Is minimally invasive radical surgery safe for patients with cervical cancer ≤2 cm in size? (MISAFE): Gynecologic Oncology Research Investigators coLLborAtion study (GORILLA-1003).

OBJECTIVE: To identify clinicopathological factors associated with disease recurrence for patients with 2018 FIGO stage IA with lymphovascular invasion to IB1 cervical cancer treated with minimally invasive surgery (MIS). METHODS: A total of 722 patients with cervical cancer between January 2010 and February 2021 were identified. Clinicopathological factors related to disease recurrence were analyzed. Disease-free survival (DFS) and overall survival (OS) rates were estimated using the Kaplan-Meier method. To determine prognostic factors for DFS, a Cox proportional hazard regression model was used. RESULTS: Of 722 patients, 49 (6.8%) experienced disease recurrence (37 pelvis, 1 para-aortic lymph node, and 11 peritoneum). Five-year DFS and OS rates were 90.7% and 98.1%, respectively. In multivariate analysis, risk factors associated with disease recurrence were residual disease in the remaining cervix (OR, 3.122; 95% CI, 1.152-8.461; p = 0.025), intracorporeal colpotomy (OR, 3.252; 95% CI, 1.507-7.017; p = 0.003), and positive resection margin (OR, 3.078; 95% CI, 1.031-9.193; p = 0.044). The non-conization group had a higher percentage of stage IB1 (77.4% vs. 64.6%; p = 0.004) and larger tumor (10 mm vs. 7 mm; p < 0.001) than the conization group. Intracorporeal colpotomy and residual disease in the remaining cervix were independent variables associated with disease recurrence in patients undergoing MIS following conization. CONCLUSION: During MIS, patients with cervical cancer ≤2 cm in size can be vulnerable to peritoneal recurrences. Patients diagnosed with invasive cancer through conization often have low-risk pathological features, which may affect their survival outcomes.

Fertility-sparing hormonal treatment in patients with stage I endometrial cancer of grade 2 without myometrial invasion and grade 1-2 with superficial myometrial invasion: Gynecologic Oncology Research Investigators coLLaborAtion study (GORILLA-2001).

OBJECTIVES: To evaluate oncologic and pregnancy outcomes of fertility-sparing treatment (FST) using progestin in patients with stage I grade 2 endometrioid endometrial cancer (EC) without myometrial invasion (MI) or grade 1-2 with superficial MI. METHODS: Multicenter data of patients with stage I grade 2 EC without MI or grade 1-2 EC with superficial MI, who received FST between 2005 and 2021, were analyzed. Cox regression analysis identified independent factors for progressive disease (PD) during the FST. RESULTS: Altogether, 54 patients received FST [medroxyprogesterone acetate (500-1000 mg) in 44, megestrol acetate (40-800 mg) in 10] with concurrent levonorgestrel-releasing intrauterine devices use in 31. With median time to achieve a complete response (CR) of 10 (3-24) months, 39 patients (72.2%) achieved CR. Of the 15 patients who attempted to conceive after achieving CR, 7 (46.7%) became pregnant (2 abortions, 5 live births). During a median FST duration of 6 (3-12) months, nine patients (16.6%) were diagnosed with PD. Fifteen (38.5%) experienced recurrence with a median recurrence-free survival of 23 (3-101) months. In the multivariable analysis, tumor size before FST ≥2 cm (HR 5.456, 95% CI 1.34 to 22.14; p = 0.018) was significantly associated with a high PD rate during FST. CONCLUSION: The overall response rate to FST was promising, however, the PD rate was significant during the first 12 months of FST. Therefore, performing thorough endometrial biopsy and imaging studies is essential to strictly evaluate the extent of the disease every 3 months from FST initiation.

Optimum selection criteria for secondary cytoreductive surgery in patients with recurrent epithelial ovarian cancer: A multicenter study from the Gynecologic Oncology Research Investigators coLLaborAtion group (GORILLA-3001).

