Direct Excision of Malar Bags: Back to the Basics.

INTRODUCTION: The pursuit of periorbital rejuvenation to counteract signs of aging is a focal point in cosmetic surgery, with eyelid surgery being a prominent choice among patients. Addressing inferior blepharoplasty, especially in cases involving chronic malar edema, malar mounds, and festoons, presents unique challenges. The terminology and classification of these conditions vary, hindering effective management. In this study, we use the term "malar bags" to encompass the spectrum of fluid-associated mounds over the malar eminence. OBJECTIVES: This study aims to demonstrate the effectiveness of direct excision as a surgical choice for treating the aesthetic concerns associated with malar bags. MATERIALS AND METHODS: A retrospective study was conducted on 53 patients who underwent direct excision of malar bags between 2013 and 2023 at our clinic. RESULTS: No major complications were encountered, overall high level of satisfaction for both patients and surgeons. CONCLUSION: Direct excision of malar bags proved to be a safe and effective technique, yielding satisfactory results in terms of both aesthetic outcomes and patient satisfaction. 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 .

Our 40 Years' Experience on Face and Neck Lift Procedures with High-SMAS Flap Techniques: How to Manage Secondary and Tertiary Surgeries.

BACKGROUND: Facial aging drives a growing demand for esthetic procedures, with nonsurgical options often falling short in longevity compared to surgery. Despite primary face and neck lift techniques receiving substantial attention, revision procedures have been relatively overlooked in terms of their unique surgical management, complication incidence, and preventive strategies. METHODS: The authors present a 40-year experience with revision face and neck lifts, comprising 283 cases. The primary focus was on the high-SMAS flap technique in revision surgeries, with data collected on complications compared to primary procedures and existing literature. Secondary analysis investigated the time-lapse between primary and revision surgeries in the author's series (secondary and tertiary rhytidectomy) compared to the literature findings. RESULTS: Out of 283 cases, 232 were secondary and 51 were tertiary procedures. Overall complication rates in secondary cases mirrored those of primary procedures, with no statistically significant difference observed (p > 0.05). The mean interval between procedures was 9.0 years (range: 3.4-28.8 years), with a significant statistical difference (p < 0.05) observed between the first and second procedures (10.7 years, range: 3.8-18.8 years) and the second and third procedures (7.8 years, range: 3.5-10.8 years). CONCLUSION: Results indicate that high-SMAS flaps yield consistent and satisfying outcomes, even in secondary and tertiary cases. Complication rates are comparable to primary surgeries, underscoring the importance of meticulous attention to detail in managing the complexities associated with previous surgeries and the aging process. 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 .

Evaluating the Effectiveness of the High-SMAS Facelift Technique: Objective Clinical Outcomes at 1-year.

BACKGROUND: The primary goal of the facelift is to rejuvenate the face without changing its natural features. This involves working on the deeper layers to preserve the surface look while adjusting the fat pads beneath. Thus, we often use a modified High-SMAS facelift method, following this deep-layer approach. The study evaluates whether the high-SMAS facelift, focusing on optimal repositioning, can effectively reduce aging signs in the mid to lower face and neck. METHODS: Conducted from 2018 to 2022, this retrospective cohort study included demographic data, relevant comorbidities, and operative details of patients undergoing lateral extended high-SMAS facial lifting, excluding revision cases. Complications were recorded, and a minimum one-year follow-up was ensured. The technique's effectiveness was assessed using pre- and one-year post-surgery images analyzed by three masked examiners with a validated scoring method by La Padula et al. RESULTS: The study included 325 patients, with no major complications reported. Significant improvements were noted in post-operative High-SMAS visual scores compared to pre-operative scores (p < 0.0001), particularly in cheek fullness, jawline, and cervical angle definition. CONCLUSIONS: The High-SMAS facelift technique, evaluated using the Face- and Neck-Lift Objective Photo-Numerical Assessment Scale, demonstrated significant cosmetic enhancements. This technique, focusing on optimal flap draping vectors, effectively restores a youthful appearance by improving facial contours. 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 .

Complete Hemifacial Paralysis Post-facelift: Making Sense of a Plastic Surgeon's Worst Nightmare.

