Minimally Invasive Post-Acne Scars Treatment with the Hybrid Filler HArmonyCa™.

Acne, a chronic inflammatory condition of the pilo-sebaceous unit, often results in scarring with significant aesthetic and psychological consequences for patients. While various treatments exist, including surgical and non-surgical approaches, a combined method has shown promise in effectively addressing acne scarring. Lipofilling, with its adipose-derived stem cells, has emerged as a promising technique for volume restoration and collagen stimulation but may not be suitable for all patients, especially those who prefer non-surgical treatments. Recently, a novel approach involving simultaneous injection of hyaluronic acid (HA) and calcium hydroxyapatite (CaHa) has been introduced in the literature, showing lifting properties, improving dermal thickness and skin texture, and inducing neocollagenesis. HArmonyCa™ (Allergan Aesthetics, an AbbVie Company) is a hybrid filler combining HA (20 mg/mL) and CaHa 55.7% (microspheres 25-45 µm) with 0.3% lidocaine in a 1.25-ml syringe. It has demonstrated volumizing, lifting, and skin-tightening effects, along with increased fullness, elasticity, and turgor of the skin. It has also shown an increase in viscoelasticity, suggesting new collagen formation, making it suitable for treating conditions like solar elastosis. Compared to lipofilling, HArmonyCa™ offers a non-surgical alternative with comparable outcomes and patient satisfaction. These findings have led us to employ this hybrid filler for the treatment of post-acne scarring. We present a case of a 35-year-old woman with post-acne scarring, treated with HArmonyCa™ combined with Volite™ injections, CO2 laser resurfacing, and chemical peels. Significant improvement in skin texture, reduction of shadowing effect, and restoration of tissue elasticity were observed, resulting in high patient satisfaction. While HArmonyCa™ presents a promising solution for post-acne scarring, further research is needed to comprehensively evaluate its efficacy and suitability. This study contributes to the growing body of literature exploring the potential applications of hybrid fillers, particularly in addressing post-acne scarring.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 .

Permanent Facial Fillers: Addressing Complications and Advancing Solutions.

Soft tissue augmentation with fillers has witnessed a surge in popularity for rejuvenating facial features, offering solutions for wrinkles, volume loss, and contour irregularities. Non-biodegradable fillers like silicone, polyacrylamide hydrogel, and polymethylmethacrylate (PMMA) have been introduced, promising enduring results. However, reports on silicone filler usage have highlighted a spectrum of adverse events, ranging from erythema and edema to more severe complications like infection, vascular occlusion, and inflammatory nodules. The adverse effects of non-resorbable facial fillers can manifest even years post-procedure, resulting in significant discomfort and dissatisfaction for patients. Consequently, the literature is focusing on potential treatments for these outcomes, including systemic antibiotics, corticosteroid injections, surgical drainage, and excision. Despite these options, consensus on optimal treatment modalities remains elusive. Surgical excision is the definitive method for removing permanent fillers, albeit with the risk of post-removal irregularities. Fat grafting has emerged as a viable solution, allowing for the correction of volume deficits and asymmetries. Utilizing the patient's own tissue, fat grafting reduces the risk of adverse reactions and rejection. It offers targeted volume enhancement, restoring facial symmetry and proportion, and promoting tissue healing and regeneration through the presence of stem cells. After permanent filler removal, further filler injections are not advisable. In such cases, fat grafting offers several advantages, including reduced risk and targeted enhancement. Facial fat grafting effectively restores facial volume and symmetry, with stem cells aiding in tissue regeneration for long-term skin health. In essence, while the demand for aesthetic procedures continues to rise, there's a shift toward absorbable fillers like hyaluronic acid-based ones, favored for their safer outcomes. Evidence-based practices and ongoing research are crucial for ensuring the safety and efficacy of aesthetic procedures, ultimately enhancing patient outcomes and confidence.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 .

Eating Disorders and Aesthetic Plastic Surgery: A Systematic Review of the Literature.