BACKGROUND: To identify those most likely to benefit from secondary cytoreductive surgery (SCS), we evaluated the survival outcomes and factors predictive of prognosis in patients with recurrent ovarian cancer. METHODS: We retrospectively reviewed the medical records of patients with recurrent ovarian cancer treated at five high-volume Korean hospitals between 2010 and 2021. Recurrence characteristics, treatment methods, and potential predictors of survival were compared between the chemotherapy and surgery groups. RESULTS: Among all 670 patients, 88.1% had initial stage III/IV disease, and 215 (32.1%) underwent SCS. Among patients who underwent SCS, only those who achieved complete resection exhibited improved survival. Even in patients with residual disease < 1 cm after SCS, we observed no significant survival benefit (p = 0.942). In the multivariate Cox analysis, residual disease at primary surgery, progression-free interval, recurrence sites (≤3 regions or limited carcinomatosis), ascites, and SCS were significant predictors of survival. Meanwhile, the only factor predictive of complete resection after SCS was recurrence sites (p < 0.001). CONCLUSIONS: The benefits of SCS appear to be exclusive to cases of complete resection. We propose limited regional platinum-sensitive recurrence (≤3 regions or limited carcinomatosis) without ascites as the optimum selection criteria for SCS.

Ultrasound-guided thread lifting for the prevention of parotid gland and diagnosing parotid duct complications.

BACKGROUND: Thread lifting is a common minimally invasive plastic surgery procedure. Parotid gland injury caused by thread lifting is a known complication; however, visual evidence of this complication is lacking. OBJECTIVES: This study aimed to present cases of parotid gland injury by thread lifting shown using ultrasound and to discuss the importance of ultrasound detection of the location of the parotid gland before thread insertion. METHODS: This study included eight patients diagnosed with parotid gland perforation and one with parotid duct injury due to threads from November 2020 to October 2022. RESULTS: Six patients showed tenderness and swelling, three were asymptomatic, and one with duct injury showed severe swelling and pain. Although the severity and duration of symptoms have differed, we confirmed the progress of improvement with conservative treatment and confirmed ultrasound findings progressed. CONCLUSIONS: Using ultrasound to detect the parotid gland's location before thread lifting might reduce the chance of parotid duct injury. Identifying immediate parotid duct or gland injury with ultrasound can help to act quickly for delayed pain or swelling and reduce the likelihood of additional complications.

Vascular Anatomy for the Prevention of Sublingual Hematomas: Life-Threatening Complication of Genioplasty.

After genioplasty, the occurrence of bleeding is rare; however, rapid enlargement or displacement of the tongue secondary to lingual or sublingual hematoma can lead to life-threatening airway obstruction, necessitating prompt recognition, and immediate management. Therefore, the investigators aimed to evaluate the underlying etiologies of sublingual hematoma and relevant anatomy to facilitate early recognition of the initial presentation of these hematomas and appropriate management. The authors conducted a literature review on cases of delayed sublingual hematoma after genioplasty. The authors also report a case of delayed hematoma after performing genioplasty. The anatomical structures involved with the development of rare and serious hematomas therein are the sublingual and submental arteries, which are located in the sublingual area, rendering them susceptible to injury during genioplasty. The results of this study suggest that submental artery ligation should be performed for proper management of airway obstruction, if symptoms of sublingual bleeding are observed during the surgical procedure. If there is continuous bleeding despite the submental artery ligation, sublingual artery ligation should be performed.

Gastrointestinal/genitourinary perforation and fistula formation with or without bevacizumab in patients with previously irradiated recurrent cervical cancer: a Korean multicenter retrospective study of the Gynecologic Oncology Research Investigators Collaboration (GORILLA) group (GORILLA-1001).

