Gluteal Augmentation with Hyaluronic Acid Filler: A Retrospective Analysis Using the BODY-Q Scale.

INTRODUCTION: Minimally invasive techniques, such as filler injection, are now available for posterior body contouring. However, limited data on the outcome of gluteal augmentation with hyaluronic acid (HA) are available in the literature. MATERIAL AND METHODS: We performed a retrospective analysis of 43 patients with Body Mass Index ≤ 30, and low-grade ptosis or no ptosis who underwent gluteal augmentation with HA at our clinics. Treatment response was evaluated with a patient-reported assessment scale (BODY-Q) at baseline, and after 6 months. RESULTS: Patients were satisfied with treatment as observed by a statistically significant increase in mean BODY-Q scores at 6 months (8.14 ± 2.19 vs. 14.40 ± 2.38, p < 0.0001). Such increase was more pronounced in patients who were treated with a higher number of vials (8-12 vials vs. 14-20 vials). No serious complications were observed during or after treatment. CONCLUSION: Gluteal augmentation with hyaluronic fillers is a safe, minimally invasive procedure with good aesthetic results. 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 .

Eyebrow lifting with barbed threads: A simple, safe, and effective ambulatory procedure.

INTRODUCTION: Changes in brow positioning are one of the first facial aging signs. A more beautiful and younger look can be achieved by repositioning the tissues involved in brow descent and sagging eyelids. METHODS: We report the outcome of eyebrow thread lifting in a series of patients who came to our clinic to improve their gaze. Response to treatment was assessed at 6- and 12-months using FACE-Q™ upperlids and eyebrow/forehead scales. RESULTS: A total of 38 patients with mild-to-moderate brow ptosis or without ptosis underwent eyebrow thread lifting (mean age 35.5, all female). No serious complications were observed during or after treatment. All patients were satisfied with the outcome of the intervention. Mean FACE-Q™ scores improved at six months compared with baseline. A statistically significant increase in mean FACE-Q™ scores was still seen at 12 months and was more evident in younger women. Patients were able to go back to their daily lives the day after the procedure. CONCLUSION: Eyebrow thread lifting is a minimally invasive procedure able to overcome mild-to-moderate ptosis with excellent aesthetic results. In the absence of ptosis, thread lifting is a good choice to reposition the brow and improve the gaze. The technique is simple to perform and safe.

Treatment With Oxygen-Enriched Olive Oil Improves Healing Parameters Following Augmentation-Mastopexy.

BACKGROUND: Breast augmentation-mastopexy can yield an aesthetically attractive breast, but the 1-stage procedure is prone to unsatisfactory outcomes, including poor wound healing. OBJECTIVES: The authors evaluated whether postsurgical application of a polyurethane bra cup coated with oxygen-enriched olive oil (NovoX Cup; Moss SpA, Lesa, Novara, Italy) would decrease pain associated with augmentation-mastopexy and improve the quality of the surgical scar. METHODS: This retrospective study was conducted at a single center from January 2016 to June 2019. All patients underwent 1-stage augmentation-mastopexy with the inverted T incision. For 2 weeks postsurgically, wounds were dressed either with the oxygen-enriched olive oil bra or with Fitostimoline (Farmaceutici Damor SpA, Naples, Italy). Patients indicated their pain intensity on postoperative days 2, 3, and 10, and patients and independent observers scored scar quality on the Patient and Observer Scar Assessment Scale (POSAS) 6 and 12 months after the procedure. RESULTS: A total of 240 women (120 per study arm) completed the study. All the patients had satisfactory aesthetic results, and there were no tolerability concerns with either postoperative dressing. Compared with patients in the Fitostimoline group, patients who received the oxygen-enriched olive oil bra cup had significantly lower pain levels, and their surgical scars were given better scores on the POSAS. CONCLUSIONS: The results suggest that maintenance of the surgical wound in a film of oxygen-enriched olive oil for 2 weeks is a safe, effective modality for suppressing pain and promoting healing following augmentation-mastopexy.

Quantitative Analysis of Nipple to Inframammary Fold Distance Variation in Tuberous Breast Augmentation: Is there a Progressive Lower Pole Expansion?

