Treatment of Severe Gynecomastia After Massive Weight Loss: Analysis of Long-Term Outcomes Measured with the Italian Version of the BODY-Q.

INTRODUCTION: The objectives of this study are: (1) comparison of long-term outcomes after correction of severe gynecomastia using different techniques; (2) apply the Italian version of the BODY-Q; (3) present the role of intercostal perforator flap (ICAP) after massive weight loss for correction of severe gynecomastia. MATERIALS AND METHODS: Between January 2008 and March 2016, we performed surgical correction of bilateral severe gynecomastia in 80 men (160 breasts) following massive weight loss. Patients answered the Italian version of BODY-Q postoperative module. All patients had experienced substantial weight loss (> 30 kg), presented with bilateral severe tissue ptosis of the breast, follow-up of almost 2 years and had a good understanding of the Italian language, and signed consents were included in the study. The sample was studied about age, BMI, comorbidity, bariatric surgical procedure, follow-up, type of post-bariatric surgical procedure, complications and secondary procedures. RESULTS: We performed 487 severe gynecomastia corrections from 2008 to 2016; 80 patients adhered to the inclusion criteria and formed our study group. This cross-sectional study compared three cohorts: 52 access using a circumareolar scar, 18 with an inframammary fold scar, 10 with an inframammary fold scar using intercostal perforator flaps. There were 16 secondary procedures in group one, 2 in group two and 1 in group three. We compared the secondary procedures of group 1 with the other groups, and we obtained a significant difference with a P = 0.04. The mean patient age was 36.5 years, and the average body mass index was 27.5 kg/m2 at the time of surgical correction of gynecomastia. From the BODY-Q analysis, the group of patients undergoing adenomammectomy with inframammary fold scar using intercostal perforator flaps has achieved significantly better results regarding the satisfaction with chest, psychosocial function, satisfaction with outcome and better body image. CONCLUSIONS: This is the first study that used the BODY-Q to analyze the correction of severe gynecomastia following massive weight loss with long-term results. The use of this patient-reported outcome measure underlined that the intercostal artery perforator flap, used in the correction of severe gynecomastia following massive weight loss, is a safe and effective technique with good outcomes and high patient satisfaction. 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 Role of Appearance: Definition of Appearance-Pain (App-Pain) and Systematic Review of Patient-Reported Outcome Measures Used in Literature.

INTRODUCTION: The objectives of the current study were: (1) to perform a systematic review of the existing scientific literature on appearance and any subsequently related disorders and (2) to research in the literature the correlation between the role of appearance and patient's disease. MATERIALS AND METHODS: A systematic review protocol was developed a priori in accordance with the Preferred Reporting for Items for Systematic Reviews and Meta-Analyses-Protocols (PRISMA-P) guidance. A multistep search of the PubMed, MEDLINE, PreMEDLINE, Embase, Ebase, CINAHL, PsychINFO and Cochrane databases was performed to identify studies on patient satisfaction, quality of life, and body image. RESULTS: Our search generated a total of 347 articles. We performed a systematic review of the 18 studies, which had sufficient data and met all inclusion criteria. All studies identified from the literature review were assessed to determine the utilization of validated patient satisfaction questionnaires. The questionnaires were analyzed by reviewers to assess adherence to the rules of the US Food and Drug Administration and the Scientific Advisory Committee of the Medical Outcomes Trust. We identified 27 individual questionnaires. We summarized development and validation characteristics and content of the 27 validated measures used in the studies. CONCLUSIONS: This is the first systematic review to identify and critically appraise patient-reported outcome measures for appearance and body image using internationally accepted criteria. DAS59 was deemed to have adequate levels of methodological and psychometric evidence. We also introduced the concept of Appearance-Pain which consists of the recomposed systematic view of the experimental indicators of suffering, linked to one of the dimensions of appearance. 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 .

Patient-Reported Satisfaction Following Post-bariatric Surgery: A Systematic Review.