BACKGROUND: This study aims to evaluate the incidence of and identify risk factors for gastrointestinal (GI) and genitourinary (GU) fistula or perforation formation with or without bevacizumab in patients with recurrent cervical cancer who underwent pelvic radiation therapy (RT). METHODS: Medical records of patients with recurrent cervical cancer who previously underwent pelvic RT between 2007 and 2020 were retrospectively reviewed. Clinicopathological factors were compared between groups that are stratified according to: 1) fistula/perforation (+) versus (-); and 2) bevacizumab plus conventional chemotherapy (BC) versus chemotherapy alone (C). Univariate and multivariate regression analyses were performed to identify risk factors for fistula/perforation. Overall survival (OS) was compared between the different groups. RESULTS: Of 219 participants, fistula/perforation of any grade occurred in 36 patients (16.4%); 27 fistulas and 9 perforations. Bevacizumab was more frequently used in Bevacizumab was more frequently used ( +) group than fistula/perforation (-) group (p = 0.015). Multivariate analysis showed that bevacizumab administration was the only independent risk factor for fistula or perforation (HR, 3.27; 95% CI, 1.18-9.10; P = 0.023). F/P was observed more frequently in women receiving BC (n = 144) than those receiving C (n = 75) (20.8% vs. 8.0%; P = 0.019). During median follow-up of 33.7 months (1.2-185.6 months), no significant OS difference was observed between fistula/perforation ( +) vs. (-) (hazards ratio [HR], 1.78; median 84.2 months [95% CI, 59.3-109.0] vs. 129.5 months [95% CI, 114.1-144.9]; P = 0.065) or BC vs. C (HR, 1.03; median 119.8 months [95% CI, 97.3-142.3] vs. 115.7 months [95% CI, 96.0-135.4]; P = 0.928). CONCLUSIONS: This study suggests that incorporation of bevacizumab in chemotherapy regimens for treating recurrent cervical cancer in patients who underwent pelvic RT incurs considerable risk for GI/GU fistula or perforation. There were no other independent risk factors for developing GI/GU fistula or perforation in this study population.

Minimally invasive surgery versus open surgery in high-risk histologic endometrial cancer patients: A meta-analysis.

OBJECTIVE: To compare the effects of minimally invasive surgery (MIS) and open surgery (OPS) on the risk of recurrence and mortality in patients with endometrial cancer (EC) of high-risk histology (grade 3 endometrioid adenocarcinoma, papillary serous carcinoma [PS], clear cell carcinoma [CC], and carcinosarcoma) using meta-analysis. MATERIAL AND METHODS: We systematically reviewed published studies comparing MIS and OPS in EC patients with high-risk histology until January 2022. The endpoints were recurrence and mortality rate. Study design features that may have affected participant selection, recurrence/death detection, and manuscript publication were assessed. For pooled estimates of the effect of MIS on recurrence/mortality, the random- or fixed-effects meta-analytical models were used after assessing the cross-study heterogeneity. RESULT: Nine observational studies (eight retrospective and one prospective) fulfilled our search criteria (MIS, 8877 patients; OPS, 5751 patients). The fixed-effects model-based meta-analysis indicated that MIS did not significantly increase the risk of recurrence (hazard ratio [HR], 0.86; 95% confidence interval [CI], 0.71-1.05; p = 0.13) and mortality (HR, 0.86; 95% CI, 0.79-0.93; p < 0.001) when compared with OPS. This pattern was also observed in the subgroup analyses based on the stage (early stage vs. all stage), histology (PS and CC), and MIS type (laparoscopy vs. robotic). There was no evidence of publication bias. CONCLUSION: This meta-analysis of observational studies revealed that MIS did not compromise the prognosis of EC patients with high-risk histology. Well-designed randomized controlled trials could verify the results of this uncommon but deadly tumor.

Retreatment with progestin for recurrence after complete response with fertility-sparing treatment in patients with endometrial cancer.

