The NIU (Nipple - Inframammary Fold - Upper Breast Border) Principle: A New Tool to Predict the Ideal Nipple/Areola Complex Position during Augmentation Mastopexy Preoperative Markings.

BACKGROUND: While the beauty of the breast depends on aesthetic proportions, the position of the nipple-areola complex on the breast mound and in relation to the implant during breast augmentation or mastopexy augmentation is critical [1][2][3]. In fact, lack of nipple position determination in relation to the breast footprint is a deficiency of most currently applied measurements and evaluation tools.We hereby present a simple formula that allows accurate and proper prediction of the ideal nipple areola complex (NAC) positioning for every patient depending on the chosen implant in case of mastopexy augmentation, or revision mastopexy with exchange of implants. METHODS: A prospective Level IV analysis of all consecutive patients undergoing primary mastopexy augmentation or revision mastopexy with exchange of implants was performed between January 2021 and January 2022.48 consecutive patients were included in the study. The "NIU" (Nipple - Inframammary Fold - Upper Breast Border) principle was applied to all patients to determine the ideal position of the NAC.Patients were photographed preoperatively and postoperatively in a standardized manner.The main end point was to determine if the NAC is located at the most projected point of the breast upon follow up. RESULTS: The NIU principle has been applied to 48 patients between January 2021 and January 2022. Of those patients, 27 underwent primary augmentation mastopexy, while 21 underwent revision augmentation mastopexy with exchange of implants.The mean follow up duration was 9.2 months (6-18 months). All patients demonstrated proper NAC positioning upon follow up. CONCLUSION: The NIU principle is a simple and reliable method to determine the ideal NAC position during mastopexy augmentation or mastopexy with implant exchange.

Surgical Correction of Tear Trough Deformity (TTD) with Orbicularis Retaining Ligament Release and Volume Augmentation for Periorbital Rejuvenation: Review of the Literature.

BACKGROUND: Tear trough deformity is a hallmark of periorbital aging. It is not, however, an exclusive feature of old age. While protruding orbital fat results in lower lid bags that are traditionally corrected by excision, correction of TTD can constitute a real challenge requiring volume enhancement in addition to addressing prolapse of orbital fat and descent of cheek tissues. Described therapeutic options include minimally invasive soft tissue augmentation with fillers or structural autologous fat transfer as well as invasive surgical procedures concomitantly with lower lid blepharoplasty or other facial rejuvenation procedures. MATERIAL AND METHODS: Six eponyms have been used in the literature to describe the condition: (1) naso-jugal fold, (2) naso-jugal groove, (3) naso-jugal ditch, (4) tear trough, (5) tear trough deformity, and (6) tear trough depression. A separate PubMed database search of each of the 6 terms was conducted in addition to an advanced literature and systematic PICO searches to identify all described clinical retrospective or prospective, comparative or simple cohort studies related to surgical correction of TTD. An additional screening of references of retrieved clinical studies was performed to identify any missed reports. RESULTS: A total of 435 publications were identified with the initial search. After excluding all none relevant studies, 44 papers were selected for review. 6 additional studies were identified by screening relevant references. CONCLUSION: Almost all authors agree on the necessity to release the tear trough retaining ligament together with volume enhancement. Transconjunctival and transcutaneous incisions are reported. Most recommend repositioning of the protruding orbital fat for volume enhancement to mostly subperiosteal, or pre-periosteal pockets. Other reported options include pedicled buccal fat pad transposition, segmental fat grafting, and minced micrografts. Internal as well as external fixation of repositioned fat flaps have been described. Despite lack of solid objective evidence, several of these techniques when properly executed for the proper indication in selected patients are reported to result in a rewarding and long-lasting outcome. Unfortunately, it is difficult to determine the most appropriate technique that would universally yield the most pleasant and harmonious facial contour without creating an unnatural puffy appearance. It remains for the surgeon to identify the safe surgical approach that does not compromise lower eyelid function and achieves the most pleasing aesthetic outcome with the least complications and downtime. 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 .