BACKGROUND: Postrhytidectomy hemifacial paralysis is a frightening clinical condition affecting the proximal facial nerve and most often associated with Bell's palsy. Associated symptoms are common and include auditory, salivary, vestibular, and gustatory complaints. OBJECTIVES: The aim of the study was to provide increased awareness of postrhytidectomy hemifacial paralysis secondary to Bell's palsy in the plastic surgery community. METHODS: Following a roundtable discussion with the senior author's (J.C.G.) plastic surgery colleagues located all over the world, 8 surgeons reported having had firsthand experience with hemifacial paralysis in patients following facelift. Descriptions of their cases, including preoperative, intraoperative, and postoperative courses were collected and reported. RESULTS: A total of 10 cases of postrhytidectomy hemifacial paralysis were analyzed based on results of a clinical questionnaire. Eight of the 10 cases involved all facial nerve branches, with 2 cases sparing the marginal mandibular branch. The vast majority of cases were referred to a neurologist and steroids initiated. Two patients were returned to the operating room for exploration. Associated symptoms reported included pain in the ear, hearing loss, ocular symptoms such as tearing or dryness, vestibular symptoms such as vertigo, changes in taste, and in 1 patient an electric-shock type sensation to the face. CONCLUSIONS: Hemifacial paralysis associated with Bell's palsy following rhytidectomy is a rare but known clinical entity that should be included in the preoperative informed consent process before facelift. Current management trends are neurology referral and steroid initiation.

2022 Practice Recommendation Updates From the World Consensus Conference on BIA-ALCL.

BACKGROUND: Laboratory and clinical research on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is rapidly evolving. Changes in standard of care and insights into best practice were recently presented at the 3rd World Consensus Conference on BIA-ALCL. OBJECTIVES: The authors sought to provide practice recommendations from a consensus of experts, supplemented with a literature review regarding epidemiology, etiology, pathogenesis, diagnosis, treatment, socio-psychological aspects, and international authority guidance. METHODS: A literature search of all manuscripts between 1997 and August 2021 for the above areas of BIA-ALCL was conducted with the PubMed database. Manuscripts in different languages, on non-human subjects, and/or discussing conditions separate from BIA-ALCL were excluded. The study was conducted employing the Delphi process, gathering 18 experts panelists and utilizing email-based questionnaires to record the level of agreement with each statement by applying a 5-point Likert Scale. Median response, interquartile range, and comments were employed to accept, reject, or revise each statement. RESULTS: The literature search initially yielded 764 manuscripts, of which 405 were discarded. From the remaining 359, only 218 were included in the review and utilized to prepare 36 statements subdivided into 5 sections. After 1 round, panelists agreed on all criteria. CONCLUSIONS: BIA-ALCL is uncommon and still largely underreported. Mandatory implant registries and actions by regulatory authorities are needed to better understand disease epidemiology and address initial lymphomagenesis and progression. Deviation from current diagnosis and treatment protocols can lead to disease recurrence, and research on breast implant risk factors provide insight to etiology.

Liporeduction: A Faster and Safer Breast Remodeling Technique.

BACKGROUND: Breast reduction is a time-consuming procedure with a relatively high complication rate. Furthermore, recurrent breast enlargement can occur in case of postoperative weight gain. The authors describe a breast reduction technique based on liposuction, followed mostly by skin resection alone, which makes this operation easier, faster, and safer, with more stable results. METHODS: Two hundred thirty-three patients were treated by breast liporeduction between 2006 and 2017, with an age range of 18 to 70 years (average age, 42 years). The patients were selected after careful clinical and instrumental assessment among those in whose breasts the fat component was prevalent over the gland. Most of the soft-tissue reduction consisted of fat aspiration. The follow-up ranged from 12 months to 9 years (average, 4.5 years). RESULTS: The results of this study have been extremely satisfactory. Most of the patients healed uneventfully and were happy with the final outcome. Very few complications were encountered, among which were small steatonecroses and partial nipple-areola complex necroses. CONCLUSIONS: For the past 15 years, all four authors have preferred this breast reduction technique over others. Fat only is selectively removed by aspiration with a blunt cannula, sparing the vascular network and easily mobilizing the nipple-areola complex. Liporeduction provides a good stable result because any postoperative weight variation will not change the volume of a breast consisting mainly of glandular and fibrous tissue. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A Single Center's Clinical Experience With Ergonomix Breast Implants.