INTRODUCTION: The aims of our study were to identify studies that evaluated patient satisfaction following post-bariatric surgery, analyse existing questionnaires, and summarise their development, psychometric properties, and content. PATIENTS AND METHODS: A multistep search was undertaken on the web-based PubMed database from the National Library of Medicine to identify studies on patient satisfaction and quality of life following post-bariatric surgery. The authors summarised all the questionnaires used in every study and categorised them as generic, surgery specific, or ad hoc, and whether they contained either validated or unvalidated measures. RESULTS: Our search generated a total of 1754 articles. We performed a systematic review of the 12 remaining studies, because these had sufficient data and met the inclusion criteria. All the studies identified from the literature review were assessed to determine the type of surgery used, and whether or not the questionnaire used to analyse patient satisfaction had been validated. The questionnaires were analysed by reviewers to assess adherence to the rules of the US Food and Drug Administration and the Scientific Advisory Committee of the Medical Outcomes Trust. We identified 20 individual questionnaires that included 10 generic instruments that assessed quality of life, six instruments specific for post-bariatric surgery, three instruments specific for breast surgery. CONCLUSIONS: In post-bariatric patients, the BODY-Q was shown to be a more objective and confident measure for evaluating the quality of life of patients following post-bariatric surgery. LEVEL OF EVIDENCE III: 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 .

Analysis of Symmetry Stability Following Implant-Based Breast Reconstruction and Contralateral Management in 582 Patients with Long-Term Outcomes.

INTRODUCTION: This study aimed to analyse the long-term outcomes following breast reconstruction and contralateral management to evaluate the stability of breast symmetry and patient satisfaction. MATERIALS AND METHODS: The study population consisted of women who had undergone implant-based monolateral breast reconstruction and contralateral management. Patients answered the BREAST-Q reconstruction module. Two reviewers analysed the post-operative outcomes of the patients included and compiled the Kroll Scale. Patients were divided into three groups: implant-based contralateral management, breast reduction and mastopexy. The Fisher's exact test was applied to the results. RESULTS: From the BREAST-Q analysis, the group of patients undergoing contralateral breast augmentation achieved significantly better results regarding the ability to wear clothing (p â‰ª 0.001), symmetry (p â‰ª 0.001), psychosocial well-being (p â‰ª 0.001) and physical well-being (p â‰ª 0.001). From the analysis of the Kroll Scale, the group of implant-based contralateral management received the highest score for symmetry (p â‰ª 0.001), shape (p â‰ª 0.001) and aesthetic result overall (p â‰ª 0.001). CONCLUSIONS: This study was the first to use BREAST-Q to analyse the stability of breast symmetry following breast reconstruction with long-term results. The implant-based contralateral management was the most effective procedure for achieving a stable and lasting result to obtain the high satisfaction of patients. 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 .

Management of contralateral breast following mastectomy and breast reconstruction using a mirror adjustment with crescent mastopexy technique.

INTRODUCTION: Heterologous breast reconstruction after mastectomy sometimes requires the management of the contralateral breast to achieve symmetric long lasting aesthetic results. Some techniques could be used for the symmetrization of contralateral breast with or without implants as breast augmentation, reduction mammoplasty, mastopexy, with T inverted, J, vertical, periareolar, semi-circular, or axillary scars. The aim of this study is to present the use of crescent mastopexy technique with implants in contralateral adjustment following monolateral breast reconstruction compared with a control group in which patients underwent other contralateral procedures. We used BREAST-Q to evaluate breast perception and patient's satisfaction and surgeon-rated aesthetic outcomes were measured using the Kroll evaluation (a global and itemized aesthetic tool). MATERIALS AND METHODS: A retrospective study was designed. We enrolled in the study 55 patients who had undergone breast reconstruction with implants and contralateral breast symmetrization procedure at our hospital between 2010 and 2016, and they answered to BREAST-Q postoperative module after almost 1 year from breast reconstruction. The study population consisted of 2 groups of women: patient underwent contralateral adjustment with crescent mastopexy and augmentation and patients underwent other contralateral procedures. Statistical analysis was performed using descriptive and summary statistics to identify a central tendency between the two groups, we applied Fisher's exact test to the results to obtain answers 1 year after the last procedure for the two groups. RESULTS: This cross-sectional study compared two cohorts in which 55 women underwent monolateral mastectomy and breast reconstruction with contralateral adjustment, 15 of these underwent contralateral crescent mastopexy with augmentation, and 40 (control group) underwent contralateral breast adjustment with other mastopexy and augmentation technique (27 patients underwent T inverted mastopexy, 2 J mastopexy, 6 vertical scar mastopexy, 5 periareolar mastopexy). Nineteen patients suffered of co-morbidities (smoking, autoimmune disease, cardiological, neurological, and dismetabolic). All patients answered the postoperative BREAST-Q reconstruction module almost 1 year from last surgical procedure. CONCLUSIONS: In patients with a pseudoptosis or mild ptosis of the contralateral breast, crescent mastopexy could be a valid procedure with minimal scars, better symmetry, and global cosmetic results than other procedures. This is the first study which compares crescent mastopexy with augmentation with other mastopexy procedures. Level III: evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group. LEVEL (III): Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.

