Conjoined thoracodorsal perforator-supercharged dorsal intercostal artery perforator propeller flap for reconstruction of a complex upper back defect: Case report and review of the literature on supercharged pedicled perforator flaps.

The reported complications' rate of perforator propeller flaps is variably high, but the etiology of distal flap necrosis, potentially linked to vascular insufficiency, is yet to be clarified. Vascular augmentation procedures have been previously described involving an extra anastomosis of a superficial vein, while a perforator-to-perforator supercharging approach has been only sporadically documented in literature. We present a case of perforator-to-perforator vascular supercharging of an extended dorsal intercostal artery perforator (DICAP) propeller flap to provide a salvage option for pedicled flap complicated by venous congestion. A 71-year-old male patient underwent Dermatofibrosarcoma Protuberans resection in the upper back, leading to a 17 × 17 cm defect with bone exposure. A 30 × 9 cm DICAP propeller flap was planned, with the distal third of the flap designed over the adjacent Thoracodorsal artery perforasome, in a conjoined fashion. Considering the small DICAP pedicle caliber and the flap lateral extension, a thoracodorsal artery perforator vein was dissected and included in the distal flap. Once the flap was raised on its main pedicle, the skin paddle turned blue, showing signs of venous insufficiency. Indocyanine green angiography (ICG) showed a viable proximal half of the flap. Hence, after rotating the skin paddle to reach the upper margin of the defect, an additional anastomosis between the perforating thoracodorsal vein and the perforating vein of the dorsal scapular pedicle was performed according to the perforator-to-perforator approach. Doing so, both clinical and ICG examinations showed a well perfused flap, with normal capillary refill. The postoperative course was uneventful, and the patient obtained a good oncological and reconstructive result 4 months postoperatively. The second Vasconez law ("all of the flap will survive except the part that you need") is often encountered in propeller flaps surgery. Our case shows that it is possible to prevent or overcome this problem by planning appropriate vascular augmentation procedures according to the perforator-to-perforator approach, being guided by advanced vascular imaging tools like ICG.

Thigh reconstruction between form and function: An algorithm for flap selection based on a series of 70 oncological patients.

INTRODUCTION: Thigh reconstruction after oncological resection represents a challenge in terms of ideal morphological and functional outcomes to aim for. Very few papers presented a comprehensive approach to this topic, most of them being only small cases series. The purpose of this article was to review our institutional experience in the field of thigh soft-tissue reconstruction, proposing an algorithm to choose the most convenient pedicled or free flap approach according to the different clinical scenarios and the specific morpho-functional requirements of the case. PATIENTS AND METHODS: The authors retrospectively reviewed patients who received flap reconstruction for thigh soft-tissue defects after oncological resection between 2014 and 2021. Demographic and operative data were recorded. Twelve months post-operatively, patients were asked to rate the esthetic and functional outcomes of the reconstructive procedure on a 5-point Likert scale. Additionally, for patients receiving a free functional muscle transfer to restore quadriceps or hamstring function, recovery was evaluated with the Medical Research Council Scale for Muscle Strength. RESULTS: Seventy flap reconstructions of the thigh were, respectively, performed after sarcoma (n = 43), melanoma (n = 13) and non-melanoma skin cancer (n = 14) resection. Pedicled flaps were used in 55 patients: 46 perforator flaps (32 ALT, 4 AMT, 4 PAP, 2 TFL, 2 MSAP, 2 DIEP) and 9 muscle or myocutaneous flaps (4 medial gastrocnemius, 2 gracilis, and 3 VRAM). Microsurgical reconstruction was performed in 15 patients for extensive defects (2 SCIP, 1 latissimus dorsi-LD, 1 thoracodorsal artery perforator-TDAP, 1 ALT, 2 DIEP flaps) or when >50% of the quadriceps or hamstring compartments were resected (eight free functional muscle transfer including five vastus lateralis, two LD, and one rectus femoris). Extensive defect surface, previous irradiation and neoadjuvant chemotherapy appeared to be predictors of free flap reconstruction. Complication (49% vs. 26.6%; p > .05) and readmission rates (32.7% vs. 13.3%; p > .05) were comparable between pedicled and free flap groups, as well as complications severity scores according to Clavien-Dindo classification (1.15 vs. 1.29; p > .05). However, patients with previous irradiation experienced worse outcomes when receiving pedicled rather than free flaps in terms of reintervention (87.5% vs. 28.6%; p = .04) and readmission rates (87.5% vs. 14.29%; p = .01), and severity of surgical complications. Overall patients' satisfaction was high, with esthetic and functional mean score of 4.31 and 4.12, respectively (p > .05). In the FFMT group, M5, M4, M3, and M2 strength was observed in 3, 3, 1, and 1 patients, respectively. CONCLUSION: Oncological thigh defects are usually well addressed with pedicled perforator flaps. Microsurgical reconstruction offers reliable and reproducible results in extensive defects and in previously irradiated fields or when functional restoration is indicated.

