Our 40 Years' Experience on Face and Neck Lift Procedures with High-SMAS Flap Techniques: How to Manage Secondary and Tertiary Surgeries.

BACKGROUND: Facial aging drives a growing demand for esthetic procedures, with nonsurgical options often falling short in longevity compared to surgery. Despite primary face and neck lift techniques receiving substantial attention, revision procedures have been relatively overlooked in terms of their unique surgical management, complication incidence, and preventive strategies. METHODS: The authors present a 40-year experience with revision face and neck lifts, comprising 283 cases. The primary focus was on the high-SMAS flap technique in revision surgeries, with data collected on complications compared to primary procedures and existing literature. Secondary analysis investigated the time-lapse between primary and revision surgeries in the author's series (secondary and tertiary rhytidectomy) compared to the literature findings. RESULTS: Out of 283 cases, 232 were secondary and 51 were tertiary procedures. Overall complication rates in secondary cases mirrored those of primary procedures, with no statistically significant difference observed (p > 0.05). The mean interval between procedures was 9.0 years (range: 3.4-28.8 years), with a significant statistical difference (p < 0.05) observed between the first and second procedures (10.7 years, range: 3.8-18.8 years) and the second and third procedures (7.8 years, range: 3.5-10.8 years). CONCLUSION: Results indicate that high-SMAS flaps yield consistent and satisfying outcomes, even in secondary and tertiary cases. Complication rates are comparable to primary surgeries, underscoring the importance of meticulous attention to detail in managing the complexities associated with previous surgeries and the aging process. 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 .

Correlation Between General Satisfaction with the Breasts and Appearance of the Scars in Patients Undergoing Inverted T-Scar Reduction Mammaplasty: A Prospective PROMs-Based Study.

BACKGROUND: Inverted-T scar reduction mammaplasty is still the most chosen technique for breast reduction even if scars are relevant. Sometimes, surgical scars may be esthetically unpleasant and may cause severe pain, tenderness, sleep disturbances, anxiety, and depression in these patients. This study aimed to assess any possible correlation between general satisfaction with the breast and appearance of the scars in patients who underwent inverted T-scar reduction mammaplasty. Secondary aim was to evaluate average variations of BREAST-Q and SCAR-Q at different postoperative times. MATERIALS AND METHODS: 121 patients who underwent breast reduction using Pitanguy technique with inferiorly based dermo-adipose flap according to Ribeiro were enrolled in this prospective cross-sectional study. All patients filled the BREAST-Q REDUCTION and SCAR-Q questionnaires in paper form at 1, 6 and 12 months after surgery. BREAST-Q REDUCTION "Satisfaction with breast" scale was also administered preoperatively. Values were exported in Prism 9 for the statistical analysis. RESULTS: Correlation index of Pearson between "Satisfaction with breast" and "Appearance of scar" was 0.09 at 1 month post-operative and - 0.07 and 0.21 at 6 and 12 months PO respectively. "Satisfaction with breast" mean value tends to rise over time. "Appearance of scar" mean value tends to decrease over time. CONCLUSION: No correlation at different postoperative times between the general satisfaction with the breast and appearance of the scars was found. Data showed that satisfaction with the breast and appearance of the scars in patients who underwent inverted T-scar reduction mammaplasty tend to improve over time. 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 .

Is the Severity of Preoperative Eyelid Dermatochalasis Directly Correlated with Patient Satisfaction After Upper Blepharoplasty? A Prospective Study Based on PROMs.

INTRODUCTION: Facial ageing, particularly in the periorbital region, is a growing concern in contemporary culture. Upper blepharoplasty, a widely performed cosmetic surgery, addresses both aesthetic and functional issues related to eyelid dermatochalasis. This study aims to investigate patient satisfaction, the relationship between satisfaction and preoperative dermatochalasis severity, and the functional impact of preoperative skin excess. METHODS: A prospective study was conducted from April 2022 to April 2023, evaluating primary upper blepharoplasty outcomes. Patient-reported outcomes were measured using the FACE-Q questionnaire, assessing quality of life and satisfaction. Preoperative symptoms were evaluated using a functional questionnaire. Dermatochalasis severity was classified into three groups. Statistical analyses were performed using SPSS. RESULTS: Seventy-nine patients met inclusion criteria. Postoperative FACE-Q results demonstrated significant improvements in upper eyelid appraisal and satisfaction with eyes. Functional questionnaire results indicated an overall clinical improvement (p < 0.01). Visual field tests showed statistically significant improvement in group 3. No correlation was found between preoperative dermatochalasis severity and postoperative aesthetic satisfaction. CONCLUSION: The study emphasizes the importance of validated questionnaires, particularly FACE-Q, in evaluating patient satisfaction and discomfort with upper lid ageing. Regardless of functional impairments, any degree of dermatochalasis may warrant treatment to ensure patient satisfaction with the cosmetic outcome. On the other hand, the functional benefits and improvements in the visual field also support the impact that the procedure has beyond purely aesthetic aspects. 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 .