INTRODUCTION: In patients with short nipple to inframammary fold (N-IMF) distance, as in tuberous breast, the cohesivity and gel distribution of shaped implants work as a controlled tissue expander, progressively adapting the tissues to the implant's shape. This phenomenon translates into a gradual increase of the N-IMF distance over time, but the true extent to which this occurs has not been quantified to date. This study aims to quantify the postoperative variation of the N-IMF distance in tuberous breast treated with shaped cohesive silicone breast implants. METHODS: We did a retrospective review of a prospective maintained database of all consecutive patients with bilateral Groulleau I and II tuberous breasts who underwent primary breast augmentation between April 2017 and May 2018 at our institution. To quantify the lower mammary pole's morphological changes, we evaluated the N-IMF distance under maximal stretch as an endpoint. We recorded this value at time 0 (preoperative), immediate post-op (equivalent to the distance planned preoperatively) and at month 1, month 6 and 1-year post-op. Then we calculated the average N-IMF distance variation of our sample of patients with a 99% interval of confidence for each breast obtained. Comparisons were performed using the Sign test and the Mann-Whitney U test. RESULTS: The average implant weight was 353g (range 290-450; SD ±46.147). Of the 54 breasts analyzed, the immediate post-op N-IMF distance was on average 2.43 cm longer than the preop IMF with a 99% confidence interval between 2.01 and 2.86 and SD of ±1.22. The mean difference between the preop N-IMF distance and after 1, 6 and 12 months was respectively 2.78 cm (SD,1.56) (99% CI, 2.24-3.34), 3.08 cm (SD, 1.57) (99% CI, 2.53-3.64), and 3.36 (1.55) (99% CI, 2.82-3.91) Comparing immediate postoperative nipple to inframammary fold distance (N-IMF) to the 1, 6 and 12 months N-IMF values, an average of 4.23% (CI 1.3-7.16), 7.74% (CI 4.25-11.23) and 10.84% (CI 7.21-14.49) of skin length, was gained respectively. According to implants' weight, subgroup analysis showed that implants > 400 g were associated with significantly higher N-IMF distance increase (p <0.05) compared to implants < 400 g. CONCLUSIONS: Our findings suggest that a significant progressive postoperative increase in N-IMF distance should be expected in all cases of tuberous breast augmentation with anatomical implants over a 1 year period. This aspect may have an important implication on the IMF incision and the new fold position preoperative planning. LEVEL OF EVIDENCE IV.

Mid-face reshaping using threads with bidirectional convergent barbs: A retrospective study.

BACKGROUND: Minimally invasive procedures, such as thread suspension techniques, are a growing trend for facial rejuvenation. However, not enough data are available on the efficacy, outcomes, and morbidity of suture suspension techniques in mid-face reshaping. AIMS: Our goal was to assess treatment outcomes and patient satisfaction following mid-face reshaping using threads with bidirectional convergent barbs (DefinisseTM free floating threads). PATIENTS/METHODS: We performed a retrospective analysis of 60 patients who underwent treatment for mid-face reshaping using DefinisseTM free floating threads. Response to treatment was assessed at 6 months using the mid-face-specific Mid-Face Volume Deficit scale (Allergan® ), Global Aesthetic Improvement and FACE-QTM scales. RESULTS: Sixty patients underwent mid-face treatment with the suspension thread technique (mean age 51.3, 90% female). No concomitant procedures were done. A reduction by one point or more in the Mid-Face Volume Deficit Scale (MDFVS) score treatment was seen in all patients after 6 months. Mean overall MFVDS and FACE-QTM scores were significantly improved. On the GAIS, most patients were rated as improved or better both by the evaluating investigators and during self-assessment. No major complications were observed, and none of the patients requested the removal of the threads (mean follow-up 9.8 months, range 6-14 months). CONCLUSION: Our results suggest that mid-face reshaping with DefinisseTM free floating threads is a safe and reliable procedure characterized by low complication rates and good esthetic results. This minimally invasive procedure is a good alternative for normal or combination skin patients who refuse or want to delay the need for traditional rhytidectomy.

Refinement Procedures for Clitorolabiaplasty in Male-to-Female Gender-Affirmation Surgery: More than an Aesthetic Procedure.