INTRODUCTION: Eating disorders (ED) and plastic surgery are two areas of healthcare that have gained significant attention in recent years. The goal of this review is to provide an overview of the existing literature concerning the interplay between ED and aesthetic surgery, identifying existing questionnaires and providing suggestions for the future research on the psychological aspects of these group of patients. METHODS: We conducted a systematic review on PubMed. We included studies that examined the type of ED, surgical procedure, outcome measures used, patients' motivations as well as physical and psychological outcomes of individuals with ED seeking or undergoing aesthetic surgery. Three independent reviewers examined each potential study. RESULTS: Eleven studies met the inclusion criteria. These studies involved 5510 patients, addressing a spectrum of ED such as Anorexia nervosa, Bulimia nervosa, and Binge eating. The primary focus was on body contouring procedures like liposuction, breast surgery, and abdominoplasty. The assessment tools employed in these studies for evaluating ED included the Eating Attitude Test (EAT), Eating Disorder Inventory (EDI), Eating Disturbance Scale (EDS), Sociocultural Attitudes Toward Appearance Questionnaire-Eating Disorder (SATAQ-ED), and the Eating Disorder Examination Questionnaire. CONCLUSIONS: There is a complex interplay between ED and aesthetic surgery, underscoring the significance of comprehending and dealing with the psychological and sociocultural factors that impact patients in this context. The optimal management for these patients and the most effective tool for plastic surgeons to assess their psychological condition remain unclear. It is, therefore, crucial to standardize the evaluation and approach to this patient subgroup, closely aligned with psychological support, to achieve the best outcomes. 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 .

Artificial Intelligence in Plastic Surgery: Analysis of Applications, Perspectives, and Psychological Impact.

Artificial intelligence (AI) is emerging as a promising tool in the field of plastic surgery, offering a wide array of applications that enhance surgical outcomes, patient satisfaction, and overall efficiency. This paper explores the utilization of AI, highlighting its various advantages and potential drawbacks. AI-driven technologies such as computer vision, machine learning algorithms, and robotic assistance facilitate preoperative planning, intraoperative guidance, and postoperative monitoring. These advancements enable precise anatomical measurements, personalized treatment plans, and real-time feedback during surgery, leading to improved accuracy and safety. Furthermore, AI-powered image analysis aids in facial recognition, skin texture assessment, and simulation of surgical outcomes, enabling enhanced patient consultations and predictive modeling. However, the integration of AI in plastic surgery also presents challenges, including ethical concerns, data privacy, algorithm biases, and the need for comprehensive training among healthcare professionals. Additionally, the reliance on AI systems may potentially lead to over-reliance or reduced surgeon autonomy, necessitating careful validation and continuous refinement of these technologies. Despite these challenges, the synergistic collaboration between AI and plastic surgery holds great promise in advancing clinical practice, fostering innovation, and ultimately benefiting patients through optimized esthetic and reconstructive 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 https://www.springer.com/00266 .

Three Key Submuscular Points for Nonsurgical Rejuvenation of the Midface in Caucasian Patients: A Methodological Approach Using Injectable Hyaluronic Acid Fillers.

INTRODUCTION: Since aesthetic medical treatments providing natural results are becoming increasingly popular, we developed an innovative hyaluronic acid infiltration technique for midface rejuvenation. METHODS: In this prospective study, only patients with a negative or neutral lower eyelid vector were included. Treatment consisted in injecting three hyaluronic acid boluses at the cutaneous projections of the levator labii superioris, zygomatic major and minor muscles insertions. All patients were administered before treatment the FACE-Q questionnaire, whereas after treatment, they were administered the FACE-Q questionnaire and the Global Aesthetic Improvement Scale (GAIS). All treatments were documented with standardized photographs. A plastic surgeon from another Institution reviewed the photos and scored the treatments according to the GAIS scale. RESULTS: We included 567 patients (101 males and 466 females) who met the inclusion criteria. The mean age was 41 years, and mean follow-up time was four months. The FACE-Q scores after treatment were significantly higher (p < 0.001) in every domain investigated. The GAIS scores demonstrated significant improvement posttreatment in 89.8% of patients. An average of 1.5 ml of hyaluronic acid (VYC-20) was used for each zygomatic region. No major complications were reported; only 27 patients reported bruising, which resolved spontaneously. In all patients, there was an inversion of the lower eyelid vector, which had transitioned from neutral or negative to positive. CONCLUSION: Lifting the insertions of three selected muscles with hyaluronic acid allows a midface upward repositioning. This technique provides a reproducible and safe approach for midface rejuvenation through tissue repositioning rather than augmenting facial volume. 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 .