OBJECTIVE: To assess the outcomes of retreatment using progestin for recurrence after a complete response with fertility-sparing treatment in patients with early endometrial cancer. METHODS: We retrospectively reviewed the data of patients with presumed stage IA, grade 1 endometrioid endometrial cancer who developed intra-uterine recurrence after a complete response with fertility-sparing treatment using progestin. Oncological and pregnancy outcomes were analyzed after repeated fertility-sparing treatment. Logistic and Cox regression analyses were performed to analyze the prognostic factors associated with a complete response with secondary fertility-sparing treatment and recurrence-free survival after secondary fertility-sparing treatment, respectively. RESULTS: Fifty patients with a median age of 31 years (range 23-40) underwent secondary fertility-sparing treatment. With a median secondary progestin treatment duration of 9 months (range 3-55), the complete response rate was 78% (39/50) and no patients had extra-uterine spread of disease. Among the 26 (67%) patients who attempted to conceive after complete response, 10 became pregnant (3 spontaneous abortions, 7 live births). Eighteen (46.1%) patients had a second recurrence, with a median recurrence-free survival after secondary fertility-sparing treatment of 14 months (range 3-36); 15 patients received tertiary fertility-sparing treatment and nine (60%) achieved a complete response. Polycystic ovary on ultrasound (OR 5.82, 95% CI 1.1 to 30.6, p=0.037) was associated with an increased complete response rate with secondary fertility-sparing treatment. Multivariable analysis revealed that recurrence-free survival after initial hormonal treatment >6 months (HR 0.11, 95% CI 0.02 to 0.51, p=0.005) and pregnancy after secondary fertility-sparing treatment (HR 0.27, 95% CI 0.08 to 0.98; p=0.047) were significantly associated with longer recurrence-free survival after secondary fertility-sparing treatment. CONCLUSIONS: Repeated progestin treatment was associated with a 78% response rate and it was safe in patients with intra-uterine recurrent endometrial cancer. Thus, it might help preserve fertility after first and second recurrences.

Gluteal Soft-Tissue Repositioning Using Polydioxane Threads.

BACKGROUND: Buttock reshaping has recently gained popularity. Gluteal soft-tissue repositioning can be performed using polydioxane threads, followed by anthropometric measurements. OBJECTIVE: To evaluate the effectiveness of polydioxane threads for noninvasive gluteal soft-tissue repositioning. MATERIALS AND METHODS: From February 2018 to August 2019, 27 women (mean age, 38.9 years; range, 26-65 years) underwent thread lifting. Multiple polydioxane threads (total, 24-30 threads for each buttock side) were used for gluteal soft-tissue repositioning. The treatment outcomes were based on comparisons of the preoperative and postoperative findings. RESULTS: The mean ratio of the upper and lower vertical proportions of the buttocks changed from 63:37 preoperatively to 55:45 postoperatively. The mean projection angle of the upper portion decreased from 60.1° preoperatively to 54.3° postoperatively. Twenty-four patients (86%) were satisfied with the results up to 8 months postoperatively. One patient developed persistent pain (>1 month), and 4 patients showed skin dimpling, which resolved within 2 weeks after minimal massages. No hematomas, foreign body sensation, or thread protrusions were noted. CONCLUSION: Polydioxane threads could be an alternative, minimally invasive tool for buttock lifting. Our novel technique of repositioning the buttock soft tissue improved lifting and augmentation and provided a better buttock shape.

A Safe Doppler Ultrasound-Guided Method for Nasolabial Fold Correction With Hyaluronic Acid Filler.

BACKGROUND: Injection of hyaluronic acid filler, a common procedure for nasolabial fold correction, poses a risk of vascular compromise, which can result in skin necrosis and blindness. OBJECTIVES: The aim of this study was to examine the facial arterial pathway in real time by Doppler ultrasound to avoid arterial complications during filler injections. METHODS: The facial artery pathway of 40 patients (80 nasolabial folds; 2 men and 38 women; mean age, 46.5 years; range, 28-72 years) was examined by Doppler ultrasound before hyaluronic acid filler injection. On the basis of this ultrasound evaluation, the filler injection targeted the subdermal, subcutaneous, and deep to submuscular layers by bypassing the facial artery. The efficacy of the filler injection was evaluated for each patient. RESULTS: The facial artery was detected lateral to the nasolabial fold in 31% of patients; it was detected beneath the nasolabial fold in the other patients as follows: subdermal layer, 13%; subcutaneous layer, 29%; muscular layer, 24%; and submuscular layer, 4%. The mean [standard deviation] Wrinkle Severity Rating Scale score was 3.68 [0.76] before injection and 2.28 [0.78] at 3 months after injection. Two patients experienced unilateral bruising of the nasolabial fold, which resolved after 2 weeks without treatment. CONCLUSIONS: Doppler ultrasound can be considered as pretreatment tool for the prevention of vascular complications during filler injections to correct nasolabial folds.