BACKGROUND: This retrospective study reports on the early experience of a private surgical center with Motiva Ergonomix SilkSurface breast implants. OBJECTIVES: The aim of this study was to examine the incidence of complications and satisfaction levels in women who received primary and revision breast augmentation or augmentation-mastopexy with Ergonomix SilkSurface breast implants. METHODS: A total of 356 consecutive patients received Ergonomix SilkSurface breast implants between April 2014 and October 2018 by 3 different surgeons and were followed-up for a minimum of 12 months. Complications were assessed by measuring the rate of rupture, capsular contracture, malposition, late seroma, double capsule, reoperation, symmastia, ptosis, extrusion, and infection. Satisfaction with aesthetic results was assessed on a Likert scale by both surgeon and patient. RESULTS: Only 6 major complications were observed in these 356 patients (712 implants): 1 unilateral implant ptosis ("bottoming out") at 12 months (0.14%) and 2 capsular contractures (0.28%), 1 at 14 months and 1 at 2 years. At all time points, 98% of the patients were "extremely satisfied or very satisfied" with the aesthetic results, and the surgeons categorized the outcomes as "very important or important improvement" in 96% of the cases. CONCLUSIONS: Motiva Ergonomix SilkSurface devices provided high patient satisfaction up to more than 5 years postoperatively with very few complications. These data are consistent with other reports in the literature. The observed favorable outcomes might be attributed, at least in part, to the bioengineered "cell-friendly" surface of these implants.

Facial Aging Surgery: Healing Time, Duration Over the Years, and the Right Time to Perform a Facelift.

BACKGROUND: The "time variable" assumes paramount importance, especially regarding facial rejuvenation procedures. Questions regarding the length of recovery time before returning to work, how long the results will last, and the ideal time (age) to undergo this particular type of surgery are the most commonly asked by patients during the initial consultation. OBJECTIVES: The authors endeavored to determine the healing time, optimal age to perform the surgery, and duration of the results after cosmetic face surgery. METHODS: A 35-year observational study of 9313 patients who underwent facial surgeries was analyzed. The principal facial rejuvenation interventions were divided into 2 subgroups: (1) eyelid and periorbital surgery, including eyebrow lift, blepharoplasty, and its variants and midface lift; and (2) face and neck lift. Significant follow-ups were conducted after 5, 10, and 20 years. To evaluate the course of convalescence, the degree of satisfaction with the intervention, and the stability of the results, a questionnaire survey was administered to a sample of 200 patients who underwent face and neck lifts. RESULTS: The answers given indicated that surgery performed according to rigorous standards allowed for a relatively rapid recovery, and the positive results were stable up to 10 years after surgery. The level of patient satisfaction also remained high even after 20 years. CONCLUSIONS: The "right time" for a facelift, taking into account age, recovery time, and the longevity of the results, is an important consideration for both the patient and the cosmetic surgeon.

Face Lifting in Bald Male Patients: New Trends and Specific Needs.

BACKGROUND: Aesthetic surgery has recently become popular also among men. The ever-increasing number of bald men wishing to undergo facial surgery represents a challenge for the surgeon, as the scars cannot be hidden in the hair and must therefore be as short as possible. The authors present their experience in face lifting in bald male patients and propose an innovative technique to handle the skin excess to achieve practically invisible scars. METHODS: A 10-year observational study was carried out on 68 bald male face-lift patients. All patients underwent deep plane lifting with a specific method for handling skin excess. This technique is the innovation presented in this article. Subjective and objective methods were used to evaluate the results. The well-known FACE-Q questionnaire was sent to all the patients together with an explanatory letter. Three ad hoc questions were added to the questionnaire to assess the degree of satisfaction with the scars. The objective method involved the evaluation of preoperative and postoperative photographs by a three-member jury. The average follow-up period was 12 months. RESULTS: All patients showed a high degree of satisfaction with the final appearance of the surgical scars and appreciation of the overall quality of the result, 1 year after face-lift surgery. No patient expressed regret about choosing to undergo this type of surgery. Very high scores were registered for the overall facial appearance and for the various critical areas examined, including scars, from patients and experts alike. CONCLUSION: The face-lifting technique for bald men proposed by the authors, involving a peculiar and innovative way of handling the skin excess, has proven to be reliably effective in obtaining virtually invisible scars.

