Artificial Intelligence, Genuine Outcome: Analysis of 72 Consecutive Cases of Subfascial Augmentation Mastopexy With Smooth Round Implants Supported by P4HB Scaffold.

BACKGROUND: Ptosis recurrence often leads to unsatisfactory results after mastopexy, even more so when additional stress is provided by implants on compromised native tissue. Poly-4-Hydroxybutyrate(P4HB) scaffold(GalaFLEX) with its favorable safety profile and proven long-term mechanical strength represents a preferred option for soft-tissue support. OBJECTIVES: Primary endpoint was to assess lower pole stretch from early post operative time up to 3 years. METHODS: Out of 151 patients operated by the first author from March 2020 to December 2023, a total of 72 with 12-month-mininum follow-up undergoing primary(46) or secondary(26) augmentation mastopexy with subfascial round smooth implants and P4HB scaffold support were included in the study. A 3-D artificial-intelligence (AI) software was used for all measurements. Further analysis included evaluation of ptosis recurrence and all complications. RESULTS: No recurrent ptosis, bottoming out, implant displacement or capsular contracture were reported during follow up (mean 24.8 months). Lower pole arch's elongation was 8.04% and 9.44% at 1 and 3 years respectively, comparing favorably with previous reports. Statistically significant correlation (p < 0.05) between implant size and lower pole stretch was noted, this being greater for larger implants (>400 cc; p = 0.0011) and primary cases (p = 0.1376). Progressive volume redistribution from upper to lower pole was observed in the first year with substantial stability thereafter. CONCLUSIONS: This is the largest published series reporting long-term results (up to 45 months) in mastopexy augmentation with GalaFLEX, suggesting its supportive role in lower pole stability even in the setting of concurrent breast augmentation with smooth implants in a subfascial plane.

Tailor-Made Mastopexy Plus Implant, A Safe Journey Toward Breast Reshaping and Augmentation.

BACKGROUND: Augmentation/mastopexy represents one of the most complex procedures in the setting of cosmetic surgery, and there is still an ongoing debate about the most suitable approach to undertake to avoid major complications and deliver the desired result. The present study aims to offer a further contribute to the topic by presenting our personal experience with an implant-guided tailor-made mastopexy technique to manage moderate breast ptosis and hypotrophy. METHODS: A retrospective analysis of our database was carried out, and a total of 194 women who underwent a tailor-made resection pattern mastopexy plus implant from November 2016 to December 2021 were enrolled. All patients included in the study presented breast hypoplasia and ptosis classified as Regnault grade II. At the first-year follow-up visit, patients received an anonymous written questionnaire that addressed their self-perception of cosmetic results and overall satisfaction. RESULTS: The technique presented in the study showed a favorable safety profile with a total complication rate accounting for an 8.2% and an overall reoperation rate as low as 4.6%. Major concerns including wound dehiscence, implant exposure, and nipple necrosis are not reported. Patients' self-reported outcomes revealed high satisfaction rates and stable results in the long-term follow-up. CONCLUSIONS: The described approach ensures proper reshaping together with the desired increased breast volume minimizing the chance of implant exposure due to wound dehiscence or any sort of tissue necrosis from devascularized skin edges. The surgical procedure described herein is safe and reliable. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Synthetic Reabsorbable Mesh (GalaFLEX) as Soft Tissue Adjunct in Breast Augmentation Revision Surgery.

BACKGROUND: A significant number of patients with a previous submuscular breast augmentation require a revision surgical procedure during their long-term follow-up period that involves changing the implant pocket from submuscular to subglandular. Reduced soft tissue thickness represents a major concern, discouraging surgeons from undertaking this approach. OBJECTIVES: The aim of this study was to determine whether a synthetic resorbable mesh used as a supplemental covering device was safe and yielded improved soft tissue thickness and protection against capsular contracture in patients undergoing implant plane shift to subglandular. METHODS: A retrospective review of 34 patients who underwent revision of a previous breast augmentation involving implant change in a subglandular pocket and upper pole GalaFLEX (Galatea Surgical, BD; Franklin Lakes, NJ) mesh coverage was conducted. Onset of minor and major complications was recorded during short- and medium-term follow-up. Patient satisfaction was assessed via an anonymous questionnaire administered 6 months postoperatively. RESULTS: During the follow-up period, which ranged from a minimum of 6 months to a maximum of 28 months, no minor or major complications were reported. In particular, no wrinkling/rippling or significant capsular contracture onset was observed. High levels of patient satisfaction were determined, according to self-reporting questionnaires. CONCLUSIONS: The initial results of this preliminary report from this case series demonstrate the safety of GalaFLEX as a supplemental device in terms of improved soft tissue coverage of the implant for complex revisional cases in breast augmentation.

