Vulvar migration of injected polyacrylamide hydrogel following breast augmentation: a case report and literature review.

BACKGROUND: Vulvar migration is a rare complication of filler injection for breast augmentation, generally presenting as repeated pain and fever. We will report a case of woman with polyacrylamide hydrogel breast injection develops vulvar abscess. CASE PRESENTATION: A woman with a history of polyacrylamide hydrogel breast injection was noted to have vulvar abscess due to migration of filler materials. Filler removal surgery and vacuum sealing drainage was performed for this patient. The patient was discharged from the hospital with no further complications. After a review of pertinent literature, only four previous case reports are found. Local inflammatory response, infection, large volume injections, inframammary fold destruction, hematogenous or lymphatic migrate, trauma, gravity and external pressure could play essential parts in the migration of injected filler. CONCLUSION: Polyacrylamide hydrogel migration poses a worldwide challenge, necessitating personalized solutions. Our case study underscores the importance of comprehensive examinations for individuals with a history of filler breast injection when suspecting vulvar filler migration.

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

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

Morphological Aesthetics Assessment of the Predicted 3D Simulation Results and the Actual Results of Breast Augmentation.

BACKGROUND: Although three-dimensional (3D) simulations are becoming more common in preoperative breast augmentation planning, this does not necessarily imply that the simulated results are highly accurate. OBJECTIVES: We aimed to evaluate the accuracy of the 3D simulation technique by comparing the differences in breast morphology between the 3D prediction model and the actual results. METHODS: The simulation and actual postoperative results of 103 patients who underwent breast augmentation were analyzed retrospectively. Therefore, a 3D model was created, and the parameters of line spacing, nipple position, breast projection, surface area, and volume were evaluated. Furthermore, consider the difference in chest circumferences and breast volume. RESULTS: In comparison with the simulation results, the actual results had a mean increase in the nipple to the inframammary fold (N-IMF) of 0.3 cm (P < 0.05) and a mean increase in basal breast width (BW) of 0.3 cm (P < 0.001), a difference that was not statistically significant in patients with larger breast volumes. There was a significant difference in the mean upper and lower breast volume distribution between simulated and actual breasts (upper pole 52.9% vs. 49.2%, P < 0.05, and lower pole 47.1% vs. 50.8%, P < 0.001). However, it was not statistically significant in patients with larger chest circumferences. CONCLUSIONS: Our study shows that 3D simulation has uncertainties related to the patient's chest circumference and breast volume. Therefore, these two critical factors must be considered when using simulation assessment in preoperative planning. 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 .

Harmonic Scalpel Versus Monopolar Electrotome in Endoscopic-Assisted Transaxillary Dual-Plane Augmentation Mammaplasty: A Retrospective Study in 122 Patients.

BACKGROUND: The transaxillary approach of breast augmentation is the most popular method in Asia, but longer period of recovery was observed in spite of the assistance of endoscope. OBJECTIVES: Introducing the ultrasonic dissection devices might be a solution to minimizing tisue damage thus relieving pain and shortening the period of recovery. METHOD: Between March 2020 and September 2022, we retrospectively reviewed the cases of 122 patients underwent endoscopic augmentation mammoplasty via the transaxillary approach using either the monopolar electrotome (ME) alone or assisted with Harmonic Scalpel (HS) in defining the retropectoral pocket and severing the pectoralis major muscle. RESULT: The total drainage volume was significantly lower in the HS group than ME group (74.33 ± 48.81 vs. 180.30 ± 125.10 mL; p < 0.0001). VAS score of the first 24 hour after surgery of the ME group was significantly higher than that of the HS group (6.10 ± 1.27 vs. 2.88 ± 1.29, p < 0.0001). Operation time in HS group was reduced compared to ME group (113.1 ± 14.46 mins vs. 131.3 ± 35.51 mins, p < 0.001). The duration of drainage placement (1.08 ± 0.27 vs. 2.72 ± 1.18 days) and hospital stay after surgery (3.08 ± 0.42 vs. 5.64 ± 2.78 days; p < 0.0001) were largely reduced in HS group. CONCLUSION: The assistance of Harmonic Scalpel significantly reduced total postoperative drainage, relieved pain and shortened operation time, length of drainage placement and hospital stay compared to using monopolar electrotome alone in endoscopic-assisted transaxillary dual-plane augmentation mammaplasty. 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 .