Ptosis and Bottoming out Following Mastopexy and Reduction Mammoplasty. Is Synthetic Mesh Internal Breast Support the Solution? A Systematic Review of the Literature.

BACKGROUND: Relying on soft tissues with low structural strength to provide long-term support of the breasts following aesthetic mammoplasty may be inadequate in many instances. To address the inherent weakness of tissues still present after surgery, use of synthetic non-autologous additional tissue reinforcement has been described. The current review is aimed at analyzing available evidence about safety and effectiveness of mesh support in various reduction mammoplasty, mastopexy, or augmentation-mastopexy. METHODS: An advanced PubMed and Medline search was conducted to identify clinical studies about the use of synthetic mesh in aesthetic breast surgery. An additional search of breast symmetrization and synthetic mesh was also conducted. Ten studies were identified and judged to be relevant to this review. RESULTS: Retrieved studies were relatively few, characterized by marked heterogeneity, lack of well-defined outcome end points, poor outcome measures, and inherent bias in outcome documentation providing low level of evidence. CONCLUSION: Despite reported relative safety and some promising results, available data indicate that meshes do not effectively prevent recurrent ptosis and bottoming out; they may not be superior to described techniques with superior pedicle and hammocks or "balcony" flaps. Well-conducted studies are yet to be conducted comparing internal bra technique to procedures with innovative autologous tissue support. 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 .

Percutaneous Thread Lift Facial Rejuvenation: Literature Review and Evidence-Based Analysis.

PURPOSE: Interest in noninvasive facial rejuvenation procedures continues to grow. With the advent of the so-called lunch-time face-lift, suture suspension facial rejuvenation has gained prominence and much popularity largely patient driven rather than data driven. We have published a decade ago a review about this rejuvenation technique. Despite its popularity at that time, serious long-term studies and peer-reviewed data about longevity and patient satisfaction were lacking to our surprise. As 10 years have passed, we have conducted a new systematic PubMed database search limited to the last 10 years interval. METHODS: The search identified 192 publications. After screening the titles and abstracts, 20 clinical and 2 experimental studies met the inclusion criteria and were selected for this review. RESULTS: Though thread lift facial rejuvenation is considered to be a promising modality, no new evidence has been added to the literature to support its use. CONCLUSION: Until evidence-based efficacy and robust data are objectively documented, patients requesting percutaneous facial rejuvenation must be well informed about adverse events, longevity of effect, and limited available data on efficacy. 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 .

The "Hug Flap": Surgical Technique to Enhance the Aesthetic Breast Projection in Autologous Breast Reconstruction.

BACKGROUND: Obtaining a natural breast mound shape contributes profoundly to a symmetrical and successful outcome in breast reconstruction. OBJECTIVES: The authors sought to describe a new and efficient technique that enhances breast projection in delayed breast reconstruction employing abdominal free flaps and compare it with the current standard methods utilized. METHODS: The charts of 490 consecutive patients who underwent delayed breast reconstruction employing free abdominal perforator flaps were reviewed between 2007 and 2017. Three methods of breast reconstruction were compared: undermining, de-epithelialization, and the "hug flap" (HF). In the newly described technique, the caudal mastectomy skin was de-epithelialized, and then the medial and lateral thirds were undermined and folded over to cover the central part. The rates of complications and secondary corrections were analyzed between the 3 groups. RESULTS: There were 570 free abdominal flaps performed. The de-epithelization technique was the most commonly utilized (328 cases) followed by the undermining technique (153 cases). The HF technique was employed in 89 cases. The majority of HFs were performed in unilateral breast reconstruction. Bilateral cases were conducted in only 12 patients. The need for additional fat grafting was significantly (P = 0.003) less required in the HF group compared with the undermining and de-epithelializing groups (12% vs 28% and 21%, respectively). CONCLUSIONS: Although all breast-enhancing options can be mixed and matched based on the surgeon's preference and experience as well as each patient's needs, the HF can be considered as an adjunct tool to provide adequate flap projection and enhance breast symmetry.

Social Media and Plastic Surgery Practice Building: A Thin Line Between Efficient Marketing, Professionalism, and Ethics.