Relevance of Self-Consciousness of Appearance on Patient Satisfaction in Primary Rhinoplasty: a 12-Month Follow-up Prospective Study.

BACKGROUND: Rhinoplasty procedure has a strong impact on patient quality of life. Plastic surgery patients show a degree of appearance-related distress higher than general population, especially patients undergoing rhinoplasty. Relationship between patient-reported outcome after rhinoplasty and self-consciousness of appearance needs further studies. The aim of this study is to investigate this correlation, considering the surgeon external evaluation as well. MATERIALS AND METHODS: A total of 50 consecutive patients underwent primary cosmetofunctional rhinoseptoplasty. Appearance-related distress and surgical outcome were assessed by DAS59 (Derriford Appearance Scale 59) and SCHNOS (Standardised Cosmesis and Health Nasal Outcomes Survey), administered before and after surgery. Follow-up period was 12 months. Third-party clinical outcome was evaluated by three plastic surgeons by a scale ranging from 1 (poor outcome) to 5 (excellent outcome). RESULTS: A first division in Group 1 (satisfied) and Group 2 (unsatisfied) was done. DAS59 mean score in Group 1 showed to be statistically lower than Group 2 (p value < 0.05). Spearman's test showed a large strong positive correlation between preoperative and postoperative DAS59 and SCHNOS-C score variations (Delta 0-12 months) (r = 0.7514, p<0.001), as well as between DAS59 and SCHNOS-O (r = 0.5117, p<0.001) and between SCHNOS-C and SCHNOS-O (r = 0.6928, p<0.001). CONCLUSION: Rhinoseptoplasty has a significant impact on the patient self-consciousness of appearance, in both negative and positive terms. We emphasize the surgeon's burden, who need to carefully assess and address the patient's expectations during the first evaluation. This distinction is crucial since unrealistic expectations may lead to dissatisfaction even after a properly performed 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.

Fresh Frozen, In-Alcohol, or Autologous Costal Cartilage? Analysis of Complications in Over 650 Revision Rhinoplasties.

BACKGROUND: When there is insufficient autologous septal cartilage for graft sculpting in revision rhinoplasty, valid alternatives need to be found. Both autologous and homologous costal cartilage usage has been described in the literature. As there is no universally accepted consensus on cartilage choice, experience with different types of cartilage assumes significant importance in the rhinoplasty learning process. OBJECTIVES: This multicenter prospective study outlined an overview of the authors' experience regarding short-term and long-term complications following revision rhinoplasty procedures in which either fresh frozen (FFCC), in-alcohol (IACC), or autologous costal cartilage (ACC) was used. METHODS: A total of 671 patients undergoing revision rhinoplasty between June 2015 and September 2020 were divided into 3 groups according to the type of cartilage used (Group 1, 212 patients with FFCC; Group 2, 239 patients with IACC; Group 3, 202 patients with ACC). Sociodemographic and clinical characteristics and short- and long-term complications were described and discussed. A statistical analysis investigating a possible significance of the differences in complication rates was conducted. RESULTS: The data obtained indicated a short-term general complication rate of 5.05%, and a long-term complication rate of 7.04%. A statistically significant difference was identified in cartilage warping rate between the homologous cartilages in comparison to ACC. CONCLUSIONS: FFCC, IACC, and ACC can be safely used in revision rhinoplasty with no statistically significant differences regarding short- and long-term complication rates. Cartilage warping rate is significantly higher for ACC compared with FFCC and IACC.

Main Factors Influencing Patient Satisfaction After Primary Breast Augmentation: A Prospective Study Based on Patient-Reported Outcome Measures.