Transumbilical Silicone Breast Augmentation: A 13-Year Experience and 5-Year Analysis.

BACKGROUND: Transumbilical breast augmentation (TUBA) with saline implants has been considered a safe and efficient technique for decades. However, because silicone implants are more popular than saline ones, TUBA with saline implants is not widely performed. In 2014, we published a report on transumbilical breast augmentation using silicone cohesive gel implants. As we have performed transumbilical silicone breast augmentation (TUSBA) for 13 years with slight modifications, this study aimed to describe this novel technique and present accompanying patient outcomes over 5 years. METHODS: We enrolled patients desiring breast augmentation at a single center. The preoperative design was initially determined with the patients in standing positions before they underwent surgery under general anesthesia in a supine position. RESULTS: Between January 2018 and December 2022, 69 women and one man underwent TUSBA at a single center. All patients underwent cohesive gel silicone implantation in the subpectoral pocket. The implant size varied from 225 to 300 mL (average 272 mL) because two patients underwent surgery with implants of different sizes due to breast asymmetry. All patients were satisfied with the surgery outcome except one who was dissatisfied because of abdominal bulging. CONCLUSIONS: TUSBA offers advantages such as minimal scarring and unrestricted arm movement; thus, it can be an alternative option for patients seeking breast augmentation. 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 https://www.springer.com/00266 .

Navigating Aesthetic Pursuits: A Google Trends Insight into Cosmetic Tourism.

BACKGROUND: The popularity of cosmetic tourism may increase unnecessary risks for patients as postoperative care is variable. However, little is known about the current trends and public perception of this growing phenomenon. This study compares interest in cosmetic tourism in popular medical tourism destinations relative to the US. METHODS: Google Trends was queried from October 2017 to September 2023, examining trends over the full period and dissecting changes between 2017-2020 and 2020-2023. Search volume data were retrieved for the top international countries and the US for each of the top five cosmetic procedures, according to the ISAPS 2022 Global Survey. A p value < 0.05 was used for statistical significance. RESULTS: Searches for liposuction, blepharoplasty, breast augmentation, mastopexy, and abdominoplasty were compared between the US, Mexico, Turkey, Thailand, and Colombia. Google Trends data mirrored the prevalence of the two most common procedures, liposuction, and breast augmentation. Differences in interest regarding liposuction were greatest in Mexico, Thailand, and Turkey compared to the US (p < 0.05). Medical tourism for blepharoplasty had the highest search interest scores for Turkey and Thailand from 2017 to 2023 (p < 0.05). Significant differences were also consistent across all time intervals for breast augmentation, mastopexy, and abdominoplasty, with higher interest in Mexico and Turkey (p < 0.05). CONCLUSIONS: Google Trends analysis serves as an insightful tool for understanding cosmetic tourism. Changing trends bring the potential to assess worldwide versus country-specific procedure interest. These observed trends may foreshadow future international aesthetic procedure trends. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 Implant Removal-Only: The Role of Targeted Compression.

BACKGROUND: The number of women seeking explantation of their breast implants has increased in recent years. Anxiety due to potential health problems has been one of the major catalysts. Mastopexy with or without autoaugmentation and fat grafting are the main techniques used in breast implant removal surgery. OBJECTIVES: To analyse the aesthetic and satisfactory outcomes after simple breast implant removal assisted by targeted compression. METHODS: Twenty-eight patients were included in the series. Targeted compression of the breast after implant removal was performed during the 1st month. A satisfaction survey using a Likert scale was used before and after the final visit. The patients were followed up for 1 year. RESULTS: The mean age of the patients was 41 years old, and the mean time between implantation and removal was 10 years. Subjective reasons for removal (46.4% of the patients) were more frequent in women with less time since implantation (5 years) versus 15 years for implant-related problems. A total of 57.14% of the women were satisfied with the aesthetic result, and 42.86% were very satisfied. Only 17.8% of the total would consider an aesthetic refinement. CONCLUSIONS: Simple breast implant removal yields good aesthetic outcomes, and patients are satisfied with the results. Good management of compression of the breast and close follow-up to treat any collection in the pocket provides good adhesion and allows for effective management of the process of deflation and setting of the breast mound. 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.

A Decalogue on Enhanced Recovery After Breast Augmentation Surgery (ERABAS).