Social media sites and platforms have grown in numbers with an enormous potential to reach and disseminate information in real time. They are impacting tremendously for better or for worse on the current practice of plastic surgery. As the demand for elective plastic surgery, in particular for aesthetic procedures, continues to rise, there is a need to determine the influence of social media advertisements and how it motivates the public to undergo cosmetic procedures. Most importantly, there is an urgent need to determine how the social media are impacting plastic surgery practice building and what is proper and efficient marketing while upholding ethics of the medical profession? A thorough PICO tool-based comprehensive literature search was conducted. Fifty-one peer-reviewed publications, 15 patient-centered, 33 provider-centered, and three combined patient/provider were identified to be relevant to the use of social media in plastic surgery and were selected for this review. Evidence on how social media influences the medical practice and helps in practice building remains scarce; nevertheless, reliance of plastic surgeons on social media to improve their practice has been increasing steadily. Social media may be a powerful tool to promote one's career. It presents, however, serious professional, legal, and ethical challenges including maintenance of professionalism and protecting patient confidentiality. If misused, it may be a quick way to end a plastic surgery practice.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 .

Simultaneous Augmentation Mastopexy: An Innovative Anatomical Approach-The Fascioglandular Flap for Improved Lower Pole Support.

Simultaneous breast augmentation and mastopexy is very challenging often considered to be one of the most difficult cosmetic breast surgeries. Although a patient is sometimes better served with 2 separately staged procedures, the demand for single-stage combined augmentation mastopexy is increasing associated with increasing demands for larger implants. Combining these 2 operations presents special problems because of the interplay of opposing forces. To avoid bottoming out, wound dehiscence, and ultimately implant extrusion, it is essential to provide proper coverage and support of the inferior breast pole. The goal of this report is to illustrate the benefit of an inferiorly based fascioglandular flap in providing adequate breast lower pole support in simultaneous breast augmentation mastopexy. 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 .

The External Jugular Vein Used as Recipient Vessel in Head and Neck Free Flap Reconstruction: Outcomes Compared to the Internal Jugular Vein.

BACKGROUND: Contradictory data exists on the success rates of employing the external jugular (EJ) vein as a recipient vessel for venous outflow in free flap head and neck reconstruction compared with the internal jugular (IJ) vein. The authors hereby present a retrospective study of prospectively collected data over a 14-year period. METHODS: Five hundred seventy-eight patients underwent 639 free flap head and neck over 14 years. Two hundred seventy-eight free flaps employed the EJ vein as the recipient vessel while 326 free flaps employed the IJ vein. Rates of acute and late complications were compared. RESULTS: There were no differences in rates of complications: flap loss, venous thrombosis, arterial thrombosis, bleeding, hematoma, or infection between the EJ and IJ vein groups. CONCLUSION: The external jugular vein as a recipient vessel for venous outflow in head and neck free flap reconstruction of postoncologic resection defects is a valid option for both primary reconstructions and secondary surgeries.

Correction to: Metrics of the Aesthetically Perfect Breast.

Bishara Atiyeh's name was misspelled in this article. It appears correctly here.

Metrics of the Aesthetically Perfect Breast.

Breast surgery has long been viewed as an art more than a science. However, defining and objectively measuring the ideal breast morphology and aesthetic proportions are fundamental for surgical planning and to setting the goals of surgery as well as to evaluate surgical outcomes. Despite the fact that much has been written about aesthetic and reconstructive breast surgery, there is still no real consensus about what the attributes are of an ideal breast. Moreover, there are in fact no objective standard measurement systems and guidelines to describe ideal or even normal breast shape. Though there is great variability in the perception of beauty among patients and surgeons alike due to many factors among which are age, sex, and sociocultural background, there is common agreement that beauty is a universal phenomenon that has a universal standard present across all civilizations and centuries, and that perceived beauty is enhanced and optimal aesthetics are achieved when proper measurements are made and anthropometric proportions as well as attractive harmonious ratios are respected. The current review is an attempt to summarize the most relevant information available trying to introduce some harmony in our perception of aesthetic ideals of breast surgery. 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 .