Mastopexy on Reconstructed Breast Following Massive Weight Loss: An Innovative Technique Using Dermo-Capsular Flaps.

BACKGROUND: We have developed a dermo-capsular flap mastopexy technique for patients who have experienced massive weight loss after breast reconstruction. The aim of this technique is to lift the inframammary fold, adequately cover the implant, and remove excess skin, elevating the breast and obtaining symmetry with the contralateral breast. METHODS: Between January 2014 and February 2017, we performed this technique on 20 women who were candidates for second-stage breast reconstruction following nipple-sparing mastectomy. All patients had experienced substantial weight loss (> 15 kg) and presented with ptosis after first-stage reconstruction. RESULTS: There were 8 patients with bilateral reconstruction following bilateral mastectomy (4 with bilateral nipple-sparing mastectomy). There were 12 patients with unilateral mastectomy, all with contralateral breast ptosis treated by augmentation via inverted-T mastopexy (n = 7) or crescent mastopexy (n = 5). The average lift of the nipple-areola complex was 5 cm (range 2-8 cm). The average follow-up was 12 months (range 4-36 months). Two patients had complications, including partial wound dehiscence (in a heavy smoker) and recurrence of breast asymmetry. CONCLUSIONS: Implant breast reconstruction after massive weight loss is still possible even in the setting of thin, ptotic, and anelastic breast tissue. Our inverted-T dermo-capsular flap mastopexy technique for reconstructed breast is safe and effective with good outcomes and high patient satisfaction. 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 Systematic Review of Patient-Reported Outcome Measures Following Transsexual Surgery.

BACKGROUND: The aims of our study were to identify studies that evaluated patient satisfaction after transsexual surgery, analyze existing questionnaires, and summarize their development, psychometric properties, and content. METHODS: A systematic review of the English-language literature was performed. Patient-reported outcome measures designed to assess patient satisfaction and quality of life following transsexual surgery were identified. Qualifying instruments were assessed for content and adherence to international guidelines for development and validation. RESULTS: From 796 articles, 19 studies had sufficient data and met the inclusion criteria. Included were a total of 2299 patients and 17 patient-reported outcome measures: 10 generic instruments that assessed quality of life, 4 specific for female genital or sexual satisfaction, 2 specific for transsexual body image or gender dysphoria, and 1 specific for plastic surgery. The questionnaires were analyzed by reviewers to assess the adherence to the rules of the US FDA and the Scientific Advisory Committee of the Medical Outcomes Trust. We identified 17 individual questionnaires that were included. All measures were limited by either their development, their validation, or their content. CONCLUSIONS: There is a need for a new self-assessment tool, which should include functional, psychorelational, and cosmetic components, to measure satisfaction and quality of life of patients who have undergone transsexual surgery. 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 .

Comparative Study Using Autologous Fat Grafts Plus Platelet-Rich Plasma With or Without Fractional CO2 Laser Resurfacing in Treatment of Acne Scars: Analysis of Outcomes and Satisfaction With FACE-Q.