Safe Glabellar Wrinkle Correction With Soft Tissue Filler Using Doppler Ultrasound.

BACKGROUND: Glabellar wrinkle corrections are usually performed by injecting botulinum toxin and hyaluronic acid fillers. The glabella is one of the most dangerous locations for filler injection because of possible visual complications. OBJECTIVES: The aim of this study was to use Doppler ultrasound to determine the anatomic relation between glabellar wrinkles and the supratrochlear artery pathway, perform safe hyaluronic acid filler injection to correct glabellar wrinkles, and determine the efficacy of the procedure. METHODS: From January 2019 to July 2019, 42 patients (74 glabellar wrinkle lines; 32 bilateral and 10 unilateral wrinkles) were evaluated. Glabellar wrinkle lines were corrected with hyaluronic acid filler. Doppler ultrasound was used to avoid the supratrochlear artery. RESULTS: Among the 74 wrinkle lines, the supratrochlear arteries were located either at the glabellar wrinkle lines (30/74, 41%) or lateral to the glabellar wrinkle lines (44/74, 59%). In the latter 44 wrinkles, fillers were injected into the subdermal layer of the glabellar wrinkle lines. In the 30 wrinkles where supratrochlear artery was located at the glabellar wrinkle lines, the artery was located at the deep subcutaneous layer in 24 and at the subdermal layer in 6; thus, filler injection was not performed. CONCLUSIONS: The supratrochlear artery may be located either at or lateral to the glabellar wrinkle lines. When performing glabellar wrinkle correction, Doppler ultrasound can be used to confirm the location of the supratrochlear artery before filler injection, which helps in avoiding vascular complications.

Aspiration Revisited: Prospective Evaluation of a Physiologically Pressurized Model With Animal Correlation and Broader Applicability to Filler Complications.

BACKGROUND: Aspiration testing before filler injection is controversial. Some believe that aspiration can help prevent inadvertent intravascular injection, whereas others cite false-negative results and question its value given that the needle position always changes somewhat during injection procedures. OBJECTIVES: The authors sought to test the relation of false-negative results to the viscosity of the material within the needle lumen and determine whether a less viscous material within the needle lumen could decrease the incidence of false-negative results. METHODS: In vitro aspiration tests were performed utilizing 30-G and 27-G needle gauges, 2 cross-linked hyaluronic acid fillers, normal saline bags pressurized at 140 and 10 mmHg to mimic human arterial and venous pressures, and 3 needle lumen conditions (normal saline, air, and filler). Testing was repeated 3 times under each study condition (72 tests in total). For in vivo correlation, aspiration tests were performed on femoral arteries and central auricular veins in 3 rabbits (4-5 aspirations per site, 48 tests in total). RESULTS: In vitro and in vivo testing utilizing 30-G needles containing filler both showed false-negative results on aspiration testing. In vitro and in vivo testing utilizing needles containing saline or air showed positive findings. CONCLUSIONS: False-negative results from aspiration testing may be reduced by pre-filling the needle lumen with saline rather than a filler. The pressurized system may help overcome challenges of animal models with intravascular pressures significantly different from those of humans. The adaptability of this system to mimic various vessel pressures may facilitate physiologically relevant studies of vascular complications.