BACKGROUND: Medical and technical advances have changed the state of postoperative surgical patient care, allowing for better and faster recovery. Since its publication, predictable 24-hour recovery in breast augmentation surgery has been controversial and has generated discussion. In this study, we present a novel, easy, and reproducible protocol for Enhanced Recovery After Breast Augmentation Surgery (ERABAS), along with a summary of the ten points to follow. METHODS: We conducted a retrospective study of all primary breast augmentation surgeries performed between 2010 and 2020 by a private activity. All surgeries were performed by the same surgeon according to the same protocol, and all implants were obtained from the same company. Data were evaluated using two binary logistic regression models, taking as variables responses to recovery time and postoperative pain and as predictor or explanatory variables to the factors age, smoking, size, and location of the implant. RESULTS: In total, 2906 patients were included in this study. Of these, 2770 patients (95%) immediately returned to normal life within the first 24 h, 129 achieved normal life in four days, and only seven needed a week to recover. In these seven patients, the main acute complications were hemorrhage and acute hematoma. The implants were always round; textured implants were used in 88.8% of patients, while smooth implants were used in 11.2%. A subfascial pocket was used in 934 patients, and a dual-plane pocket was performed for 1972 patients. The only factor that showed a significant effect on recovery time was the location of the implant (p < 0.05), with the dual-plane pocket being the intervention associated with a later recovery, specifically a probability of recovery after 24 hour, 2.86 times greater than subfascial. CONCLUSIONS: The ERABAS protocol allowed rapid return to daily activities with low complication rates. Further prospective comparative multicenter studies are required to confirm these results. 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.

Letter to the Editor Regarding "Effect of Ropivacaine Intercostal Nerve Block Combined with Patient Controlled Intravenous Analgesia on Postoperative Analgesia After Breast Augmentation".

We read the recently published article "Effect of Ropivacaine Intercostal Nerve Block Combined with Patient Controlled Intravenous Analgesia on Postoperative Analgesia after Breast Augmentation" by You et al. We have noticed several issues in the methods and results of this study and would appreciate the responses from the authors. We question several aspects, opioid-sparing effect, sufentanil consumption, sample size evaluation, exclusion reasons, and side effects.

Reply to: A Two-Step Approach for Breast Augmentation with Chest Wall Deformity?

Patients asking for cosmetic breast surgery often appreciate that their breasts have an unpleasing appearance, but they often do not have a full appreciation of the degree of potential anatomic abnormalities of the chest wall and of the specific anatomical characteristics, which require a meticulous surgical planning and techniques in comparison with a standard breast cosmetic surgery. Failure to recognize this will predispose the patient to an unsatisfactory outcome and secondary deformities. To maximize surgical predictability and patients' satisfaction, the authors proposed a two-stage approach in the scenario of patients presenting with chest wall deformities and asking for breast augmentation. However, as we contemplate adopting the authors' approach to our case, we anticipate encountering two primary challenges. Firstly, utilizing custom-made 3D silicone implants might exacerbate the projection of the chondrocostal prominence present in our patient. Indeed, we believe that these implants are more beneficial for addressing concave defects (such as pectus excavatum) rather than convex prominences, as observed in our case.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 .

Reply to Comment to: Tuberous Breast Associated with Chest Wall Deformity: A Challenging Planning for Breast Augmentation.

Even in cases of noticeable breasts asymmetry, such as in our case, it is advisable to use implants with the same volume and projection, in order to maintain a similar breast footprint and allow a similar aging behavior over time. This can be achieved by reducing the size of the larger breast, thereby addressing the volume discrepancy before the placement of the implants. However, in our case, the skeletal deformities resulted in a significant disparity in the projection of the right and left sides of the chest wall, hindering the use of breast implants with identical projection. Therefore, due to this asymmetrical chest wall deformity, the left prosthesis was placed behind the central and lateral glandular parenchyma, avoiding hyper-projection in the medial part of the breast.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 .

Aesthetic Surgery Fellowship at Akademikliniken Stockholm: Survey among Graduates.