Extended Clinical Experience With Nipple-Sparing Mastectomy and Prepectoral Polyurethane Implant Positioning (BRAND4P method).

BACKGROUND: Direct-to-implant prepectoral breast reconstruction in the last years demonstrated to be a feasible and advantageous method in selected cases because it respects chest wall musculature integrity and avoids animation deformity. Current approaches involve implant wrapping with Acellular Dermal Matrix (ADM) or synthetic mesh to guarantee implant coverage and stability and reduce complications. Prepectoral polyurethane implant positioning without further coverage is an alternative breast reconstruction method poor described in literature. PATIENT AND METHODS: A single-institution retrospective analysis was performed on 453 patients, extending our previous preliminary experience, who underwent nipple-sparing mastectomy (NSM) and prepectoral polyurethane implant positioning between December 2017 and June 2021. Follow-up included postoperative complications record and self-reported patient's satisfaction. RESULTS: A total of 784 mastectomies were performed in 453 patients. 331 were bilateral procedures (73.1%) and 122 were unilateral (26.9%). Minimum follow-up time was 6 months and maximum was 42 months. No major complications were reported. Contour defects and excessive implant visibility occurred in 82 patients (18.1%) and was successfully managed with autologous fat grafting. CONCLUSION: Nipple-sparing mastectomy with immediate prepectoral polyurethane implant reconstruction without the need for ADM or mesh is a feasible and safe option. Accurate patient selection and respectful mastectomy technique is crucial to achieve optimal outcomes with this approach. Fat grafting is a useful refinement procedure to improve cosmetic results in this setting.

Breast Asymmetry, Classification, and Algorithm of Treatment: Our Experience.

BACKGROUND: In the literature, several classifications of breast asymmetries and treatment protocols have been proposed over time, which are mainly based on etiological or morphological characteristics of the deformity. The aim of this study was to present our new classification, based on patient's self-consciousness of breast asymmetry, a simple and reliable treatment algorithm is also presented. METHODS: The case series included 343 patients treated between January 2006 and January 2015. Only patients presenting with developmental breast asymmetries were included in the study. All patients underwent prior classification in three groups based on the patient's degree of awareness of their asymmetry. A specific treatment algorithm was associated with each group according to breast size, grade of ptosis, and patient's desire. At the 48-month follow-up appointment, patients completed an anonymous questionnaire that addressed satisfaction with breast shape, size, and symmetry, scar appearance, body perception, self-esteem, perceived attractiveness, intimate life, and overall feelings about their breasts. RESULTS: Mean patient age was 24.6 years (range 18-57 years). Mean follow-up was 54.4 months (6 months to 9 years). At the 48-month follow-up, 66.7% of the patients completed a visual analog scale (VAS) satisfaction questionnaire. An overall satisfaction rate of 77.0% was reported, and a statistically significant difference in the distribution of the overall satisfaction between groups was found. No patient expressed complete dissatisfaction. CONCLUSIONS: The proposed classification and the surgical algorithm is a simple, applicable, and reliable method to assess and treat breast asymmetries with a high satisfaction rate as confirmed from our results. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266.

Breast Reconstruction Actualized in Nipple-sparing Mastectomy and Direct-to-implant, Prepectoral Polyurethane Positioning: Early Experience and Preliminary Results.