The association between urinary bisphenol A levels and nonalcoholic fatty liver disease in Korean adults: Korean National Environmental Health Survey (KoNEHS) 2015-2017.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is becoming a global health problem. Bisphenol A (BPA), one of most widely used environmental chemicals, is suspected to be a contributor to the development NAFLD. This study was performed to examine the relationship between human BPA levels and risk of NAFLD. METHODS: The data (n = 3476 adults: 1474 men and 2002 women) used in this study were obtained from the Korean National Environmental Health Survey III (2015-2017). BPA levels were measured in urine samples. NAFLD was defined using hepatic steatosis index after exclusion of other causes of hepatic diseases. RESULTS: There was a significant linear relationship between the elevated urinary BPA concentrations and risk of NAFLD. In a univariate analysis, odds ratio (OR) of the highest quartile of urinary BPA level was 1.47 [95% confidence interval (CI) 1.11-1.94] compared to the lowest quartile. After adjusted with covariates, the ORs for NAFLD in the third and fourth quartiles were 1.31 [95% CI 1.03-1.67] and 1.32 [95% CI 1.03-1.70], respectively. CONCLUSIONS: Urinary BPA levels are positively associated with the risk of NAFLD in adults. Further experimental studies are needed to understand the molecular mechanisms of BPA on NAFLD prevalence.

Practical Guidelines for Hyaluronic Acid Soft-Tissue Filler Use in Facial Rejuvenation.

BACKGROUND: Hyaluronic acid (HA) fillers are the most commonly used fillers for soft-tissue augmentation. The face is a dynamic structure. Facial rejuvenation by filler products depends on mechanical forces on the region of the face. The successful use of injectable HA fillers requires an understanding of the options available. OBJECTIVE: The purpose of this study is to measure the rheological properties of HA fillers and to clarify how to select these fillers considering their rheological properties. MATERIALS AND METHODS: Rheological characterization was performed on 41 fillers. Physical parameters directly linked to product performance were measured. RESULTS: The properties of the HA fillers varied. These findings provide a basis for selection guideline regarding rheological properties in facial rejuvenation. CONCLUSION: The authors' report is the largest study to determine the rheological properties of HA fillers to date. Understanding the fillers' properties can help physicians select the appropriate fillers for more predictable and sustainable results.

Soft Tissue Filler Properties Can Be Altered by a Small-Diameter Needle.

BACKGROUND: Small-bore needles reduce the complications associated with soft tissue filler injection. Gel particles must be sized appropriately to pass through fine-bore needles with an acceptable extrusion force. However, most soft tissue filler particles are larger than the inner diameter of the needle. The authors hypothesized that the physical properties of these particles change as the gel passes through the needle. OBJECTIVE: The authors aimed to investigate whether the predesigned physical and rheological properties of the filler change after passage through the small-bore needle. METHODS AND MATERIALS: Particle sizes of 4 hyaluronic acid (HA) fillers were analyzed using a particle size analyzer. Five soft tissue fillers with different particle sizes were subjected to rheological characterization. All tests were performed using fillers with and without a 30-G needle. RESULTS: Monophasic HA fillers with smaller particle sizes exhibited small changes between particle sizes but no differences in rheological properties. Biphasic HA fillers with larger particle sizes exhibited remarkable changes in particle size and rheological properties. Calcium fillers exhibited changes in rheological properties. CONCLUSION: Injection through small-bore needles can alter the physical properties and rheological equilibrium of soft tissue fillers. The authors suggest avoiding small-bore needles as they may affect the rheological equilibrium and clinical performance of fillers.

Staged Mosaic Punching Excision of a Kissing Nevus on the Eyelid.

BACKGROUND: A congenital divided nevus, also known as kissing nevus, is a type of congenital compound nevus that affects equal areas of the upper and lower eyelids. The edges of the nevus touch or "kiss" during closure of the lids, owing to its extension to the lid margins. Multiple treatment modalities, such as dermabrasion, cryotherapy, primary closure after excision, and skin grafts, have been proposed; however, complications such as recurrence, ectropion, skin color mismatch, and scar contractures are known to occur. This study aimed to introduce a staged excision using the 10,600-nm CO2 pulsed laser to remove a congenital divided nevus without noticeable complications. MATERIALS AND METHODS: From August 2015 to December 2018, patients with congenital divided nevus underwent staged laser excision. Seven patients underwent staged mosaic pattern punch excision with a laser. Eight patients underwent concomitant excision, and one patient underwent skin grafting of the medial canthus. Patient satisfaction was assessed immediately and at 3 months after the procedure. RESULTS: During the study period, 15 patients (10 women and 5 men), with a mean age of 26.0 years (range 13-73 years), underwent laser excision. Continuity of the eyelid margins was maintained in 13 patients. In one patient, the eyelashes grew inward and developed inflammation. No patient developed complications during the healing process, except for partial loss of cilia. Eleven patients were very satisfied, whereas three were satisfied with the results. One patient discontinued treatment after two laser sessions. CONCLUSION: We performed multiple staged mosaic punching excisions of a congenital divided nevus with the CO2 laser in 15 cases. We observed consistent therapeutic results without definite recurrence, while maintaining the continuity of the eyelid and eyelash. 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 .