Artificial Intelligence in Plastic Surgery: Analysis of Applications, Perspectives, and Psychological Impact.

Artificial intelligence (AI) is emerging as a promising tool in the field of plastic surgery, offering a wide array of applications that enhance surgical outcomes, patient satisfaction, and overall efficiency. This paper explores the utilization of AI, highlighting its various advantages and potential drawbacks. AI-driven technologies such as computer vision, machine learning algorithms, and robotic assistance facilitate preoperative planning, intraoperative guidance, and postoperative monitoring. These advancements enable precise anatomical measurements, personalized treatment plans, and real-time feedback during surgery, leading to improved accuracy and safety. Furthermore, AI-powered image analysis aids in facial recognition, skin texture assessment, and simulation of surgical outcomes, enabling enhanced patient consultations and predictive modeling. However, the integration of AI in plastic surgery also presents challenges, including ethical concerns, data privacy, algorithm biases, and the need for comprehensive training among healthcare professionals. Additionally, the reliance on AI systems may potentially lead to over-reliance or reduced surgeon autonomy, necessitating careful validation and continuous refinement of these technologies. Despite these challenges, the synergistic collaboration between AI and plastic surgery holds great promise in advancing clinical practice, fostering innovation, and ultimately benefiting patients through optimized esthetic and reconstructive outcomes.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 https://www.springer.com/00266 .

Eating Disorders and Aesthetic Plastic Surgery: A Systematic Review of the Literature.

INTRODUCTION: Eating disorders (ED) and plastic surgery are two areas of healthcare that have gained significant attention in recent years. The goal of this review is to provide an overview of the existing literature concerning the interplay between ED and aesthetic surgery, identifying existing questionnaires and providing suggestions for the future research on the psychological aspects of these group of patients. METHODS: We conducted a systematic review on PubMed. We included studies that examined the type of ED, surgical procedure, outcome measures used, patients' motivations as well as physical and psychological outcomes of individuals with ED seeking or undergoing aesthetic surgery. Three independent reviewers examined each potential study. RESULTS: Eleven studies met the inclusion criteria. These studies involved 5510 patients, addressing a spectrum of ED such as Anorexia nervosa, Bulimia nervosa, and Binge eating. The primary focus was on body contouring procedures like liposuction, breast surgery, and abdominoplasty. The assessment tools employed in these studies for evaluating ED included the Eating Attitude Test (EAT), Eating Disorder Inventory (EDI), Eating Disturbance Scale (EDS), Sociocultural Attitudes Toward Appearance Questionnaire-Eating Disorder (SATAQ-ED), and the Eating Disorder Examination Questionnaire. CONCLUSIONS: There is a complex interplay between ED and aesthetic surgery, underscoring the significance of comprehending and dealing with the psychological and sociocultural factors that impact patients in this context. The optimal management for these patients and the most effective tool for plastic surgeons to assess their psychological condition remain unclear. It is, therefore, crucial to standardize the evaluation and approach to this patient subgroup, closely aligned with psychological support, to achieve the best outcomes. LEVEL OF EVIDENCE III: 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 .

