Secondary Breast Augmentation: The Six Winning Moves.

BACKGROUND: Breast augmentation in 2019 was the first among the top five cosmetic surgical procedures performed worldwide, according to the International Society of Aesthetic Plastic Surgery. It is not only the most commonly performed cosmetic surgery, but also the aesthetic procedure with the highest reoperation rate. METHODS: A retrospective observational study of 306 female patients who underwent secondary breast surgery, with a follow-up of at least 1 year after surgery, from 2010 to 2020 is presented. For patients'selection, we decided to include all patients who performed a secondary breast surgery for aesthetic reasons; only patients with history of previous radiotherapy were excluded. RESULTS: Patients were divided into different groups according to the performed procedure (the six winning moves) and associated postoperative outcomes are shown. CONCLUSIONS: The aim of this paper, based on authors' own experience, is to present a personalized approach to secondary breast reshaping, describing the six "winning" moves to apply, which, differently combined among each other, intend to address each specific cause of reintervention with a dedicated surgical procedure. 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 .

Rejuvenation in Men Facial Aging: A Combined Approach.

Facelift surgery, also known as rhytidectomy, is a popular cosmetic procedure aimed at reversing the signs of facial aging. While facelift surgery is more commonly performed in women, an increasing number of men are seeking this procedure to maintain a youthful appearance. The long recovery period conflicts the overall primary outcome anticipated by men undergoing rhytidectomy, i.e., appear younger, youthful, and ready to reaffirm their value in the working environment. Anterior direct neck lift, blepharoplasty (upper and lower eyelid blepharoplasty), and lipofilling are three techniques that have been shown to be effective in improving facial rejuvenation outcomes in elderly male patients. However, there is little to no evidence of the safety and efficacy of these techniques when used in combination. By combining these techniques, we hypothesized that we could achieve outcomes comparable to traditional facelift surgery, but with a lower risk of complications and a shorter recovery time. We conducted a retrospective case series study of 18 male patients who underwent facial rejuvenation surgery using the combination of anterior direct neck lift, blepharoplasty (upper and lower eyelid blepharoplasty), and lipofilling at our institution between 2018 and 2021. All 18 patients completed the study, with an average follow-up of 12 months. No major complications were observed, and all patients reported a high level of satisfaction with their outcomes.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 .

Implant-Based Breast Reconstruction: Impact of Body Mass Index on Postoperative Complications and Aesthetic Results: A 5-Year, Single-Center Study.

BACKGROUND: Increasing adoption of implant-based breast reconstruction (IBR) has raised expectations regarding postoperative outcomes and aesthetic results. BMI has been extensively explored as a predictor of complications. This study is the first to examine complication rates in underweight subjects, and compares these rates among underweight, normal weight, overweight, and obese patients. OBJECTIVES: The aim of this study was to investigate the influence of BMI on postoperative complications and aesthetic results in IBR following mastectomy. METHODS: Retrospective analysis encompassed patients undergoing mastectomy with subsequent IBR, performed by a collaborative team of breast and plastic surgeons. Demographics, treatment specifics, and outcomes were evaluated by univariate and multivariate regression models. Significance was determined at P < .05. RESULTS: In total, 1046 IBRs were performed in 921 patients, of whom 63 had a BMI <18.5 kg/m2, 572 were normal weight, 215 were overweight, and 71 were obese. Significantly higher complication rates were observed in both obese and overweight patients compared with normal-weight patients (P < .001). Each unit increase in BMI correlated to 7% increased odds of overall complications and 13% increased odds of reconstructive failure. Underweight individuals had higher capsular contracture rates than normal-weight patients, 14.3% vs 3.65%, respectively (P = .001). In addition, aesthetic complications rates in underweight patients were higher than in normal-weight patients, 36.4% vs 25.7%, respectively (P < .05). CONCLUSIONS: This study confirmed BMI to be a strong predictor of postoperative complications and aesthetic outcomes, and demonstrates that low BMI has a significant impact on the incidence of capsular contracture and aesthetic complications.

Aesthetic and Functional Abdominoplasty: Anatomical and Clinical Classification based on a 12-year Retrospective Study.