BACKGROUND: Implant-based breast reconstruction after nipple-sparing mastectomy has been the most common breast reconstruction procedure performed, for both breast cancer treatment and prophylactically. Subpectoral implant placement with partial detachment of the pectoralis major muscle has been the procedure of choice for staged reconstruction and direct-to-implantation. Prepectoral implant placement has recently increased in popularity among plastic surgeons owing to the high rates of animation deformity, loss of muscle function, and chronic pain observed with submuscular implant placement. Acellular dermal matrices or synthetic meshes have been used for implant coverage and support to avoid capsular contracture and implant visibility. In the present study, we have introduced breast reconstruction actualized in nipple-sparing mastectomy and direct-to-implant with prepectoral polyurethane positioning (BRAND4P). PATIENTS AND METHODS: A total of 34 nipple-sparing mastectomies and immediate direct-to-implant breast reconstructions with prepectoral polyurethane-coated implant placement were performed in 21 patients (13 bilateral and 8 unilateral). The implant was placed subcutaneously in the exact place of the excised breast parenchyma with no further coverage. RESULTS: After a mean follow-up of 4 months, no major complications had been observed. No patient presented with animation deformity or grade III-IV capsular contracture. Patient satisfaction, assessed using the BREAST-Q, was excellent. CONCLUSIONS: The BRAND4P method represents a novel prepectoral approach and a feasible alternative to subpectoral implant placement among the available implant-based breast reconstruction techniques.

Nipple sparing mastectomy and direct to implant breast reconstruction, validation of the safe procedure through the use of laser assisted indocyanine green fluorescent angiography.

BACKGROUND: Nipple sparing mastectomy (NSM) is a psychologically effective and oncological safe procedure followed by immediate breast reconstruction. METHODS: Between January 2015 and September 2015 the authors conducted a retrospective review of 40 patients divided into two groups depending on breast volume and weight of mastectomy: group A, 20 patients with small breast; group B, 20 patients with medium breast for nipple sparing mastectomy and direct to implant (DTI) breast reconstruction using strict patient selection and a standardized surgical technique. The nipple areola complex/flap viability were analysed intraoperatively through the use of laser assisted indocyanine green (ICG) fluorescent angiography. RESULTS: A total of 44 procedures were followed-up for 24 months. Nineteen patients were assisted in DTI breast reconstruction by acellular dermal matrix (ADM) for inferior/lateral part of the implant coverage. Encouraging results are presented with a unique case of implant failure. CONCLUSIONS: We report our retrospective experience corroborated by intraoperative laser assisted ICG fluorescent angiography to demonstrate the safety and reliability of the oncoplastic procedure proposed. We also advocate the central role of oncoplastic surgeon as "one man band" to manage breast cancer from the oncological procedure to the breast reconstruction.

The Balcony Technique of Breast Augmentation and Inverted-T Mastopexy With an Inferior Dermoglandular Flap.

BACKGROUND: Optimal breast augmentation-mastopexy involves a reliable technique, fast recovery, minimal complications, and aesthetic results that are excellent and enduring. OBJECTIVES: The authors sought to determine whether the balcony technique of augmentation-mastopexy was safe and yielded satisfactory long-term outcomes in patients with breast ptosis and hypoplasia. METHODS: The authors conducted a retrospective review of 207 patients who underwent subglandular augmentation and inverted-T mastopexy with a customized Wise keyhole resection pattern and an inferior flap. Patient satisfaction was assessed anonymously on a visual analog scale via a questionnaire administered 4 years postoperatively. RESULTS: A total of 182 women received follow-up for 48 months and were included in statistical analyses. High levels of satisfaction were determined using Fischer exact test for breast shape, size, and symmetry, but not for other items, such as scar appearance, body perception, or self-esteem. The most common complications were Baker II capsular contracture and wound dehiscence. No patient experienced nipple loss or skin flap necrosis. CONCLUSIONS: The results of this long-term analysis demonstrate that the balcony technique of augmentation-mastopexy is suitable for patients with breast ptosis and hypoplasia. LEVEL OF EVIDENCE: 4.

Outcome Evaluation after 2023 Nipple-Sparing Mastectomies: Our Experience.