Minimally Invasive Post-Acne Scars Treatment with the Hybrid Filler HArmonyCa™.

Acne, a chronic inflammatory condition of the pilo-sebaceous unit, often results in scarring with significant aesthetic and psychological consequences for patients. While various treatments exist, including surgical and non-surgical approaches, a combined method has shown promise in effectively addressing acne scarring. Lipofilling, with its adipose-derived stem cells, has emerged as a promising technique for volume restoration and collagen stimulation but may not be suitable for all patients, especially those who prefer non-surgical treatments. Recently, a novel approach involving simultaneous injection of hyaluronic acid (HA) and calcium hydroxyapatite (CaHa) has been introduced in the literature, showing lifting properties, improving dermal thickness and skin texture, and inducing neocollagenesis. HArmonyCa™ (Allergan Aesthetics, an AbbVie Company) is a hybrid filler combining HA (20 mg/mL) and CaHa 55.7% (microspheres 25-45 µm) with 0.3% lidocaine in a 1.25-ml syringe. It has demonstrated volumizing, lifting, and skin-tightening effects, along with increased fullness, elasticity, and turgor of the skin. It has also shown an increase in viscoelasticity, suggesting new collagen formation, making it suitable for treating conditions like solar elastosis. Compared to lipofilling, HArmonyCa™ offers a non-surgical alternative with comparable outcomes and patient satisfaction. These findings have led us to employ this hybrid filler for the treatment of post-acne scarring. We present a case of a 35-year-old woman with post-acne scarring, treated with HArmonyCa™ combined with Volite™ injections, CO2 laser resurfacing, and chemical peels. Significant improvement in skin texture, reduction of shadowing effect, and restoration of tissue elasticity were observed, resulting in high patient satisfaction. While HArmonyCa™ presents a promising solution for post-acne scarring, further research is needed to comprehensively evaluate its efficacy and suitability. This study contributes to the growing body of literature exploring the potential applications of hybrid fillers, particularly in addressing post-acne scarring.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 .

Permanent Facial Fillers: Addressing Complications and Advancing Solutions.

Soft tissue augmentation with fillers has witnessed a surge in popularity for rejuvenating facial features, offering solutions for wrinkles, volume loss, and contour irregularities. Non-biodegradable fillers like silicone, polyacrylamide hydrogel, and polymethylmethacrylate (PMMA) have been introduced, promising enduring results. However, reports on silicone filler usage have highlighted a spectrum of adverse events, ranging from erythema and edema to more severe complications like infection, vascular occlusion, and inflammatory nodules. The adverse effects of non-resorbable facial fillers can manifest even years post-procedure, resulting in significant discomfort and dissatisfaction for patients. Consequently, the literature is focusing on potential treatments for these outcomes, including systemic antibiotics, corticosteroid injections, surgical drainage, and excision. Despite these options, consensus on optimal treatment modalities remains elusive. Surgical excision is the definitive method for removing permanent fillers, albeit with the risk of post-removal irregularities. Fat grafting has emerged as a viable solution, allowing for the correction of volume deficits and asymmetries. Utilizing the patient's own tissue, fat grafting reduces the risk of adverse reactions and rejection. It offers targeted volume enhancement, restoring facial symmetry and proportion, and promoting tissue healing and regeneration through the presence of stem cells. After permanent filler removal, further filler injections are not advisable. In such cases, fat grafting offers several advantages, including reduced risk and targeted enhancement. Facial fat grafting effectively restores facial volume and symmetry, with stem cells aiding in tissue regeneration for long-term skin health. In essence, while the demand for aesthetic procedures continues to rise, there's a shift toward absorbable fillers like hyaluronic acid-based ones, favored for their safer outcomes. Evidence-based practices and ongoing research are crucial for ensuring the safety and efficacy of aesthetic procedures, ultimately enhancing patient outcomes and confidence.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 .

Do Small Scars Lead to Better Results? Analysis of Long-term Outcomes and Satisfaction of Patients Undergoing Anchor-line Abdominoplasty Following Massive Weight Loss.