BACKGROUND: Primary breast augmentation is one of the most sought-after procedures in cosmetic surgery. It is generally related to a high degree of patient satisfaction, but it is not always obvious which factors have greater influence on patient satisfaction. OBJECTIVES: The aim of this prospective study was to evaluate how anthropometric, psychological, and social parameters, in association with the main surgical variables, influenced patients' satisfaction with their breasts after surgery. METHODS: Patients undergoing primary breast augmentation between October 2018 and February 2022, who completed a 12-month follow-up without complications, were enrolled in the study. For each patient we recorded: BMI, pinch test (upper pole of the breast), surgical access, implant pocket, implant volume, bra size increase, age, smoking habit, civil status, education level, pregnancies, and psychiatric disorders. Each variable was statistically correlated with patient's satisfaction, assessed by BREAST-Q questionnaire preoperatively and 12 months postoperatively. RESULTS: Analyzing the data of the 131 patients, we found 3 factors affecting their satisfaction (P<.05); BMI: underweight patients were less satisfied than normal and overweight patients; pinch test: patients with a pinch test >2 cm were more satisfied; volume of the implant and bra size increase: patients with implant volume <300 cc and a less than 2 bra size increase were less satisfied than patients with larger augmentation. CONCLUSIONS: BMI, pinch test, implant volume, and extent of volumetric enhancement should be taken into careful consideration by the surgeon during preoperative consultation and surgical planning, because they can be critical to patient satisfaction.

Correction of Rectus Abdominis Diastasis: A Prospective Comparative Study Between a New Suturable Polypropylene Mesh vs Polypropylene Standard Suture Plication.

BACKGROUND: Duramesh (Mesh Suture Inc., Chicago, IL) is a new suturing concept, combining the principles of mesh with the precision, flexibility, and versatility of a suture, suitable also for abdominal rectus diastasis (ARD) correction. OBJECTIVES: This prospective research aimed to compare mesh with the standard polypropylene suture plication for rectus diastasis repair with regard to safety (infection, seroma, hematoma, surgical wound dehiscence, and fistula rates and hospital stay); effectiveness (ARD recurrence by ultrasound sonography, palpability of the muscular suture, surgical time, and postoperative pain evaluation); and satisfaction of the patients based on the BODY-Q, a patient-reported outcome measure. METHODS: Sixty-five of the initial 70 patients who underwent rectus diastasis repair with a 6-month follow-up were randomly divided into 2 groups, comprising 33 patients treated with Duramesh and 32 patients treated with standard 0 polypropylene suture plication. Data regarding infection, seroma, hematoma, surgical wound dehiscence, and fistula rates; hospital stay; ARD recurrence; palpability of the muscular suture; surgical time; postoperative pain evaluation (measured by visual analog scale, or VAS); and the BODY-Q were analyzed by Prism 9 (GraphPad Software Inc., San Diego, CA). RESULTS: No significant differences were reported between the 2 groups with regard to infection, seroma, hematoma, surgical wound dehiscence, and fistula rates and hospital stay. The mesh decreased the time required to perform plication compared with standard polypropylene detached sutures. No statistically significant differences were found with respect to the VAS and BODY-Q data. CONCLUSIONS: Duramesh 0 application for rectus diastasis repair is safe and effective without compromising aesthetic improvement when compared with standard 0 polypropylene plication.

An Original Approach to Massive Weight Loss Deformities in the Lower Thigh: A Retrospective Assessment of Results and Patients' Satisfaction.

INTRODUCTION: Massive weight loss (MWL) patients present skin and soft-tissue laxity and ptosis involving inner thighs. Previous efforts were focused on the upper two thirds of the thigh, while literature has never dealt specifically with lower thigh contouring. We present an original approach to the lower inner thigh, intended for patients who already had upper thigh lift, discussing outcomes, advantages, and limits of our technique. MATERIALS AND METHODS: Sixteen female MWL patients with persisting severe deformities in the lower inner thigh, following an upper thigh lift, received lower third medial thigh contouring, through concurrent liposuction and skin excision, between 2017 and 2019. The excision pattern consisted of an inferiorly-based vertical triangular component, centered on the inner midline, and a distal horizontal crescent, resulting in an inverted-T scar. Our series was retrospectively investigated, comparing preoperative and 12-month postoperative pictures and assessing the outcomes by means of a tailor-made 11-item survey. RESULTS: Three patients had minor complications (two cases of skin de-epithelization at the wound margin, one granuloma). Photographic assessment showed a 15.9% transverse diameter reduction (p<0.05). The questionnaire showed encouraging scores for all the investigated items. Mean overall satisfaction was 9.6/10. CONCLUSION: Despite the retrospective design and the limited sample size, in consideration of the applicability of this technique in selected cases, and the need for a two-step procedure, separate upper and lower thigh contouring, the results of our study showed a considerable improvement of the inner thighs by our personal combined liposuction and lower medial thigh lift approach. 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 .

Breast Augmentation in the Digital Era: The Power of Social Media in a Surgeon's New Practice.