BACKGROUND: A multitude of options are traditionally used for the treatment of acne scars; however, newer treatment modalities are emerging to decrease the propensity for post-inflammatory hyperpigmentation and upregulate new collagen production. The aim of this study was to evaluate the efficacy of nanofat and platelet-rich plasma (PRP) infiltration alone and combined with fractional CO2 laser resurfacing to improve atrophic scars of the face. METHODS: From March 2014 to June 2015, 30 patients with atrophic acne scars on the cheeks were selected for this study. Patients were evaluated pre- and postoperatively by physical examination, photographs and ultrasound with a 22-MHz probe to measure subcutaneous tissue thickness. All patients were treated with infiltration of nanofat plus PRP. The production of PRP was achieved using the RegenLab THT tube® method. In 15 randomly chosen patients, a fractional CO2 laser resurfacing at 15 W was also performed right after the infiltration. An Italian version of the FACE-Q postoperative module was administered to analyze each patient's satisfaction and aesthetic perception of the result. RESULTS: The average preoperative thickness of subcutaneous tissue of patients from group A was 0.532 cm, while the average preoperative thickness of subcutaneous tissue of patients from group B was 0.737 cm. The average postoperative thickness of subcutaneous tissue was 1.201 cm in group A and 1.367 cm in group B. The improvement of thickness of subcutaneous tissue was 0.668 cm in group A and 0.63 cm in group B. We applied a t test on unpaired data, comparing the difference in thickness obtained with the treatment in both group A and in group B, with a p value =0.7289 (not significant). All patients in both groups had a treatment benefit, confirmed with FACE-Q postoperative module, but without a significant difference between the two groups. CONCLUSIONS: Subcutaneous infiltration with nanofat and PRP seems to be effective to improve atrophic scars, either alone or combined with fractional CO2 laser resurfacing. The FACE-Q module confirmed the impact of treatment of facial acne scars in social life and relationships. 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 .

Patient Satisfaction and Clinical Outcomes Following 414 Breast Reductions: Application of BREAST-Q.

BACKGROUND: The aim of this study was to measure breast satisfaction and quality of life using the BREAST-Q Reduction Module in a large sample of postoperative patients having breast reduction using the inverted T technique. METHODS: With due approval from the ethics committee of our university, 414 patients who were seen in consultation for breast reduction surgery between 2005 and 2015 performed by the same team were asked to fill out BREAST-Q surveys. The patient factors collected for all those undergoing breast reduction included age, body mass index, incision pattern, areola complex pedicle used, amount of tissue resected, concurrent procedures, and complications. RESULTS: At our Department of plastic, reconstructive, and aesthetic surgery, 414 women underwent reduction mammoplasty with the inverted T technique from 2005 to 2015. All patients answered the BREAST-Q reduction mammoplasty postoperative module. Postoperative patients who presented with severe hypertrophy and asymmetry Grade C were more satisfied than others. CONCLUSIONS: Our study represents the largest number of patients who answered the BREAST-Q reduction mammoplasty module. The goal of breast surgery should be the attainment of patient satisfaction with good breast volume, shape, and symmetry. LEVEL OF EVIDENCE IV: 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. http://www.springer.com/00266.

A systematic review of patient-reported outcome measures after rhinoplasty.

The literature still lacks a review regarding PROs applied for rhinoplasty. Thus, we performed a systematic review of the literature to identify PROMs that assess patient satisfaction and quality of life after rhinoplasty. The aim of our study was to identify existing questionnaires and to summarize their development, psychometric properties, and content. A multi-step search of the web-based PubMed database from the National Library of Medicine was performed to identify PROMs that are designed to evaluate satisfaction and quality of life following rhinoplasty. Each potential PROM was examined by three independent reviewers for adherence to inclusion/exclusion criteria. Questionnaires included in the analysis were appraised for their adherence to international guidelines for the development and validation of health outcome questionnaires, as outlined by the Scientific Advisory Committee of the Medical Outcome Trust and the U.S. Food and Drug Administration. Our search generated a total of 457 articles, 351 that were retrieved in the primary search, and 106 that were found in the references of the first set of articles. The process of development and validation of each of the included PROMs was examined. Only ten of these were identified as surgery-specific questionnaires about rhinoplasty. These were divided into three categories: (1) functional self-assessment (Nasal Surgical Questionnaire, Nasal Obstruction Symptoms Evaluation Scale, and Nasal Obstruction Septoplasty Effectiveness); (2) aesthetic self-assessment (Utrecht Questionnaire, FACE-Q rhinoplasty module, Glasgow Benefit Inventory); and (3) aesthetic and functional self-assessment (Rhinoplasty Outcomes Evaluation), Functional Rhinoplasty Outcome Inventory 17, RHINO Scale, and Evaluation of Aesthetic Rhinoplasty Scale).

Ten years experience with breast reconstruction after salvage mastectomy in previously irradiated patients: analysis of outcomes, satisfaction and well-being.