INTRODUCTION: Do smaller scars lead to higher patient satisfaction? The aim of this study is to analyze long-term satisfaction of patients who underwent abdominoplasty after massive weight loss. METHODS: Patients inclusion criteria: no previous abdominal remodeling procedures, previous bariatric surgery followed by a weight loss of at least 30 kg, weight stability for at least one year, good understanding of the Italian language and standardized pre- and postoperative photographs. We divided the population in 2 groups based on the surgical procedure: group 1, conventional abdominoplasty, and group 2, anchor-line abdominoplasty. All patients presented scars in the epigastric and mesogastric region resulting from previous laparoscopic or laparotomic bariatric surgery and/or other laparoscopic or laparotomic procedures. At least 2 years after surgery, we administered the Italian version of the post-operative BODY-Q module and the SCAR-Q questionnaire. RESULTS: We enrolled 20 males and 69 females aged between 25 and 55 years, with a mean follow-up of 2 years. Analyzing the questionnaires, it resulted that patients undergoing anchor-line abdominoplasty were significantly more satisfied in the body perception of the result (p = 0.035) and in the satisfaction with abdomen domain (p = 0.0015) compared to the conventional abdominoplasty group. Scars assessment with the SCAR-Q did not show any significant differences between the groups. CONCLUSION: Despite its long scars, the anchor-line pattern shows an overall higher satisfaction, due to the possibility of reducing the abdomen both cranio-caudally and circumferentially. These findings might be an important guide when approaching abdominoplasty in post-bariatric patients, debunking the myth "shorter is better". 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 .

Three Key Submuscular Points for Nonsurgical Rejuvenation of the Midface in Caucasian Patients: A Methodological Approach Using Injectable Hyaluronic Acid Fillers.

INTRODUCTION: Since aesthetic medical treatments providing natural results are becoming increasingly popular, we developed an innovative hyaluronic acid infiltration technique for midface rejuvenation. METHODS: In this prospective study, only patients with a negative or neutral lower eyelid vector were included. Treatment consisted in injecting three hyaluronic acid boluses at the cutaneous projections of the levator labii superioris, zygomatic major and minor muscles insertions. All patients were administered before treatment the FACE-Q questionnaire, whereas after treatment, they were administered the FACE-Q questionnaire and the Global Aesthetic Improvement Scale (GAIS). All treatments were documented with standardized photographs. A plastic surgeon from another Institution reviewed the photos and scored the treatments according to the GAIS scale. RESULTS: We included 567 patients (101 males and 466 females) who met the inclusion criteria. The mean age was 41 years, and mean follow-up time was four months. The FACE-Q scores after treatment were significantly higher (p < 0.001) in every domain investigated. The GAIS scores demonstrated significant improvement posttreatment in 89.8% of patients. An average of 1.5 ml of hyaluronic acid (VYC-20) was used for each zygomatic region. No major complications were reported; only 27 patients reported bruising, which resolved spontaneously. In all patients, there was an inversion of the lower eyelid vector, which had transitioned from neutral or negative to positive. CONCLUSION: Lifting the insertions of three selected muscles with hyaluronic acid allows a midface upward repositioning. This technique provides a reproducible and safe approach for midface rejuvenation through tissue repositioning rather than augmenting facial volume. 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 .

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 .

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 autologous septal cartilage is not enough or even not disposable for graft sculpting in revision rhinoplasty, valid alternatives have to be found. Both autologous and homologous costal cartilage usage has been described in scientific literature. As there is no universally accepted consensus on the cartilage choice to use in these cases, the experiences with the different types of cartilage usage assume 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: 671 patients undergoing revision rhinoplasty from June 2015 to September 2020 were divided into three groups according to the type of cartilage used (Group1/FFCC with 212 patients, group2/IACC with 239 patients and group3/ACC with 202 cases). 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 rate was conducted. RESULTS: Authors' data outlined 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 complications rate. Cartilage warping rate is significantly higher for ACC in comparison 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.

Risks and Complications Rate in Liposuction: A Systematic Review and Meta-Analysis.