Abdomen reshaping is a common plastic surgery procedure, and numerous surgical techniques have been described in the scientific literature. To standardize surgical approach, we propose our protocol that correlates patients' anatomy with the type of procedure performed. METHODS: Between 2008 and 2020, we retrospectively analyzed 582 consecutive female patients who underwent abdomen reshaping procedures, assessing anatomical features, complication rate, patient satisfaction, and surgical result, comparing them with previous reports in the literature. Aesthetic outcomes were evaluated with VAS scale (0-10). RESULTS: Among the 582 patients recruited in the study, we performed 74 liposuctions as a single procedure, 62 mini-abdominoplasties, 28 T-inverted abdominoplasties, and 418 full-abdominoplasties. Aesthetic outcome evaluation reported a mean value of 8.2 from patients and 7.8 from surgeons. We experienced four early postoperative bleedings requiring hemostasis revision, 18 wound dehiscences, five seromas, and 24 re-interventions for aesthetic issues. We found no differences in the complication rate while comparing our data with previous reports in the literature. CONCLUSIONS: Our protocol and surgical technique have proved to be effective, safe, and reproducible, with high patient and surgeon satisfaction, low complication rate, and fast recovery time.

The Periareolar Approach: All Seasons Technique for Multiple Breast Conditions.

The periareolar approach was first introduced by Hollander in 1924 and, since then, numerous contributions have been reported by different authors. Despite all the strengths associated with this versatile technique, the periareolar approach still poses three main problems: large areolar diameter with poor quality scar, flattening of the breast cone, and poor stability of the results. The purpose of this article is to show how this surgical technique, with a good patient selection, can be applied to different situations and obtain excellent results. METHODS: We performed a retrospective study on 5028 consecutive procedures in 4198 female patients treated with a periareolar approach in two regional institutions between 2008 and 2018. We considered 853 pure mastopexies, 362 breast augmentations, 422 secondary breast augmentations, 402 corrections of stenotic breast, 2921 oncoplastic surgeries, and 68 breast reductions. Postoperative complication, as well as patient and surgeon satisfaction were assessed. RESULT: Patient and surgeon satisfaction 1 year after the procedure was excellent, and the complication rate was low. CONCLUSIONS: When the indication is set correctly, the periareolar approach can obtain excellent results. This versatile technique, initially introduced as a mastopexy technique, has expanded its applications and can now be used for multiple surgical situations.

Gynecomastia: Ultrasound-Confirmed Classification Pertainent to Surgical Correction.

BACKGROUND: Gynecomastia is the most common form of breast alteration in men, due to proliferation of the gland ducts and stromal components, including fat. In addition to the most obvious indications (weight loss, pharmacotherapy, and drugs suspension), the surgical treatment is needed for long-standing gynecomastia, combining liposuction, adenectomy, partial mammary adenectomy, periareolar skin resection, and round-block suture. MATERIALS AND METHODS: A retrospective study was conducted on 148 patients undergoing gynecomastia correction from May 2012 to April 2018. Follow-up ranged from 9 to 14 months. The authors propose a new ultrasound-confirmed classification system, dividing patients into six categories. The authors analyzed immediate complications, revision, recurrence, and minor aesthetic problems (retracted/depressed areas) and introduced a way to correct the irregularities with fat grafting and needles. RESULTS: The total complication rate was 11.5% (17/148). Most of the complications (11) were observed in patients who underwent glandular resection and 3 after liposuction only. Retrospective surveys about patients' and surgeons' satisfaction were performed, showing excellent feedbacks regarding the results accomplished. CONCLUSIONS: The simple classification helps surgeons choose the most suitable approach, avoiding insufficient or invasive treatments and undesirable scars. Moreover, the analysis of the type of sequelae and their correction allow high patients' satisfaction. 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 .

Fat Grafting for Treatment of Facial Scars.

Autologous fat grafting has become more and more popular among plastic surgeons in the last few years due to recent discoveries on the mesenchymal stem cells stored in the harvested fat. These cells have a great regenerative potential and have the ability to restore the damaged tissues. The authors focused their practice on the treatment of the facial scars (derived from burns, trauma, degenerative diseases, and radiotherapy) and confirm that lipofilling is an excellent solution because it is able to improve the quality of the damaged tissues in terms of better scar color, pliability, thickness, relief, itching, pain, scar vascularization, and pigmentation.

Superior Pedicle Breast Reduction with Prefiguration of Final Shape: A 10-year Retrospective Study.