BACKGROUND: Opening a new practice is always challenging, and one of the main problems is how to engage patients. Most of them use social media to gather information about surgery and surgeons. OBJECTIVES: The aim was to evaluate social media's impact on a new practice, compared with a long-standing practice run by the same surgeon. Furthermore, changes in patients' and surgeons' perspectives regarding social media in recent years were studied. METHODS: In the 2 aforementioned practices, a questionnaire was administered to patients seen in consultation for primary breast augmentation regarding their interaction with social media before booking the visit. Another questionnaire was administered to 152 surgeons to assess their perceptions of social media. RESULTS: Two hundred forty-seven patients in Italy and 129 in Sweden answered the questionnaire. In the first year of the Italian practice, 97.2% of patients booked a consultation with the surgeon thanks to social media; after 3 years, the percentage dropped to 68.02%. Comparing Italian and Swedish patients, 68.02% vs 28.68%, respectively, booked a consultation with the surgeon specifically thanks to social media, 91.09% vs 79.84% did research about the surgeon before booking a consultation, and 36.03% vs 10.08% contacted the surgeon before booking an appointment. One hundred fifty-two surgeons from 24 different countries answered the questionnaire, and 77.9% opined that social media positively affected their practice. CONCLUSIONS: Social media is fundamental in patient-surgeon interaction and can strongly influence patient inflow, especially at the beginning of a new practice. Surgeons should be capable of using these tools to engage patients, bearing in mind the important role of these media in patients' education.

The Correlation Between the Improvement in Patient's Quality of Life and Surgeon's Satisfaction Following Primary Breast Augmentation: A Prospective Study.

BACKGROUND: Patient satisfaction is the primary goal in breast augmentation, but in a few cases patient satisfaction and surgeon satisfaction are in disagreement. OBJECTIVES: The authors try to explain the reasons associated with disparity between patient and surgeon satisfaction. METHODS: Seventy-one patients who underwent primary breast augmentation with dual-plane technique, with inframammary or inferior hemi-periareolar incision, were enrolled in this prospective study. Quality of life was evaluated with BREAST-Q preoperatively and postoperatively. Preoperative and postoperative photographic analysis was performed by a heterogeneous group of experts who completed the validated Breast Aesthetic Scale (BAS). The patient satisfaction score was compared with the overall appearance as determined by the validated BAS; a difference in score of 1 or more was considered a discordant judgement. Statistical analysis was performed with SPSS version 18.0, with values of P < .01 considered statistically significant. RESULTS: BREAST-Q analysis showed a significative improvement in quality of life on the psychosocial well-being, sexual well-being, and physical well-being chest scale and satisfaction with the breast (P < .01). Of the 71 pairs, 60 had a concordant judgment between patient and surgeon, and 11 were discordant. The score expressed by the patients (4.35 ± 0.69) was on average higher than that of the third-party observers (3.88 ± 0.58), with P < .001. CONCLUSIONS: Patient satisfaction is the main goal following the success of a surgical or medical procedure. BREAST-Q and photographs during the preoperative period are helpful to understanding the patient's real expectations.

"Temporal MORE (Modified Orbicularis REpositioning): going beyond the limits of temporal lifting".

BACKGROUND: Periorbital rejuvenation is often challenging and requires comprehensive evaluation of its various components to obtain satisfying results. Considering the crucial role of the orbicularis muscle in the periorbital aging process, the first author recently described his personal technique for temporal lifting through a subcutaneous approach in conjunction with an orbicularis muscle flap. In the current article, the authors present a modified and extended temporal lift approach, which allows for remarkable improvement not only in the temporal and brow region, but in the whole periorbital area up to the malar region, therefore named "Temporal MORE" (Modified Orbicularis REpositioning). METHODS: 212 consecutive patients underwent Temporal MORE by the same surgeon between May 2021 and September 2022. Each patient filled a FACE-Q© questionnaire preoperatively and 12 months postoperatively. 5 independent surgeons were asked to score the results evaluating patients' preoperative and postoperative pictures. RESULTS: No major complications were recorded. The most satisfying aspect of this technique was dramatic periorbital rejuvenation noticeable in all patients.FACE-Q pre-operative score was 34.29±5.872, while the post-operative was 80.11±6.796 (p<0.05); delta (post-pre) mean value was 45.82±8.925. Surgeons' questionnaire mean value was 41.92±6.010. Statistical analysis showed a strong correlation between surgeons' and patients' satisfaction ("r" value 0.7488). CONCLUSIONS: Temporal MORE proved to achieve a comprehensive rejuvenation of the periorbital area in a straightforward and reproducible way, with a fast recovery and a low complication rate. In this cohort, patient satisfaction with the result was remarkable and comparable to the judgment of the surgeons interviewed.

Innovative Application of GalaFLEX Poly-4-Hydroxybutyrate Scaffold in Breast Reduction/Mastopexy with Inferiorly Based Dermo-adipose Flap.