BACKGROUND: Aesthetic Surgery is one of the most competitive fields of plastic surgery. Although there is a certain demand for highly educated surgeons in this field, training in cosmetic procedures remains challenging. Akademikliniken Stockholm offers a highly appreciated fellowship program for aesthetic plastic surgeons and trained more than 200 surgeons from all over the world. OBJECTIVES: The aim of the present work was to provide insights into this fellowship program, analyze what graduates have learned and if this had implications on their further professional orientation. METHODS: Participants of the Akademikliniken fellowship program, who graduated between 10/2008 and 10/2018 (n = 66) were invited to take part in an online survey which included 30 questions about general demographics and about experience before, during and after the fellowship. RESULTS: Thirty-four graduates participated in the survey (52%). Twenty-four graduates (71%) had been already specialists in plastic surgery before commencing the fellowship program. Mean length of fellowship was 7 months (range 3-24months). Numbers of aesthetic procedures performed by the applicants significantly increased after the fellowship, and moreover, the scope of daily clinical practice shifted toward aesthetics in almost all applicants. CONCLUSIONS: A well-designed dedicated aesthetic surgery fellowship can improve the lack of training, aesthetic surgeons have during their residency. Graduates of our fellowship program reported great improvements in confidence in performing aesthetic procedures and a benefit for their future career. 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 .

Rib Reduction Technique in Patients with Isolated Chondrocostal Chest Wall Prominence Undergoing Breast Augmentation.

INTRODUCTION: When planning for breast augmentation, it is important to consider not only implant choice, surgical technique and patient desires, but also the chest wall shape and deformities or irregularities, which remain often underestimated. They can be responsible for implant malposition and breast asymmetry after augmentation. Chondrocostal junction prominence is a minor but frequent chest wall deformity. The aim of this study is to report a new technique for sculpturing isolated chondrocostal prominence deformities in patients undergoing breast augmentation. METHODS: A retrospective study was conducted to review surgical outcomes of a novel technique for costal prominence sculpturing and reshaping in patients undergoing breast augmentation. After reaching the subpectoral space, an inferiorly-based perichondral-periosteal flap is harvested just above the prominence. Once the deformity is corrected, the perichondral flap is repositioned over the sculpted rib. RESULTS: A total of six patients presenting with isolated chondrocostal prominence underwent bilateral breast implant placement and costal reduction using the described technique. Three patients were primary augmentations while the remaining patients were two secondary breast augmentation and one augmentation mastopexy. No complications were reported. No additional pain was referred at the side of rib remodelling in comparison with the contralateral breast. All the patients were satisfied with cosmetic results. CONCLUSIONS: The described technique for contouring of isolated chondrocostal deformities is fast, easy reproducible and offers advantages over the standard partial rib reduction technique. It can prevent implant malposition and projection asymmetry, eventually enhancing breast augmentation 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 www.springer.com/00266 .

Pectoral Nerve Blocks Under Direct Vision During Endoscopic-Assisted Transaxillary Breast Augmentation: A Novel, Effective Regional Blocking Approach.

BACKGROUND: Endoscopic-assisted transaxillary breast augmentation allows performing Pecs block under direct visualization. This study aimed to describe this new technique and demonstrat its short-term efficacy and safety with a preliminary clinical study. METHODS: Patients enrolled for transaxillary endoscopic-assisted prosthetic breast augmentation between February 2022 and March 2023 in two medical centers were included in the pectoral nerve block group. Postoperative VAS scores at 1, 4, 12, 24, 48, and 72 h, surgery duration, and the occurrence of nausea and vomiting were compared with a historical cohort of patients collected between February 2021 and January 2022 with the same inclusion criteria. RESULTS: 229 patients were included in the Pecs group and 116 patients were identified in the control group. No statistical difference was observed in patient characteristics. VAS score at postoperative 1 h and 72 h was similar between the two groups, whereas VAS score at postoperative 4 h, 12 h, 24 h and 48 h in Pecs group was significantly lower than control group. The occurrence of PONV in the Pecs group is significantly lower than in the control group. The duration of surgery is similar between the two groups. No block-related complication was observed in the Pecs group. CONCLUSION: A novel approach by combining pectoral nerve blocks with transaxillary endoscopic-assisted breast augmentation to perform blocks under direct vision was proposed and its short-term efficacy and safety was determined by this study. 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 .

Enhanced Recovery After Surgery (ERAS) Pathways for Aesthetic Breast Surgery: A Prospective Cohort Study on Patient-Reported Outcomes.