Liposuction is a surgical procedure used to remove localized excess adipose tissue. According to The Aesthetic Society's latest annual report, liposuction is the most commonly performed cosmetic procedure. Despite its popularity, the existing literature lacks a unified understanding of the risks associated with liposuction. The aim of this study was to measure complications of liposuction. A systematic review and meta-analysis was reported according to PRISMA guidelines and registered on the PROSPERO database (CRD42023471626). The primary outcome was overall complication rate. The absolute risk for individual complications was also assessed. From 2957 articles, 39 studies were selected for analysis. In total, 29,368 patients were included, with a mean age of 40.62 years and mean BMI of 26.36 kg/m2. Overall, the rate of any complication was 2.62 (95% CI, 1.78-3.84). The most common complication was contour deformity, with a prevalence of 2.35% (95% CI, 1.05%-5.16%). The prevalence of hyperpigmentation was 1.49% (95% CI, 1.12%-1.99%), seroma 0.65% (95% CI, 0.33%-1.24%), hematoma 0.27% (95% CI, 0.12%-0.60%), superficial burn 0.25% (95% CI, 0.17%-0.36%), allergic reaction 0.16% (95% CI, 0.050%-0.52%), skin necrosis 0.046% (95% CI, 0.013%-0.16%), generalized edema 0.041% (95% CI, 0.0051%-0.32%), infection 0.020% (95% CI, 0.010%-0.050%), venous thromboembolism 0.017% (95% CI, 0.0060%-0.053%), and local anesthesia toxicity 0.016% (95% CI, 0.0040%-0.064%). Liposuction is a safe procedure with low complications, of which contour deformity is the most common. Raising awareness of specific risks can enhance surgical outcomes and improve patient-physician understanding.

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.

The Effect of Adjuvant Radiotherapy on One- and Two-Stage Prosthetic Breast Reconstruction and on Autologous Reconstruction: A Multicenter Italian Study among 18 Senonetwork Breast Centres.

Purpose: In modern breast cancer treatment, a growing role has been observed for breast reconstruction together with an increase in clinical indications for postmastectomy radiotherapy (PMRT). Choosing the optimum type of reconstructive technique is a clinical challenge. We therefore conducted a national multicenter study to analyze the impact of PMRT on breast reconstruction. Methods: We conducted a retrospective case-control multicenter study on women undergoing breast reconstruction. Data were collected from 18 Italian Breast Centres and stored in a cumulative database which included the following: autologous reconstruction, direct-to-implant (DTI), and tissue expander/immediate (TE/I). For all patients, we described complications and surgical endpoints to complications such as reconstruction failure, explant, change in type of reconstruction, and reintervention. Results: From 2001 to April 2020, 3116 patients were evaluated. The risk for any complication was significantly increased in patients receiving PMRT (aOR, 1.73; 95% CI, 1.33-2.24; p < 0.001). PMRT was associated with a significant increase in the risk of capsular contracture in the DTI and TE/I groups (aOR, 2.24; 95% CI, 1.57-3.20; p < 0.001). Comparing type of procedures, the risk of failure (aOR, 1.82; 95% CI, 1.06-3.12, p=0.030), explant (aOR, 3.34; 95% CI, 3.85-7.83, p < 0.001), and severe complications (aOR, 2.54; 95% CI, 1.88-3.43, p < 0.001) were significantly higher in the group undergoing DTI reconstruction as compared to TE/I reconstruction. Conclusion: Our study confirms that autologous reconstruction is the procedure least impacted by PMRT, while DTI appears to be the most impacted by PMRT, when compared with TE/I which shows a lower rate of explant and reconstruction failure. The trial is registered with NCT04783818, and the date of registration is 1 March, 2021, retrospectively registered.

Abdominal wall reconstruction with the free functional L-shaped latissimus dorsi flap: A case report.