BACKGROUND: Among the various steps of a penile inversion feminizing genitoplasty, reconstruction of the clitoris and labia minora remains the most challenging procedure. AIM: This study aims to evaluate surgical outcomes of neoclitoroplasty performed before and after the introduction of the labia minora's creation in our surgical technique. METHODS: A retrospective analysis was carried out comparing 2 groups of patients that underwent penile inversion feminizing surgery: group A (64 patients) who had labia minora and clitoral hood creation and group B (103 patients) who did not. OUTCOMES: To describe the surgical technique and outcomes of clitorolabiaplasty in male-to-female gender-affirmation surgery. RESULTS: Concerning overall complication rates, there were significant differences in the incidence of hemorrhage and urethral stenosis (P < .01). Hemorrhage surrounding the urethra and labia was identified in 40 patients (group A: n = 8 [12.5%]; group B: n = 32 [31%]) (P = .006). Neomeatal stenosis occurred in 17 patients (group A: n = 1 [1.5%]; group B: n = 16 [15.5%]) (P = .003). Partial necrosis of the clitoris occurred in 2 cases (group A: n = 0; group B: n = 2 [1.9%]) (P = .52). Necrosis of the labia majora occurred in 3 cases (group A: n = 0; group B: n = 3 [2.9%]) (P = .28). 5 patients (group A: n = 2 (3.1%); group B: n = 3 [2.9%]) (P = .93) developed rectovaginal fistula. 6 patients experienced neovaginal canal stricture (group A: n = 3 [4.6%]; group B: n = 3 [2.9%]) (P = .54). 2 patients (group A: n = 0; group B: n = 2 [1.9%]) (P = .52) reported introital stenosis; Persistent granulation tissue inside the neovagina that required in-office treatments occurred in 4 cases (group A: n = 2 [3.1%]; group B: n = 2 [1.9%]) (P = .62). Wound dehiscence occurred in 23 patients (group A: n = 13 [20.3%]; group B: n = 10 [9.7%]) (P = .05). 24 patients (group A: n = 3 [4.6%]; group B: n = 21 [20.3%]) (P = .004) underwent 28 different types of aesthetic refinements. CLINICAL IMPLICATIONS: Incorporating the creation of labia minora and clitoral hood in one step is a safe and viable option in patients undergoing male-to-female gender-affirmation surgery. STRENGTHS & LIMITATIONS: Strength of the study is the large cohort of patients included and the consistent surgical technique. To our knowledge, this is the first study that compares with a control group, the introduction of labia minora creation in male-to-female gender-affirmation surgery. Limitations include the retrospective nature of the study and the absence of patient-reported outcomes measures. CONCLUSION: Technical refinements of our technique led to a significative reduction in urethral stenosis and postoperative hemorrhage without an increased risk of major complications. Raigosa M, Avvedimento S, Descarrega J, et al. Refinement Procedures for Clitorolabiaplasty in Male-to-Female Gender-Affirmation Surgery: More than an Aesthetic Procedure. J Sex Med 2020;17:2508-2517.

Bleeding in Plastic-Aesthetic Surgery: A Prognostic Pathway with Clinical Application.

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 .

Bleeding in Plastic-Aesthetic Surgery: A Prognostic Pathway with Clinical Application.

One of the potential complications of aesthetic surgery is bleeding. Given the high surgical activity carried out in our center and the variety of interventions performed, the risk of bleeding is not negligible: A clinical practice that could reduce this postsurgical complication is necessary. The goal of this article is to value effectiveness of a bleeding score obtained through the evaluation of anamnestic data. The study was divided into two steps. The preliminary data consist in the creation of a form for the evaluation of the bleeding score based on literary data. Subsequently, the first step was put on a retrospective study on 163 patients who underwent aesthetic surgery from January 2013 to July 2017. In the second step, the bleeding score was introduced in clinical practice, submitting the form to 223 patients operated on from September 2017 to September 2018. Retrospective results showed that patients with a low bleeding index had no hemorrhagic complications. One patient of three with a medium-high bleeding score showed a hemorrhagic complication in the postoperative course. The prospective study showed that in three patients with an index between 4 and 7, the level II panel analysis confirmed a medium risk of incurring bleeding episodes during or after the surgery. One patient in 223 obtained a bleeding index of 9: This patient was not operated on and he was sent to the reference center for further investigation. This routine will help to recognize, manage, and prevent hemorrhagic complications of aesthetic 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.

Standardized Practice Reduces Complications in Breast Augmentation: Results with the First 290 Consecutive Cases Versus Non-standardized Comparators.