Modified Rotational Anterior Segmental Osteotomy for Prevention of Common Complication (Aged Appearance).

Although anterior segmental osteotomy (ASO) is powerful procedures in treating the patient who has bimaxillary dentoalveolar protrusion, there is significant change in all soft and hard tissue parameters. Soft tissue changes in response to ASO can have a deleterious effect of an aged appearance. To prevent this aged appearance, the authors tried to rotate the maxillary anterior segment rather than simply posteriorly translating the segments. The application of a clockwise pivot rotation method during ASO can prevent overcorrection by controlling the degree of setback of the piriform aperture, and it can also affect convexity of the facial profile.

Augmentation mammoplasty with silicone implant using transumbilical approach at a subpectoral level.

Endoscopic placement of breast implants has been described through an umbilical incision. Limitations include the fact that only inflatable implant can be used through umbilical approach. The purpose of this study is to describe the authors' evolutionary transumbilical technique with cohesive silicone gel implant insertion and to retrospectively analyze preliminary results. The authors' technique is the placement of a cohesive silicone gel implant using a transumbilical approach in a subpectoral plane. Patients who were selected had mammary hypoplasia without ptosis and who requests breast augmentation with a scarless and natural feel breast were considered candidates. The technique and indications are presented thoroughly. From June of 2011 to January of 2012, 42 women aged 23 to 46 years (average, 31.6 years) underwent the endoscopic transumbilical breast augmentation. All patients had round silicone implants placed in the retropectoral pocket location. The results of this study indicate that transumbilical technique is highly successful. Complication included transient periumbilical bulging (5 patients, 11.9%), hypertrophic scar needing revision (1 patient, 2.3%), and conversion to other breast incision due to capsular contracture (3 of 84 breasts, 3.5%). Transumbilical breast augmentation with prefilled implant is a safe and attractive technique for breast implant placement in selected patients. With this inventory modification, the result can permit surgeons expanded spectrum of implant selection for transumbilical approach.

"Cohesiveness of Hyaluronic Acid Fillers": Evaluation Using Multiple Cohesion Tests.

Background Hyaluronic acid fillers can be manufactured using various processes. They have multiple properties, including their concentration, degree of modification, and rheological data. Cohesion is one such property to evaluate gel integrity; however, there is no standardized method for calculating this parameter. This study aimed to evaluate different tests for calculating hyaluronic acid cohesion and discuss the importance of hyaluronic acid cohesion as a consideration when selecting fillers. Methods The cohesion levels of five different hyaluronic acid fillers with different rheological properties were evaluated and compared using the drop weight, compression, tack, and dispersion time tests. Results The cohesion tests yielded different results in the samples. Samples 2 and 4 showed approximately two times the number of droplets when compared with Sample 5 in drop weight test. Samples 1, 2, 3, and 4 were superior to Sample 5 in tack test. Samples 1, 2, and 3 showed cohesive appearances at 95 seconds in most cases in dispersion test. Rheological test results did not reflect the measures of cohesion. Conclusion Although there are no definite standardized tests to evaluate the cohesion of hyaluronic acid fillers, our proposed tests showed similar results for different hyaluronic acid filler products. Further studies are needed to evaluate the cohesion of hyaluronic acid fillers and determine the clinical use of this distinguishing characteristic for clinicians selecting the product of choice. Level of evidence statement: These data are Level IV evidence.