Extensive tridimensional defects of the abdominal wall are usually addressed with soft tissue flaps combined with meshes. In this scenario, the additional value of dynamic abdominal wall reconstruction with functional flaps has yet to be demonstrated. In this paper the authors describe for the first time a unique case of total abdominal wall reconstruction with the free functional L-shaped latissimus dorsi (LD) flap, designed to increase the surface area of skin flap coverage while minimizing donor site morbidity, highlighting technical tips and long-term outcomes. A 65-year-old patient underwent abdominal wall resection for a dermatofibrosarcoma protuberans, leaving her with a 23 × 15 cm full-thickness defect. After placing a mesh, a myo-cutaneous free LD Flap with an L-shaped configuration was planned. The flap was composed of Paddle A, designed vertically along the anterior margin of the muscle and Paddle B, designed over the inferior aspect of the LD muscle, extending obliquely from the midline and intersecting Paddle A laterally with a 60° angle. End-to-end anastomoses to the deep inferior epigastric artery and vein and thoracodorsal nerve coaptation to a sizeable intercostal nerve were performed. The LD muscle was sutured according to its native tension while the two skin islands allowed an almost complete resurfacing of the abdominal wall defect. Donor site was closed primarily. Post-operative course was uneventful. One year postoperatively, good abdominal contour was observed, with adequate abdominal tone at rest in laying and standing position. Muscle neurotization was confirmed with clinical examination showing voluntary contraction of the transplanted muscle and the patient reported very high functional outcomes at the hernia-related quality-of-life (HerQles) questionnaire. The free L-shaped LD flap represents an innovative solution to reconstruct extensive full-thickness defects of the abdominal wall while reducing donor site morbidity. Flap neurotization should be attempted whenever possible to improve functional outcomes of the procedure.

Perforator-based chimeric anterolateral thigh flap U-shaped insetting for total pharyngoesophageal reconstruction: Surgical technique and functional outcomes.

BACKGROUND: Pharyngoesophageal reconstruction with the tubed anterolateral thigh (ALT) flap is burdened by possible strictures and pharyngocutaneous fistulae (PCF). We present our experience with the U-shaped insetting of perforator-based chimeric ALT flap focusing on surgical technique, complications and functional outcomes. METHODS: We retrospectively included 10 patients with a total circumferential defect of the hypopharynx undergoing reconstruction with ALT flap. A perforator-based chimeric ALT flap with two independent skin paddles was harvested: the trapezoid paddle with the greater base cranially and the height oriented vertically was used for pharyngoesophageal reconstruction while the second paddle was exteriorized and used for flap monitoring and reducing tension on skin closure. Mean age was 56.4 years. Eight patients were affected by squamous cell carcinoma. Modified barium swallow radiogram and fiberoptic laryngoscopy were performed to assess strictures and PCFs. Swallowing and speech outcomes were evaluated through the Deglutition Handicap Index (DHI), M.D. Anderson Dysphagia Inventory (MDADI) and Voice Handicap Index (VHI) questionnaires. RESULTS: Mean flap dimension was 7.9 × 6 × 9.2 cm. Mean ischemia time was 58.2 min (range 42-80). No flap loss nor flap-related complications were reported. Two PCFs were observed. Fiberoptic laryngoscopy documented a complete integration of the flap with no strictures or stenosis. Mean follow-up was 13.6 months (range 1-45 months). Mean DHI score was 33.8, mean MDADI score was 62.5, mean VHI score was 32.2. CONCLUSIONS: The ALT flap U-shaped insetting is a reliable option for pharyngoesophageal reconstruction yielding a high success rate, low number of strictures and fistulae and good swallowing and voice outcomes.

Does a High-Quality Scar Overcome its Length? Italian Validation of the SCAR-Q Questionnaire.