BACKGROUND: Patients' expectations of an anticipated timeline of recovery and fear of anesthesia in aesthetic breast surgery have not been studied. OBJECTIVE: This study aims to assess patient anxiety, expectations, and satisfaction after Enhanced Recovery after Surgery (ERAS) pathways for aesthetic breast surgery and the progress of postoperative recovery. MATERIALS AND METHODS: All consecutive patients who underwent aesthetic breast surgery between April 2021 and August 2022 were included in this single-center prospective cohort study. The ERAS protocol consists of more than 20 individual measures in the pre-, intra-, and postoperative period. Epidemiological data, expectations, and recovery were systematically assessed with standardized self-assessment questionnaires, including the International Pain Outcome Questionnaire (IPO), the BREAST-Q or BODY-Q, and data collection forms. RESULTS: In total, 48 patients with a median of 30 years of age were included. Patients returned to most daily activities within 5 days. Eighty-eight percent of patients were able to accomplish daily activities sooner than expected. The time of return to normal daily activities was similar across all procedure types. There was no statistically significant difference regarding postoperative satisfaction between patients who recovered slower (12%) and patients who recovered as fast or faster (88%) than anticipated (p=0.180). Patients reporting fear of anesthesia in the form of conscious sedation significantly diminished from 17 to 4% postoperatively (p<0.001). CONCLUSION: Enhanced Recovery after Surgery (ERAS) pathways for aesthetic breast surgery are associated with rapid recovery and high patient satisfaction. This survey study provides valuable insight into patients' concerns and perspectives that may be implemented in patient education and consultations to improve patient satisfaction following aesthetic treatments. 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 .

Efficacy and Safety of Nerve Block for Postoperative Analgesia in Patients Undergoing Breast Cosmetic Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: To evaluate the postoperative analgesic efficacy and safety of nerve block (NB) in patients undergoing breast surgery for cosmetic purposes. METHODS: PubMed, Web of Science, Embase and Cochrane Libraries were searched from inception to September 2022, to identify all eligible randomized controlled trials (RCTs). Continuous data are presented as mean difference (MD) with 95% confidence intervals (CI), whereas dichotomous data are provided as odds ratios (OR) with 95% CI. This meta-analysis was performed in RevMan 5.4. RESULTS: A total of 10 RCTs with 565 patients were meta-analyzed. Compared to the control group, the pain score of the NB group was significantly lower at postoperative 2, 3-4, 6-8, 12-16 and 24 h. Opioid consumption in the first postoperative 24 h was significantly lower in the NB group (MD = - 9.02, 95% CI - 14.29 to - 3.75, P < 0.05), I2 = 95%). In addition, the NB group showed a prolonged time to first postoperative analgesic requirement (MD = 43.15, 95% CI 4.74-81.56, P < 0.05, I2 = 96%), decreased incidence of additional postoperative analgesia (OR 0.14, 95% CI 0.07-0.28, P < 0.05, I2 = 0%) and reduced incidence of postoperative nausea or vomiting (OR 0.33; 95% CI 0.22-0.48; P < 0.05; I2 = 0%). There was no significant difference in operation duration between the two groups. CONCLUSIONS: Nerve block is an effective and safe option for postoperative analgesia after breast cosmetic surgery. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Internal Bra: A literature Review and Sub-Classification of Definitions.

BACKGROUND: The term 'internal bra' refers to a range of techniques that aim to stabilise the position of the breast and improve longevity of surgical results. It is increasingly being used to describe techniques in surgical literature and on patient information platforms, including social media. However a lack of consistency in the use of the term is a potential source of confusion and conflicting information. OBJECTIVES: This narrative review aims to improve understanding of what is meant by the term 'internal bra', by providing an overview of the different techniques it refers to and suggesting more specific terminology for use going forward. METHODS: A literature search of the Medline, Embase, and Google Scholar databases was conducted to identify papers in which a surgical technique was described using the term 'internal bra'. RESULTS: 'Internal bra' techniques can be categorised into 5 groups: mesh techniques, acellular dermal matrix techniques, suture techniques, dermal flap techniques, and muscle techniques. Promising results exist for techniques in each group; however, research is generally limited by small studies with short follow up periods, and significant inconsistencies exist in use of the term 'internal bra'. CONCLUSIONS: The titles of the five groups identified in this paper should be used going forward when discussing 'internal bra' techniques, in order to bring greater clarity to both surgical literature and patient information. Further research is also required to establish if 'internal bra' techniques truly improve longevity of surgical results and if one technique, or group of techniques, is superior. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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.

