education. To the best of our body of scientific knowledge to date, there have not been any concrete or evidence-based studies or peer-reviewed data concerning the formation of a new syndrome: “silicone implant illness.” Silicone breast implants are used in nearly 300,000 breast augmentation and 100,000 breast reconstruction operations annually in the United States. 1 Silicone gel–filled implants were first approved by the U.S. Food and Drug Administration in 1962. Since that time, few medical devices have been studied as closely for their safety and associated adverse outcomes. Despite multiple generations of implant shells and gel fillers, the basic components remain as originally designed. 2,3

Cosmetic Surgeon Representation

Previous studies revealed that patients preferred plastic surgeons over cosmetic surgeons for surgical procedures, but few knew that any physician with a medical degree was legally qualified to perform cosmetic surgery. Results also indicated that a primary consideration for patients in selecting a surgeon was board certification. Although patient preferences concerning aesthetic surgery have previously been surveyed, no study examined a consumer's ability delineate between specialties based on Web sites. The purpose of this study was to investigate the responses of medical students to questions regarding a cosmetic and plastic surgeon's board certification. A total of 4 cosmetic and 5 plastic surgeon Web sites were selected, in a single large city, from a Google search for the following procedures: liposuction, breast augmentation, blepharoplasty, rhytidectomy, and abdominoplasty. Screenshots of the Google search link, the page after clicking on the link, and the about the doctor page were collected to simulate an actual patient search experience. Four randomized surveys were created using screenshots and scenarios through Survey Monkey. Surveys were distributed and collected anonymously. Data analysis was accomplished using a chi-square test of independence (P < 0.05). A total of 474 medical students responded, and the difference between cosmetic and plastic surgeon variables was significant (P < 0.001). Upon comparison of different procedures, the cosmetic and plastic groups were found to be statistically different (P < 0.05), with some exceptions. On average, when presented with a plastic surgeon, 95.3% thought this was a board-certified plastic surgeon. When presented with a cosmetic surgeon, 54.3% also thought this was a board-certified plastic surgeon. The decline in responses regarding board certification, for the first and second cosmetic surgeons presented, was found to be statistically different (P < 0.0001). Over 50% of medical students had difficulty distinguishing between a cosmetic and plastic surgeon based on Web site advertisements; therefore, patients may have a more difficult experience. Results of this study prove the need for a universal definition, and patient education, relating to board certifications.

Anh H. Nguyen, MD.

I want to thank my colleague Dr. Anh Nguyen for serving as guest editor of this edition of Seminars in Plastic Surgery and the talented group of authors he has invited to contribute to this issue on cosmetic Asian blepharoplasty and periorbital surgery. Dr. Nguyen is a board-certified plastic surgeon specializing in both reconstructive and cosmetic surgery. He earned his medical degree from the University of Minnesota, Minneapolis, and completed a plastic surgery residency at the University of Southern California Medical Center, Los Angeles, California. Dr. Nguyen continued his training with fellowships in microvascular surgery and craniofacial surgery at the Chang Gung Memorial Hospital, Taipei, Taiwan. He also completed a wound care/burn reconstruction fellowship at Rancho Los Amigos Medical Center, Downey, California. Dr. Nguyen's interests are broad. On the aesthetic side, he is developing a practice that encompasses cosmetic surgery of the face and body, with a particular focus on facial bone contouring and jaw surgery, fat transfer, blepharoplasty, and rhinoplasty, as well as Asian cosmetic surgery. For the reconstructive component, his focus includes complex microsurgical reconstruction of the trauma and oncological defects of the head and neck, breast, and lower extremity; facial reanimation; adult brachial plexus reconstruction; and the body contouring of the massive weight-loss patient. His research concentrates on clinical outcomes and the development of techniques for both reconstruction and aesthetics. He is committed to the education and training of future generations of plastic surgeons at Baylor College of Medicine in Houston, Texas.