Breast reduction, also defined as reduction mammaplasty, is one of the most common procedures performed in aesthetic surgery. Multiple techniques have been proposed throughout the years and several classification systems have been adopted according to: type of incision, pedicle blood supply (cutaneous, glandular, dermoglandular), extent of undermining, excision area, simultaneous or separate tissue excision (fat/gland, skin, or both), and combination of the aforementioned. In the present article, we share our 10 years' experience with reduction mammaplasty and we describe our personal technique, a modified superior pedicle breast reduction. METHODS: We performed a retrospective analysis on 823 consecutive patients undergoing either aesthetic or functional reduction mammaplasty at Humanitas Research Hospital between 2009 and 2018. For each patient, we evaluated the mean resection volume and complication rate. We also assessed patients' satisfaction (VAS scale) and aesthetic outcome (assessed by independent surgeons, scale from 1 to 5). RESULTS: The average patient age was 48, ranging from 17 to 77 years. The average operative time was 77 minutes, ranging from 62 to 123 minutes. After a thorough follow-up of these patients, we can conclude that our technique has a low complication rate, patients' satisfaction is excellent, and the result is stable over time in terms of shape and symmetry (the mean VAS score was 8.1). Postoperative surgeon's photographs evaluation scores were 4.5 ± 0.5. Average resected volume was 860gr. CONCLUSION: The proposed technique is safe, fast, and simple with a relatively short learning curve, making it didactic and intuitive for young surgeons.

Stenotic Breast Malformation and Its Reconstructive Surgical Correction: A New Concept From Minor Deformity to Tuberous Breast.

BACKGROUND: Several classification systems have been reported to define the spectrum of tuberous breast deformity, and a range of surgical techniques has been described. In this paper, we proposed a new classification including tuberous breast and minor deformity based on stenosis type, glandular trophism and ptosis adapting surgical planning to different breast types. METHODS: A total of 246 patients meeting our definition for stenotic breasts asking for surgery were analyzed in this study. We considered eight different types of stenotic breasts analyzing anatomical presentations, and we then proposed eight key-point maneuvers, finalized to the correction of different breast deformities and their possible association according to the stenotic breast type. Results have been evaluated by a group of three surgeons and by patients. In addition, we evaluated the complication incidence in terms of re-intervention rate. RESULTS: Following our classification eight different groups were distinguished. For each one we reported the prevalence and the surgical procedure adopted. Results evaluated by the surgeon group reported a mean aesthetic outcome of 8.2 (range 5-10), whereas patients reported a mean value of 7.9 (range 6-10). During a follow-up period with a mean of 16 months we observed a 4.9% re-intervention rate. CONCLUSIONS: We believe this new classification to be very complete in evaluating breast shape, including most of the breast evaluable features. Our results confirmed the suitability of the approach for appropriate preoperative planning, thus improving the global surgical outcome. 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 .

The Prevalence of Tuberous/Constricted Breast Deformity in Population and in Breast Augmentation and Reduction Mammaplasty Patients.

BACKGROUND: The exact prevalence of tuberous breast deformity (TBD) has not been properly investigated and still remains undetermined. We report our data about TBD prevalence with the aim of demonstrating its high prevalence. MATERIALS AND METHODS: A retrospective analysis was performed on preoperative photographs of 1600 Caucasian female patients admitted to our department from January 2009 to July 2014 for augmentation or reduction mammaplasty and other breast clinical conditions. The main features of TBD included a contracted skin envelope, a reduction in breast parenchyma of the lower medial and lateral quadrants, a constricted breast base, abnormal elevation of the inframammary fold, herniation of the breast into the areola with a constricted breast base, and nipple areola complex herniation with a normal breast base. Patients were classified into three groups: breast augmentation group (AUG group), breast reduction group (RED group), and general population group (POP group). RESULTS: Four hundred patients were analyzed for each group (AUG and RED group); 194 patients (48.5 %) and 189 cases (47.3 %), respectively, demonstrated at least one tuberous breast deformity; in 800 patients of the POP group, we found 221 patients (27.6 %) with at least one tuberous breast deformity. CONCLUSIONS: Retrospective analysis reveals a high prevalence of TBD in the general population and in particular in women seeking breast augmentation or breast reduction (about 50 %). TBD is characterized by a wide range of clinical features with a spectrum of degrees. Preoperative evaluation is crucial to achieve an optimum outcome and patient satisfaction. LEVEL OF EVIDENCE II: 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 .

Periareolar Approach in Oncoplastic Breast Conservative Surgery.