Effect of Ropivacaine Intercostal Nerve Block Combined with Patient Controlled Intravenous Analgesia on Postoperative Analgesia after Breast Augmentation.

BACKGROUNDS: To observe the effect of ropivacaine intercostal nerve block combined with PCIA as early postoperative analgesia following breast augmentation surgery with prosthesis (axillary approach) METHODS: A total of 80 women with breast augmentation surgery were selected in the plastic surgery department of Chongqing Huamei Plastic Surgery Hospital from December 2021 to May 2022. They were equally randomized into control group and observation group, with 40 cases in each one. Before placing the prosthesis, the control group was given 0.9% normal saline for intercostal nerve block; the observation group was given 0.75% ropivacaine + 1‰ adrenaline for intercostal nerve block. Patient controlled intravenous analgesia (PCIA) was used after operation. Observation indexes the visual analog scale (VAS) of resting and motor state at 4 h, 24 h, 48 h and 72 h after operation and the adverse reactions. RESULTS: The VAS scores of patients at rest and exercise and adverse reactions in the observation group were lower than those in the control group (P<0.05). CONCLUSION: Ropivacaine intercostal nerve block combined with PCIA can effectively alleviate the pain after breast augmentation with pectoralis major prosthesis through axillary incision, help patients more comfortably through the perioperative period, accelerate postoperative recovery, reduce the dosage of systemic opioids and effectively reduce side effects. LEVEL OF EVIDENCE II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Elderly Women Have a Higher Survival Rate of Grafted Donor Fat than Do Young Women Under the Influence of Low Estrogen Conditions.

BACKGROUND: Fat grafting is widely used in breast reconstruction and aesthetic plastic surgery. However, the success rate and effects of fat grafting, especially in elderly female donors, are observed. This study aimed to explore the difference in the survival rate of donor fat from elderly women and young women in fat grafting. METHODS: We collected adipose tissue samples from two healthy Chinese women: a young woman and an elderly woman. In addition, adipose tissue samples were collected from female nude mice in four experimental groups-CON-Y, CON-O, OVX-Y, and OVX-O-after fat transplantation. Grafts were harvested, weighed, and subjected to assessment of histology and angiogenesis. RESULTS: An ovariectomy model was successfully established to validate the effect of low estrogen levels on fat grafting results. Due to the influence of low estrogen levels, the graft survival rate of donor site fat was significantly higher in elderly women than in young women, accompanied by a lesser degree of angiogenesis. Low estrogen levels led to adipocyte hypertrophy, which may be related to decreased AQP-7 expression. CONCLUSIONS: AQP-7 downregulation due to low estrogen levels induces adipocyte hypertrophy, and donor fat from elderly women exhibits a higher survival rate after fat transplantation. 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 .

Breast Lipofilling: Is the Bra Really Full? Clinical Bra Pressure Measurement and In Vitro Testing of Processed and Unprocessed Fat Cells.

BACKGROUND: Breast lipofilling, a popular cosmetic and reconstructive procedure, involves the transplantation of autologous fat to enhance breast volume and contour. Despite its widespread use, cell processing and the aftertreatment remain controversial. This study investigates the pressure applied by a compression bra and reports in vitro stress tests of processed and unprocessed fat cells. METHODS: Clinical bra pressure measurements were conducted on a cohort of 45 patients following lipofilling, reduction mammoplasties and DIEP flaps. Laboratory analysis included cell vitality testing using Resazurin assays of processed and unprocessed fat cells after exposure to mechanical or hyperbaric pressure. RESULTS: Our findings show a mean overall pressure value of the compression bra for all patients of 6.7 ± 5.7 mmHg (range 0-35). Cell processing is superior to sedimentation only regarding fat cell vitality. However, neither mechanical pressure within the specified range nor hyperbaric oxygen exposure significantly affected fat graft survival as measured by Resazurin assays. CONCLUSION: The in vitro measurements showed that it was impossible to harm fat cells with external pressure during lipofilling procedures, regardless of their processing. In the clinical context, the compression bra applied pressure values deceeding the perfusion pressure and may therefore not diminish oxygen supply nor harm the transplanted cells. Therefore, we recommend the use of a compression bra for all lipofilling procedures around the breast. 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 Table of Contents or online Instructions to Authors www.springer.com/00266.