OBJECTIVE: Reconstruction following mastectomy offers women an opportunity to mollify some of the emotional and aesthetic effects of this devastating disease. PATIENTS AND METHODS: The authors reviewed the files of 83 patients who underwent immediate postmastectomy reconstruction with tissue expander between January of 2003 and June of 2012 at our hospital. The patients were divided into two groups: Group A (study group) included 30 patients with previous quadrantectomy and radiotherapy who underwent salvage mastectomy after local recurrence; Group B (control group) included 53 patients submitted to primary radical mastectomy. We submitted Breast-Q reconstruction post-operative module to all of our patients. RESULTS: The median follow-up time for the whole group was 36 months (range = 12-144 months). Between group A and group B, there were no significant differences. In the group A, the median time from RT to reconstruction was 24 months (range = 9-192 months). The overall rate of complications was not similar between the two groups (66.6% vs. 58.5%; p = NS). However, the  major complications occurred mostly in the irradiated group, showing a trend of statistical significance (53.3% vs. 32.0%; p = 0.07). In this group, the occurrence of major complications was not different according to time from RT to reconstruction (p = 0.313). In particularly, patients from the irradiated group (group A) had a significantly higher risk of grade III-IV capsular contracture (relative risk 3.75, p = 0.02) and autologous salvage reconstruction (relative risk 10.4, p = 0.02). CONCLUSIONS: The results of this study prove that heterologous reconstruction is still possible following salvage mastectomy in previously irradiated patients.

How to assess appearance distress and motivation in plastic surgery candidates: Italian validation of Derriford Appearance Scale 59 (DAS 59).

OBJECTIVE: The Derriford Appearance Scale (DAS) 59 was specifically designed to measure psychosocial adjustment in patients with appearance problems. Previous studies using the DAS59 have proven it to be a reliable method of assessing the appearance-related quality of life after plastic surgery procedures. The aim of this study was to develop a valid and reliable Italian version of the DAS59. PATIENTS AND METHODS: The first Italian translation of this questionnaire was conducted according to the DAS59 protocol that was designed by the original authors of the questionnaire. Eight hundred patients participated in this study and filled out three questionnaires (DAS59, General Health Questionnaire (GHQ)12 and Beck's Depression Inventory (BDI)-II). There were 400 adult patients with a history of previous plastic surgeries and 400 adult patients without any personal history of previous plastic surgery procedures. A total of 50 patients were selected randomly for test-retest analysis. RESULTS: The overall internal consistency was excellent (α = 0.95) and equal to that of the original article that first described the scale. There was a good correlation between all the items. Domains demonstrated good internal consistency (Cronbach's alpha) and correlation within themselves. The construct validity of the Italian DAS59 was assessed under convergent validity that confirmed the correlation with scales related to other psychological conditions. GHQ12 showed relevant correlation with DAS59, while BDI-II did not. CONCLUSIONS: A valid and reliable Italian DAS59 version was developed that can be used for research and clinical assessment of patients with appearance problems and concerns, especially before and after plastic surgery procedures.

Breast hypertrophy and asymmetry: a retrospective study on a sample of 344 consecutive patients.

BACKGROUND: Preoperative evaluation of the anatomical features of the region around the breast is strongly recommended in order to choose the most appropriate technique of reductive mammaplasty. Normally breast hypertrophy presents itself as a bilateral clinical picture, but no study in the literature refers to the incidence of volumetric asymmetry. AIMS: This study aims to analyze weight differences between the right and left breast on a selected sample of patients who underwent reductive mammaplasty or mastopexy over the last five years at our Plastic Surgery Unit and have maintained a good postoperative symmetry for at least 1 year subsequently. PATIENTS AND METHOD: 344 consecutive cases treated between January 2005 and April 2010 were considered for this study. Patients were classified according to the degree of hypertrophy and age. Breast asymmetry was scored, according to the senior author's original classification, on the weight difference of glandular resection. RESULTS AND CONCLUSION: In 20% of the patients a difference greater than 200 g was found. The statistical analysis showed no significant differences in the predominant side (left or right). Breast hypertrophy is confirmed as a substantially bilateral pathology, but in 1 out of 5 patients a difference of more than one quadrant can be present: thus a careful evaluation is essential in order to decide the correct surgical strategy.

Cutaneous lymphoadenoma: a rare clinicopathological entity.

Cutaneous Lymphadenoma (Benign Lymphoepithelial tumour of the skin) is a rare tumour, with distinctive clinical and histological features. To date, very few cases of this entity have been reported. We present a case of cutaneous lymphoadenoma in a 52-year-old man and a short review of the literature, summarizing the principal clinical and morphological characteristics of this rare tumour.