Breast cancer represents the most frequent cancer in female population. Nowadays breast conservative surgery (BCS) is an accepted option for breast malignancies, and its indications has been extended thanks to the advent of oncoplastic surgery, reducing both mastectomy and re-excision rate, avoiding at the same time breast deformities. From January 2008 to November 2011, 84 women underwent BCS with periareolar approach for oncoplastic volume replacement. We divided patients into four groups analyzing breast size and resection volume (Group 1: small-moderate sized breast with resection <20%; Group 2: small-moderate sized breast with resection >20%; Group 3: big sized breast with resection <20%; Group 4: big sized breast with resection >20%). We evaluated patients' satisfaction regarding final esthetic outcome using the specific module "Satisfaction with outcome" of the Breast-Q questionnaire 1 year after surgery. The mean age was 52.1 years, and the mean follow-up was 11.2 months. During the follow-up, 12 patients have been lost. We obtained high satisfaction mean value with Breast-Q questionnaire in each group: 75.8 in group 1, 63.4 in group 2, 81.1 in group 3, 69.7 in group 4. Periareolar approach as oncoplastic volume replacement technique is useful in correction of breast deformity after BCS: it is a versatile technique that can be easily adapted for any breast tumor location and for wide glandular resection.

Regenerative Approach to Scars, Ulcers and Related Problems with Fat Grafting.

The article focuses on the authors' autologous fat grafting technique and its application in regenerative treatment of different scars and ulcers. Although easy to perform, this surgical approach requires some technical procedures and specific management to maximize its effectiveness which are highlighted in the article. In the authors' experience, autologous fat graft has proved to be an efficient and safe procedure to treat scars of different origin demonstrating the capability of lipostructure to achieve an architectural remodeling and loose connective regeneration.

Autologous fat graft in postmastectomy pain syndrome following breast conservative surgery and radiotherapy.

BACKGROUND: Breast cancer is the most common cancer in women worldwide, affecting one in eight women. Breast-conserving surgery (BCS) has become a well-established alternative to mastectomy in the treatment of breast cancer, providing a less invasive treatment. Just as life expectancy after breast cancer has improved, so has morbidity increased. One of the most relevant and debilitating consequences of oncological breast surgery is postmastectomy pain syndrome (PMPS). Our results published in 2011 on the treatment of PMPS in patients who had undergone mastectomy and radiotherapy and our experience in scar treatment with fat grafts were the theoretical bases for this prospective study. METHODS: From April 2011 to April 2012 a total of 96 patients, who had undergone lumpectomy and radiation therapy, with the diagnosis of PMPS were considered for fat grafts. We performed autologous fat grafting in 59 patients (study group), whereas 37 patients did not receive any further surgical procedure (control group). Pain assessment was performed using the visual analog scale (VAS) before and after treatment in the treated group and in the control group at the first visit and the control visit, with a mean follow-up of 10 months. Results were analyzed using the Wilcoxon rank sum test. RESULTS: Four patients were lost to follow-up (two patients in the control group and two patients in the treated group). A significant VAS pain decrease was detected in patients treated with autologous fat grafting (3.1 point reduction, p ≤ 0.005). CONCLUSION: Because of the safety, efficacy, and optimal tolerability of the procedure, we believe that fat grafting can be considered useful in treating PMPS in patients who have undergone BCS and radiotherapy. LEVEL OF EVIDENCE III: 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.

Autologous fat graft in scar treatment.

INTRODUCTION: Regenerative medicine is an emerging and rapidly evolving field of research and therapy, thanks to new discoveries on stem cells. Adipose tissue is a connective tissue which contains a reserve of mesenchymal stem cells. Clinical improvements in trophic characteristics of teguments after autologous fat graft are well described in literature. In this paper, we present our observation after 6 years of autologous fat graft experience in scar remodeling. MATERIALS AND METHODS: All patients recruited had retractile and painful scars compromising the normal daily activity/mobility of the joint involved. We performed surgical procedure with Coleman technique. In 20 patients, we performed a clinical assessment using Patient and Observer Scar Assessment Scale (POSAS) and Durometer measurements. RESULTS: In all treated scars, a qualitative improvement was shown both from an aesthetic and functional point of view. Most importantly, reduction or complete resolution of pain and increases in scar elasticity were objectively assessable in all cases. In patients studied using Durometer and POSAS score, areas treated with autologous fat graft showed statistically significant reduction in hardness measurements in comparison with areas infiltrated with saline solution. POSAS scores showed a statistically significant reduction of a great deal of POSAS parameters as a result of an improvement of both clinical evaluation and patient perception. CONCLUSIONS: Injection of processed autologous fat seems to be a promising and effective therapeutic approach for scars with different origin such as burns and other trauma scars, and post-surgery and radiotherapy outcomes. In general, we can affirm that treated areas regain characteristics similar to normal skin, which are clinically objectivable, leading not only to aesthetic but also functional results.