BACKGROUND: Although quadrantectomy and lumpectomy help diminish the psychological and physical devastation inflicted, mastectomy is still elected in 20 to 30 percent of breast cancers. Although initially inciting controversy over heightened risk of local recurrences, recent studies maintain that nipple-sparing mastectomy can be used in any patient qualifying for total mastectomy and also improves aesthetic and psychologic outcomes. The manner in which mastectomy influences reconstructive implant outcomes has been documented by several groups. This report details the authors' experience performing nipple-sparing mastectomy with immediate implant-based breast reconstruction, focusing attention on patient characteristics and aspects of surgical mastectomy that influence reconstruction outcomes. The aim of the study was to examine various issues, such as surgical access, mode of tissue dissection, and flap thickness, clearly linked to development of complications and poor results. METHODS: A retrospective study was conducted, analyzing patients with breast cancer. An external three-surgeon panel served to generate average scores for predefined parameters. Based on total scores, outcomes were designated excellent, good, moderate, or poor. RESULTS: The authors' cohort included 1647 patients. Overall, 2023 nipple-sparing mastectomies were performed, including bilateral procedures in 376 patients. After a minimum follow-up period of 12 months, the authors' cohort was stratified by scored outcomes. Significant impact of body mass index, skin incision, flap thickness, and grade of ptosis has been demonstrated. CONCLUSIONS: The authors' data suggest that proper patient selection and well-executed operations are mandatory to limit complications. They also indicate that aesthetic outcome is clearly dependent on surgical proficiency and some patient characteristics. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Skin-reducing mastectomy and immediate breast reconstruction in patients with macromastia.

INTRODUCTION: In women with macromastia, a type IV skin sparing mastectomy is often required to achieve an aesthetically pleasing reconstruction. The introduction of "skin-reducing mastectomy", which inserts a permanent prosthetic device into a large pouch made by the pectoralis major muscle and an inferior pedicle dermal flap, allows the surgeon to achieve a safe oncologic result plus a cosmetically satisfying reconstruction. OBJECTIVE: We report here our experience with the skin-reducing mastectomy with the aim of emphasizing the problems associated with the technique. MATERIALS AND METHOD: A study was conduced from April 2009 to November 2012, 74 patients with breast cancer were selected then received a skin-reducing mastectomy. The enrolled women satisfied the criteria of Nava. Statistical analysis was conduced to estimate the significance of the outcome results and complication rate. RESULT: A total of 88 SRMs were performed and the outcomes were as follows: excellent in 34 patients, good in 21, and poor in 8. We recorded 25 % of adverse events and statistic helped us to identify patient related factors whose can increase the complications onset. CONCLUSION: Skin-reducing mastectomy is an indispensable procedure to treat cancer in large and pendulous breasts. The correct patient selection is mandatory to reduce the not negligible complication risk. Skin reducing mastectomy when is well conduced allow to obtain good results with patient satisfaction but, like other breast-conserving surgeries, in some case is not the ultimate solution, because it may require some revisions to maintain the optimum results. To day it be consider relatively safe in selected patient and the gold standard in macormastia immediate reconstruction.

Direct to implant breast reconstruction by using SERI, preliminary report.

BACKGROUND: There has been a "rising tide" in mastectomy utilization that can be attributed to more skin-sparing mastectomies (SSMs) performed concurrently with immediate breast reconstruction. We report our experience of the first use of SERI Surgical Scaffold (SERI; Allergan, Inc.) in 21 cases of direct to implant (DTI) breast reconstruction after SSM. METHODS: Our retrospective experience, from April 2013 to May 2014, is based on 21 cases of direct to implant (DTI) breast reconstruction after SSM (9 monolateral 6 bilateral). All the patients were oncological with a preoperative cancer stage was into 0-2 stage. In order to assess the level of satisfaction with the aesthetical result, on 4-13 months post-operative patients were asked to complete a questionnaire that evaluated various parameters by means of a Visual Analogue Scale (V.A.S.). RESULTS: Over a 13-months period, a total of 15 patients underwent 21 immediate breast reconstructive procedures with Allergan Natrelle 410 style implants plus SERI after SSMs. Definitive histological examination give evidence of 5 patients intraductal carcinoma, 6 patients multifocal carcinoma and 4 patients carcinoma in situ. 6 bilateral cases of direct to implant (DTI) breast reconstruction after SSM had a monolateral oncological treatment and on the other side a prophylactic treatment. At the end of the short follow up (minimum 6 months) all the patient were cancer free with an excellent outcome. Complication rate presents just one implant exposure followed by a revised surgery. At V.A.S. the mean patient satisfaction was 5,77 (good), 4,09 (fair) for sensitivity of the nipple areola complex, 6,33 (good) assessment of implant position, 6,28 (good) self esteem, 5,2 (good) attraction ability, 4,99 (fair) intimate life, 6,81 (good) overall feelings about breast reconstruction, 6,71 (good) simmetry. CONCLUSIONS: The really encouraging results of our early experience will help surgeons introducing SERI into their practice to select appropriate patients for direct-to-implant single-stage immediate breast reconstruction. A larger study cohort and longer follow-up times are required to identify additional predictors and indications.