Correction of Pectus Excavatum With Breast Hypoplasia Using Simultaneous Pectus Bar Procedure and Augmentation Mammoplasty

Most women with asymmetric pectus excavatum suffer from hypoplastic breasts. Hence, aesthetic correction of pectus excavatum has to address thoracic wall deformity, breast hypoplasia, and asymmetry.In retrospective series, 21 patients with a diagnosis of pectus excavatum with hypoplastic breasts were corrected using the pectus bar procedure and subpectoral augmentation mammoplasty. Results were assessed by analyzing prospectively collected data and calculating pectus indices from computed tomographic scans. At 12 months postoperatively, cosmetic evaluations were performed by the patients and by an independent, board-certified plastic surgeon using score from 0 (very poor) to 4 (very good).Cosmetic results evaluated by plastic surgeon were good (3.33 ± 0.03) and patient satisfaction was high (3.52 ± 0.03). Furthermore, indices of pectus excavatum were corrected to near normal.The authors consider that the pectus bar procedure with subpectoral augmentation mammoplasty is useful for the aesthetic correction of pectus excavatum with hypoplastic breasts.

The Use of Intercostal Nerve Blocks for Implant-Based Breast Surgery

Sir: Postoperative pain following breast surgery has been a significant problem and the subject of extensive research for its prevention and management.1 Over the past two decades, there has been considerable interest in the use of intercostal nerve blocks for the management of pain following breast surgery. However, most studies have focused on oncologic breast surgery,2,3 except for Cooter et al., who showed the use of nerve blocks for breast augmentation procedures.4 A recent meta-analysis by Tahiri et al.5 compared several studies and showed that, in general, the use of intercostal nerve blocks has led to significantly improved postoperative parameters (e.g., analgesic consumption, reduced amounts of nausea and vomiting) and has led to increased patient satisfaction and reduced length of hospital stay. We demonstrate the use of intercostal nerve blocks in 57 consecutive patients undergoing bilateral implant-based breast surgery. After institutional review board approval, data were gathered for all patients undergoing breast surgery with the use of intercostal nerve blocks. Informed consent was obtained from the patients. All blocks and breast procedures were performed by a board-certified anesthesiologist and board-certified plastic and reconstructive surgeon, respectively. After positioning the patient, 2 to 4mg of intravenous midazolam was administered for sedation. Blocks were administered using a 25-gauge ⅝- to 1½-inch needle at the anterolateral chest wall at the midaxillary line, at each level from T2 to T9 bilaterally. Each intercostal nerve was infiltrated with 2ml of a solution containing 0.25% bupivacaine with 1:200,000 epinephrine. A total of 78mg of bupivacaine was administered, and no aspiration of blood or air was noted. Monitored anesthesia care was provided for the duration of the procedure. Fifty-seven patients underwent implant-based nononcologic breast procedures consisting mainly of bilateral augmentation mammaplasty (n = 42), followed by bilateral implant exchange with capsulectomy (n = 11), bilateral augmentation mammaplasty with mastopexy (n = 2), bilateral implant removal with capsulectomy (n = 1), or bilateral augmentation mammaplasty with blepharoplasty (n = 1). All patients were women, with a mean age of 35 years. Mean operative time was 74 minutes and mean time from the conclusion of the operation to discharge was 116 minutes. None of the patients was converted to general anesthesia. There were no complications related to the intercostal nerve blocks or surgery. Intraoperative and postoperative drug use was tabulated (Table 1). All patients received fentanyl and midazolam intraoperatively, and antiemetics. Postoperatively, only 44 percent of patients received intravenous fentanyl, 14 percent received acetaminophen-oxycodone, and 12 percent of patients received antiemetics.Table 1: Intraoperative and Postoperative Drug UseImplant-based nononcologic breast surgery can be safely performed with the use of intercostal nerve blocks without the need for conversion to general anesthesia. The lack of general anesthesia also leads to decreased consumption of postoperative narcotics and antiemetics. Although a limitation of this study is that there was no postdischarge survey of patients’ use of narcotics, all patients were given a prescription for 30 tablets of acetaminophen-oxycodone (325mg/5mg). No refills were requested. DISCLOSURE None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article.