BACKGROUND: Several systematic methods for breast augmentation have been published, providing key principles and technical steps for minimizing complications and optimizing patient satisfaction. The aim of this study was to compare complication rates in patients receiving a breast augmentation performed using a structured, standardized approach versus comparator patients operated on without a standardized approach. METHODS: This was a single-center, retrospective review of 290 consecutive breast augmentations performed between October 2016 and September 2017 based on a standardized technique (Randquist's "five P's" combined with Adams' 14-point plan), and 235 comparators who underwent breast augmentations prior to standardization between April 2014 and September 2016. All study subjects were females aged ≥ 18 years, undergoing bilateral breast augmentation, either alone or in the context of augmentation mastopexy or implant replacement. Various implant ranges were used before standardization; most (94.8%) of the standardized procedures used Natrelle® devices. Follow-up lasted for ≥ 12 months. RESULTS: Significantly fewer patients in the standardized surgery group experienced complications (14.5%, n = 42) compared with the non-standardized group [29.4%, n = 69; Chi square = 6.57; degrees of freedom (df) = 1; p = 0.01041]. Complication rates were also significantly lower in the standardized surgery group for each of the three types of breast augmentation surgery assessed separately. Reoperation rates with standardized and non-standardized surgery were 4.1% (n = 12) and 11.9% (n = 28), respectively (Chi square = 6.4; df = 1; p = 0.01145). Patient satisfaction was increased post-surgery in both groups. CONCLUSIONS: The use of a structured, standardized approach to breast augmentation reduced the risk of postoperative complications. 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 .

Do Not Fear an Implant's Shape: A Single Surgeon's Experience of Over 1200 Round and Shaped Textured Implants in Primary Breast Augmentation.

BACKGROUND: Breast implants can be characterized by their fill material, surface texture, or shape. Whereas long-term good quality studies have provided evidence for the fill material and texture, there is still little consensus for choosing the shape of an implant. Surveys indicate that many surgeons choose only one implant shape, for reasons that may not always agree with outcomes from long-term studies. OBJECTIVES: We reviewed the first author's experience over the last six years with both round and anatomical implants, compared the rate of complications with either implant shape, and discussed the importance of keeping an open mind about using both implant shapes for primary breast augmentation. METHODS: A review of all consecutive primary breast augmentation patients by the first author over a six-year time period who had a minimum follow up of 6 months after surgery. RESULTS: Six-hundred and forty-eight female patients had 1296 silicone breast implants inserted over the six-year period. Mean age at surgery was 30.5 years and mean BMI was 20.6 kg/m2. All implants were textured, 134 (in 67 patients, 10.3%) were round in shape with mean volume of 338 cc (range, 220-560 cc), while 1162 implants (in 581 patients, 89.7%) were anatomical shaped with a mean volume of 309 cc (range, 140-615 cc). Among these patients, 11.9% (n = 8) with round implants and 9.0% (n = 52) of those with anatomical implants developed complications postoperatively. CONCLUSIONS: A single, ideal implant that is suitable for every primary breast augmentation does not exist. The optimum choice of implant shape in any given situation should take into account the patient's physical characteristics, available implant types, patient's desires, and the surgeon's experience. Together with round implants, anatomical devices ought to be considered as one of the tools in the surgeon's toolbox. By choosing to ignore them a priori means that the surgeon will only have access to half of his armamentarium and will therefore be able to offer a limited set of options to his patients.

Autologous Collagen Matrix (ACM): Lower Pole Support With a Supero-Anterior Capsular Flap in Secondary Subpectoral Breast Augmentation.

Background: Secondary aesthetic breast surgery is a complex and challenging scenario. It requires the surgeon to identify contributing factors, provide patient education, make a further management plan, and optimize the conditions for a favorable result. Various techniques have been described in literature but the rate of reoperation is still high. The first author has been using a supero-anterior capsular flap with a neopectoral subcapsular pocket and an implant change in these cases. Objectives: To review the patient characteristics, indications, and early results of using part of the existing implant capsule for secondary subpectoral breast augmentations. Methods: All patients who underwent secondary breast augmentation, over a period of 2 years by the first author (P.M.), using the supero-anterior capsular flap technique were included. The technique involves dissection of a new subpectoral pocket and uses the existing implant capsule as an internal brassiere. Results: A total of 36 patients were operated by this technique. Of these, 17 patients had developed a complication while 19 patients wanted a change in size only. At a mean follow up of 10.2 months, there was no bottoming out, double bubble, or capsular contracture. Conclusions: This reliable technique provides stable results as shown by low rate of complications with the existing follow up.

Implementation of an Integrated Biodimensional Method of Breast Augmentation with Anatomic, Highly Cohesive Silicone Gel Implants: Short-Term Results With the First 620 Consecutive Cases.