Technique to achieve the symmetry of the new inframammary fold.

The literature outlines several surgical techniques to restore inframmammary fold definition, but symmetry of the fold is often left to irreproducible procedures. We report our personal technique to restore the symmetry of the inframmammary fold during multistep breast reconstruction.

Transcutaneous lower blepharoplasty, painless suture removal.

Despite being referred to as one of the more challenging procedures in plastic surgery, lower blepharoplasty is one of the most commonly requested and performed aesthetic procedures.Our experience, from February 2007 to March 2012, is based on 214 transcutaneous lower blepharoplasty procedures in which the skin flap was sutured by means of the epidermal-dermal U stitch, a new, simple, and reliable method. Patients were followed up for a mean period ranging from 7 to 70 months. To our knowledge, the literature proposes a single-stitch closure or continuous suture in transcutaneous lower blepharoplasty using nylon or silk 4-5-0 to close the skin incision (1-3-5). According to our experience before 2007 based on patients' reports, single-stitch subciliary suture removal is a source of stress for the patient that causes anxiety, discomfort, and pain.Thus, in February 2007, following transepithelial lower blepharoplasty, we started using a new, simple way to suture the subciliary skin flap adopting the epidermal-dermal U nylon 5-0 stitch to avoid any discomfort and drastically reduce the level of anxiety and pain at the time of suture removal. According to our experience, the healing of the wound does not require any subsequent scar revision resulting from healing defects or pathological scar tissue; the complication rate in our series is in keeping with that reported by other authors in the literature.In conclusion, our experience indicates that the suture technique we describe is an easily reproducible, rapid, discomfort-free, and painless means of removing stitches.

Nipple reconstruction using a star flap enhanced by scar tissue: the Regina Elena Cancer Institute experience.

BACKGROUND: We propose a new, simple, and reliable method of nipple reconstruction using a star flap and a free graft of a linear fragment of scar tissue. The harvested fragment is deepithelialized and fixed under the flap to give the reconstruction consistency and make it steady. METHODS: The study included 218 nipple reconstructions performed between 2002 and 2008. In an attempt to estimate their satisfaction, patients were then asked to complete a 1-year postoperative questionnaire. Patients were directed to use a numerical scale of 1-10, with 1 as the worst outcome and 10 as the best possible outcome. RESULTS: The average projection of the nipple in the immediate postoperative period was 7.08 ± 0.5 mm (mean ± standard deviation). After 1 year, the average projection of the reconstructed nipple was 6.08 ± 0.5 mm. The average diameter of the reconstructed nipple in the immediate postoperative period was 14.9 ± 3 mm. After 1 year, the average diameter of the reconstructed nipple was 14.2 ± 4 mm. The average patient satisfaction with nipple projection was 7.28, sensation of the nipple, 4.11; color of the nipple, 6.36; position of the reconstructed nipple, 7.34; and symmetry compared with the opposite nipple-areola complex, 7.97. Overall patient satisfaction was 6.61. CONCLUSION: We maintain that the technique presented here is safe, easy to perform, and reproducible and improves the long-term projection of the reconstructed nipple.