Medical Surgery Leagues

Medical plastic surgery league is a group of medical students interested in plastic surgery and a professional volunteer in the area willing to share and produce knowledge. Students define their direction, and are coordinated by an board certified plastic surgeon. Students should be aware that the league is an opportunity to learn, to seek knowledge, to develop clinical and scientific reasoning, and stimulate its interaction with the community. It means strengthening and enhancement of expertise in different levels of learning. Even if they do not become plastic surgeons, students build skills that can be adapted to other conditions and situations in the future. 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 .

Azita Madjidi, M.D., M.S.

I want to thank Dr. Madjidi for serving as guest editor of this edition of Seminars in Plastic Surgery and the talented group of authors she has invited to contribute to this issue on “Ear Reconstruction.” Dr. Madjidi obtained her medical degree from Caen Medical School in Normandy, France, where she went on to complete her residency training in Maxillofacial Surgery and Stomatology in 1991. Following extensive training and French Board certification, Dr. Madjidi went on to work at the prestigious Necker-Enfants Malades Hospital in Paris as Chief of Clinics-Assistant in Pediatric Plastic and Maxillofacial Surgery. There, she taught medical students and residents, and performed reconstructive surgeries on children with cleft lips, palates, and other birth defects. Dr. Madjidi built a private practice in affiliation with Laennec Hospital, St. Vincent-de-Paul Children's Hospital and the St. Joseph Foundation Hospital. She broadened her skills by participating in three plastic surgery fellowships: pediatric plastic and maxillofacial surgery and stomatology at Necker-Enfants Malades Hospital in Paris, craniofacial surgery at the University of Texas Southwestern Medical Center in Dallas, and a plastic and reconstructive microsurgery fellowship at Baylor College of Medicine in Houston, Texas. After moving to Texas, she completed formal American training by completing the General Surgery residency program at Baylor College of Medicine in Houston in 2004 and the Plastic Surgery residency program at Baylor in 2008. Currently, Dr. Madjidi is a board-certified plastic surgeon in private practice in Houston, where she has a true passion for reconstructive and cosmetic plastic surgery. Her vast medical education and fluency in several languages has allowed her to expand the scope of her practice to a broad population. In addition, she also dedicates much of her time to helping underprivileged children in Central America, Africa, and the Middle East by performing reconstructive surgeries on children with cleft lips, palates, and other birth defects.

Cosmetic Surgery Training in Plastic Surgery Residency Programs in the United States: How Have We Progressed in the Last Three Years?

In 2006, a survey performed by Morrison et al analyzed the experience of aesthetic surgery training from the perspective of residents and their program directors in plastic surgery programs across the United States. The authors conducted a survey to follow-up on the Morrison results three years after publication, to assess the changes in plastic surgery residency programs. In December 2009, a 17-question survey was sent to program directors, and a 19-question survey was sent to senior residents in all Accreditation Council for Graduate Medical Education-approved plastic surgery residency programs in the United States. The questions were posed in a five-point ranking format. The two additional questions included in the senior resident survey related to career aspirations and desirable areas of additional training. Ninety-two program directors and 397 senior residents received the survey. Forty-four program director surveys (47.8%) and 117 (29.5%) senior resident surveys were returned. Two-thirds of programs offered a residents' clinic, which was considered the preferred method of cosmetic surgery education by residents. Residents reported increased exposure to nonsurgical procedures such as lasers and injectables. Abdominoplasty, breast augmentation, and breast reduction remained the procedures most frequently performed by residents with confidence, as in the 2006 survey. Facial aesthetic procedures, including rhinoplasty and facelift, remained challenging to residents. Many residents (55.7%) felt confident integrating cosmetic surgery into their practice. One-third of residents reported that they would apply for a cosmetic fellowship. This survey shows an improvement in cosmetic surgery training for plastic surgery residents in the United States, particularly in that noninvasive cosmetic treatments are being increasingly taught. Since 2006, steps have been taken to provide more comprehensive cosmetic surgery education to residents, encouraging the delivery of the safe, high-quality care expected of a board-certified plastic surgeon.