BACKGROUND: The previously described Akademikliniken (AK) method is a comprehensive approach to breast augmentation with form stable implants that has been shown to afford favorable outcomes when applied by experienced surgeons. OBJECTIVES: To evaluate outcomes of a surgeon newly adopting this method at the beginning of his career. METHODS: A retrospective review of patients undergoing dual plane subpectoral augmentation with Style 410 implants between April 2009 and December 2014 was undertaken. The review was performed one year after the last operation. The first author (P.M.) performed all operations. Complications and reoperation rates were analyzed and correlated with patient and implant characteristics using the chi-square or Fisher's exact test, as appropriate. RESULTS: A total of 620 consecutive patients met the inclusion criteria with a mean follow up of 8 months (range, 1 week-60 months). Complications occurred in 14.8% of the patients: request for larger size (3.3%), rotation (3%), and Baker III/IV capsular contracture (2.2%) were the most common ones. Low implant projection was a statistically significant risk factor (P < 0.05) for the most common complication - request for a larger size. The overall reoperation rate was 8.7%. The most common indication for reoperation was request for larger size (2.2%) followed by rotation (2.2%) and capsular contracture (2%). CONCLUSIONS: Breast augmentation with form stable anatomical implants requires a considerably different process. By implementing a systematic approach such as the AK method, novices in this terrain can expect to achieve reasonable outcomes. LEVEL OF EVIDENCE: 4.

Role of Macrotextured Shaped Extra Full Projection Cohesive Gel Implants in Primary Aesthetic Breast Augmentation.

Background: Extra full projection implants are used in a select group of aesthetic breast surgery patients. Their use is selective enough that they have not been included in long term manufacturer studies and the indications for their use have attracted much debate. Only a handful of studies have reported the outcomes from implantation of these devices. Objectives: We review our experience of using extra full projection anatomically shaped macrotextured silicone gel implants discussing our rationale, indications, and results. Methods: All patients undergoing primary aesthetic breast surgery with extra full projection anatomical implants by the first author (P.M.) over a seven-year period (January 2009 to December 2015) were included. Results: Three hundred and ten female patients had 620 macrotextured extra full projection anatomically shaped cohesive silicone gel breast implants of mean volume 338 cc (range, 195-615 cc) placed over the seven-year period. All of them had at least a 6-months follow up. There were 39 complications (12.6%) at an average follow up of 12.3 months, including implant malposition/rotation (5.4%), capsular contracture (2.6%), and bottoming out (1.6%). A total of 41 patients (13.2%) were reoperated, of which 30 (9.7%) were due to a complication and 11 (3.5%) because of patient choice. Most of the complications were in the initial part of the case series. Conclusions: The outcomes following the use of extra full projection implants in a carefully selected group of patients are comparable in the short term to those reported for other shaped implants and complications appear to decrease with experience. Level of Evidence: 4.

Male-to-Female Genital Reassignment Surgery: A Retrospective Review of Surgical Technique and Complications in 60 Patients.

BACKGROUND: Patients with male-to-female gender dysphoria (GD) require multidisciplinary assessment and management. Nowadays, more and more patients decide to undergo genital reassignment surgery (GRS) to have aesthetic and functional external female genitalia. Different techniques of this procedure have been described. Orchiectomy, penile disassembly, creation of a neovaginal cavity, repositioning of urethral meatus, and clitorolabioplasty may be identified as the five major steps in all of these techniques. METHODS: We conducted a retrospective study of 60 patients who underwent genital reassignment procedure for male-to-female GD at our department between November 2008 and August 2013 with a minimum follow-up of 1 year. Data were collected on surgical technique, postoperative dilations protocol, complications, and functional and aesthetic outcomes. We describe and critically evaluate the surgical technique used in our department. RESULTS: Follow-up ranged from 14 to 46 months. Two patients developed late neovaginal stricture, and two patients experienced rectovaginal fistulae (one required surgical revision with dermal porcine graft placement). Minor complications occurred in 13 patients and included urethral stenosis, partial wound dehiscence, and minor bleeding. Secondary aesthetic revision surgery was performed in 13 cases. CONCLUSIONS: GRS can provide good functional and aesthetic outcomes in patients with male-to-female GD. However, despite a careful planning and meticulous surgical technique, secondary procedures are frequently required to improve the function and appearance of the neovagina.