Scars play a pivotal role in plastic surgery: as surgeons, we continuously seek the best approach to perform a surgical procedure through a minimal access, possibly hidden in natural creases of the body, in order to create a scar less noticeable as possible. This behavior is explained by the fact that commonly, both patients and surgeons believe that the smaller the scar, the better the result. However, this is not always true and the quality of the scar is as important as its length (Barone in Aesthetic Plast Surg, 2022. https://doi.org/10.1007/s00266-022-03081-5 ). A small but widened scar can be less tolerated than a longer linear scar. Scar appearance is an important aspect influencing patient satisfaction after a surgical procedure that is often unaddressed (Barone in Aesthetic Plast Surg 42(6):1506-1518, 2018). The SCAR-Q represents the first validated comprehensive patient-reported outcome measure (PROM) designed for children and adults to assess scars (Klassen in Plast Reconstr Surg Glob Open 6(4):e1672, 2018). It is composed of three domains: scar appearance, scar symptoms, and psychosocial impact. The scar appearance scale investigates how bothered the patient is about his/her scar and consists of 12 items asking about length, width, color, shape, and size of the scar, as well as how it looks up close and from different angles. The symptoms scale investigates how bothered are patients by how their scar has felt in the past week and it consists of 12 items asking whether the scar is painful, numb, itchy, hard or firm, tight, and sensitive when touched, as well as whether the scar makes it hard to move parts of the face or body or do some activities. The psychosocial impact scale investigates how the patient feels about his/her scar and involves 5 items asking about feeling upset, embarrassed, or unhappy about the scar, as well as how they feel when someone sees their scar. The three scales are independent and can also be administered separately. Scores for SCAR-Q scales range from 0 to 100, with higher scores representing a better outcome. Following a rigorous five-step process in cooperation with the developers, our team translated and validated the SCAR-Q questionnaire in Italian in order to allow Italian surgeons to use it in their clinical practice overcoming the language barrier that was often encountered with patients who are not fluent in English. We believe this is a precious tool for plastic surgeon to assess patient satisfaction, any issues related specifically to the scar and analyze the outcomes of the procedure performed.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 https://www.springer.com/00266 .

Minimally Invasive Facial Rejuvenation with the Hybrid Filler HArmonyCa™.

There is an increasing request of minimally invasive procedures for facial rejuvenation, allowing a fast recovery while still offering satisfying outcomes. Hyaluronic Acid (HA) fillers are very useful to restore facial hollows and have a mild lifting effect, but are not effective in increasing dermal thickness and improving skin texture, which are amongst the main features of the aging face.Evidences in literature support the winning combination between HA and calcium hydroxyapatite (CaHa) in facial rejuvenation thanks to the hydrating and volumizing effect of HA and the neocollagenesis and lifting properties following CaHa injection Fakih-Gomez (Facial Plast Surg Clin North Am 13(3):371-80, 2005), Amiri (Front Med 10:1195934, 2023).HArmonyCa™ (Allergan Aesthetics an AbbVie Company) is a hybrid filler that combines HA (20 mg/mL) and CaHa 55.7% (microspheres 25-45 µm) with 0.3% lidocaine in a 1.25 ml syringe.Studies performed specifically with HArmonyCa™, showed very encouraging data on both safety and efficacy of this treatment Urdiales-Gálvez (J Cosmet Dermatol 22(8):2186-2197, 2023). In fact, besides its volumizing properties, HArmonyCa™ showed both a lifting and tightening effect on the skin visible throughout the 6-month follow-up period Urdiales-Gálvez (J Cosmet Dermatol 22(8):2186-2197, 2023).We hereby present the clinical case of a 56-year-old woman presenting moderate skin laxity, reduced skin thickness and turgor and negative eyelid vector with hollowness in the malar region bilaterally. She was treated with injection of 2.5 ml of HArmonyCa™ (Allergan Aesthetics an AbbVie Company) and 1 ml of Voluma™(Allergan Aesthetics an AbbVie Company) per side. The malar region regained its anatomical fullness, skin elasticity and turgor of both cheeks improved significantly and the patient was very satisfied with her outcome.The literature concerning patient satisfaction after treatments with HA and CaHA hybrid fillers is very poor as reported by Rivers (in: Rivers (ed) Forty-fourth Congress of the Italian Society of Aesthetic Medicine, Rome, Italy, 2023). This is one of the first contributes to the existing literature, but large and systematic studies are necessary in order to better assess a very important aspect of this very promising treatment for non-invasive facial rejuvenation.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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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 .