Targeting the Formyl Peptide Receptor type 1 to prevent the adhesion of ovarian cancer cells onto mesothelium and subsequent invasion.

BACKGROUND: The biological behavior of epithelial ovarian cancer (EOC) is unique since EOC cells metastasize early to the peritoneum. Thereby, new anti-target agents designed to block trans-coelomic dissemination of EOC cells may be useful as anti-metastatic drugs. The Urokinase Plasminogen Activator Receptor (uPAR) is overexpressed in EOC tissues, and its truncated forms released in sera and/or ascitic fluid are associated with poor prognosis and unfavorable clinical outcome. We documented that uPAR triggers intra-abdominal dissemination of EOC cells through the interaction of its 84-95 sequence with the Formyl Peptide Receptor type 1 (FPR1), even as short linear peptide Ser-Arg-Ser-Arg-Tyr (SRSRY). While the pro-metastatic role of uPAR is well documented, little information regarding the expression and role of FPR1 in EOC is currently available. METHODS: Expression levels of uPAR and FPR1 in EOC cells and tissues were assessed by immunofluorescence, Western blot, or immunohystochemistry. Cell adhesion to extra-cellular matrix proteins and mesothelium as well as mesothelium invasion kinetics by EOC cells were monitored using the xCELLigence technology or assessed by measuring cell-associated fluorescence. Cell internalization of FPR1 was identified on multiple z-series by confocal microscopy. Data from in vitro assays were analysed by one-way ANOVA and post-hoc Dunnett t-test for multiple comparisons. Tissue microarray data were analyzed with the Pearson's Chi-square (χ2) test. RESULTS: Co-expression of uPAR and FPR1 by SKOV-3 and primary EOC cells confers a marked adhesion to vitronectin. The extent of cell adhesion decreases to basal level by pre-exposure to anti-uPAR84-95 Abs, or to the RI-3 peptide, blocking the uPAR84-95/FPR1 interaction. Furthermore, EOC cells exposed to RI-3 or desensitized with an excess of SRSRY, fail to adhere also to mesothelial cell monolayers, losing the ability to cross them. Finally, primary and metastatic EOC tissues express a high level of FPR1. CONCLUSIONS: Our findings identify for the first time FPR1 as a potential biomarker of aggressive EOC and suggests that inhibitors of the uPAR84-95/FPR1 crosstalk may be useful for the treatment of metastatic EOC.

International Expert Panel Consensus on Fat Grafting of the Breast.

BACKGROUND: Autologous fat grafting has broad applications in reconstructive and aesthetic breast surgery as a natural filler and for its regenerative purposes. Despite the widespread use of fat grafting, there remains no shared consensus on what constitutes the optimal fat grafting technique and its oncological safety. For this reason, the authors of this study have organized a Survey and an International Consensus Conference that was held at the Aesthetic Breast Meeting in Milan (December 15, 2018). METHODS: All studies on fat grafting, both for breast aesthetic and reconstructive purposes, were electronically screened. The literature review led to 17 "key questions" that were used for the Survey. The authors prepared a set of 10 "key statements" that have been discussed in a dedicated face-to-face session during the meeting. RESULTS: The 10 key statements addressed all the most debated topics on fat grafting of the breast. Levels of evidence for the key statements ranged from III to IV with 2 statements (20%) supported by a level of evidence III and 6 statements (60%) by level of evidence IV. Overall consensus was reached for 2 statements (20%) with >75% agreement reached for 7 statements. CONCLUSIONS: The survey demonstrated a diversity of opinion and attitude among the panelists with regard to technique. Clear recommendations for evidence-based clinical practice for fat grafting use both in aesthetic and reconstructive breast surgery could not be defined due to the scarcity of level 1 or 2 studies.