Breast reduction is one of the most required plastic surgery procedures worldwide, improving significantly the quality of life for patients with macromastia and gigantomachia. Despite various proposed approaches aiming to yield more stable results postreduction, no single technique has demonstrated unequivocal superiority. Recurrence ptosis at 6-12 months postoperative remains a challenging concern. To improve this issue, the authors propose a novel application of the poly-4-hydroxybutyrate (P4HB) scaffold on the anterior surface of the Ribeiro dermo-adipose flap. The primary aim was to establish a durable and resilient biological connection between the mammary gland and the flap, thereby promoting long-lasting outcomes in breast reduction procedures. The P4HB scaffold is a monofilament, single-layer, biologically derived, fully resorbable, rapidly integrating within breast tissue; this biological process stimulates the formation of freshly vascularized connective tissue up to a thickness of 2-3 mm. Within 18-24 months, the scaffold undergoes gradual resorption through hydrolysis-based mechanism, providing enhanced strength and resistance to the native tissue, as shown in animal model. A key innovation proposed by the authors involves the division of a 15 × 20 cm rectangular sheet of the P4HB scaffold along its diagonal, resulting in two right triangles. This modification ensures increased height of the device if compared with the traditional splitting technique of the scaffold. The strategic establishment of a biological bridge between the mammary gland and flap through the implementation of the P4HB scaffold could potentially enhance the longevity and aesthetics of breast reduction outcomes.

LYMPH-Q translation, cultural adaptation and validation in Italian language: A prospective PROMs-based study on breast cancer-related arm lymphedema for patients' education.

BACKGROUND: Upper Extremity Lymphedema following oncological breast surgery affects not only the patient's physique, but also the patient's psychological sphere. One of the best known PROMs-based questionnaires for investigating the condition is the LYMPH-Q. The study aimed to perform the Italian translation and cultural adaptation of the LYMPH-Q and to assess if, independently from disease evolution, arm sleeve improves QoL in these patients. MATERIALS AND METHODS: Translation included 4 steps: Forward translation, Back translation, Back translation review and Patient interviews. The questionnaire was administered to 50 female patients older than 18 years of age with UEL who received a prescription for daily use of a compression sheath. A second administration took place 30 days after. Forty-four patients completed the study (Group 1: 26 patients with indication to use compression sleeve who wore it; Group 2:18 patients who despite the prescription did not want to wear it. A descriptive statistical analysis was performed with Prism 9 software. RESULTS: T-tests showed statistical significance for changes in "Symptoms," "Function," "Appearance" and "Psychological" scales. There were no statistically significant changes for "Information scale" in Group 1 and for all scales in Group 2. CONCLUSION: Data from this observational study show that HR-QOL analyzed from the patients' perspective also tends to improve in terms of symptoms, function, appearance, and psychological sphere in patients with BCRL when using a compression sheath. The Lymph-Q has proven to be a valuable ally of the physician attempting to improve treatment approaches for BCRL based not only on scientific evidence but also on PROMs.

Puboplasty as an integral step in massive weight loss abdominal contouring: a retrospective assessment of results, stability, and patients' satisfaction.

Ex-obese patients complain about abdomen and pubis deformities following massive weight loss, due to skin and soft tissue redundancy. Abdominoplasty is often the first corrective procedure performed, but residual mons pubis deformities may impair the final outcome, thus concomitant correction becomes necessary. Sixty patients were treated by the same surgeon between 2008 and 2018, 30 of them receiving only standard umbilical transposition abdominoplasty (A group), and 30 having concurrent monsplasty (AM group), namely skin excess removal, pubic suspension and skin redistribution following superolateral vectors, re-establishment of superficial fascia continuity, with or without liposuction. Retrospective comparison of the two groups included: a subjective evaluation through administration of questionnaires (BODY-QTM, a questionnaire assessing functional and aesthetic improvements after surgery, a questionnaire assessing the overall satisfaction), and an objective evaluation of pre- and post-operative pictures to estimate mons pubis suspension and result stability. Four minor complications were recorded: 1 wound dehiscence in A group, 3 seromas in AM group. All measured outcomes were higher in AM group, with statistically significant difference (p < 0.05) in almost all the questionnaire and BODY-QTM items, and the photographic assessment confirmed higher degree of mons pubis suspension and superior result stability in AM group. We presented a standardized approach to mons pubis reshaping during abdominoplasty, through a straightforward, safe and quick procedure. Our experience supports the significance of the concomitant correction of abdominal and mons pubis deformities, improving the results of the surgery from both a subjective and objective point of view.