Somatosensory and psychosocial profile of migraine patients: A cross-sectional study.

BACKGROUND: Migraine is a chronic neurological disorder that involves the brain, characterized by a series of abnormal neuronal networks interacting at different levels of the central and peripheral nervous system. Furthermore, it is known that psychosocial features contribute to the exacerbation and chronicity of symptoms. OBJECTIVE: To compare the somatosensory and psychosocial profiles of migraine patients with a control group. METHODS: We conducted a cross-sectional study comparing the somatosensory and psychosocial profiles of patients with migraine and healthy volunteers. A total of 52 women were included. For the somatosensory profile, Mechanical Detection Threshold (MDT), Pressure Pain Threshold (PPT), Temporal Summation (TS), and Conditioned Pain Modulation (CPM) in the trigeminal and extra-trigeminal areas were evaluated. Psychosocial profiles were assessed using questionnaires, the Central Sensitization Inventory, the Generalized Anxiety Disorders, the Pain Catastrophizing Scale, and the Tampa Scale of Kinesiophobia. Mann-Whitney U test was used to compare differences in the profiles between groups. The significance level was set at 5%. RESULTS: Migraine patients showed a loss of somatosensory function in the trigeminal area for MDT (p = 0.019, r = 0.34 and p = 0.011, r = 0.37 for the ophthalmic nerve and masseter muscle respectively), lower PPT in trigeminal and extra-trigeminal areas (p < 0.001, r=>0.60) and less efficient CPM (p < 0.001, r=>0.60). No statistically significant differences were found in the TS (p=>0.05). Statistically significant differences were found in all psychosocial variables (p = <0.001 r=>0.60). CONCLUSION: Migraine patients showed loss of somatosensory function, lower pressure pain threshold, and an inhibitory pro-nociceptive profile with high scores on central sensitization and fear of movement compared to the control group.

Do Small Scars Lead to Better Results? Analysis of Long-term Outcomes and Satisfaction of Patients Undergoing Anchor-line Abdominoplasty Following Massive Weight Loss.

INTRODUCTION: Do smaller scars lead to higher patient satisfaction? The aim of this study is to analyze long-term satisfaction of patients who underwent abdominoplasty after massive weight loss. METHODS: Patients inclusion criteria: no previous abdominal remodeling procedures, previous bariatric surgery followed by a weight loss of at least 30 kg, weight stability for at least one year, good understanding of the Italian language and standardized pre- and postoperative photographs. We divided the population in 2 groups based on the surgical procedure: group 1, conventional abdominoplasty, and group 2, anchor-line abdominoplasty. All patients presented scars in the epigastric and mesogastric region resulting from previous laparoscopic or laparotomic bariatric surgery and/or other laparoscopic or laparotomic procedures. At least 2 years after surgery, we administered the Italian version of the post-operative BODY-Q module and the SCAR-Q questionnaire. RESULTS: We enrolled 20 males and 69 females aged between 25 and 55 years, with a mean follow-up of 2 years. Analyzing the questionnaires, it resulted that patients undergoing anchor-line abdominoplasty were significantly more satisfied in the body perception of the result (p = 0.035) and in the satisfaction with abdomen domain (p = 0.0015) compared to the conventional abdominoplasty group. Scars assessment with the SCAR-Q did not show any significant differences between the groups. CONCLUSION: Despite its long scars, the anchor-line pattern shows an overall higher satisfaction, due to the possibility of reducing the abdomen both cranio-caudally and circumferentially. These findings might be an important guide when approaching abdominoplasty in post-bariatric patients, debunking the myth "shorter is better". 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 .

Reconstruction of Scroll and Pitanguy's Ligaments in Open Rhinoplasty: A Controlled Randomized Study.

INTRODUCTION: In the preservation rhinoplasty era, ligament management represents a hot topic. The aim of this study is to analyze the role of ligaments as indispensable elements of support of the nasal tip to have an adequate, safe, and predictable aesthetic and functional result. MATERIAL AND METHODS: Patients meeting the following criteria were included in the study: primary rhinoplasty, minimum 2-year follow-up, proficiency in Italian language, signed consent, and standardized pre- and postoperative photographic documentation. The study was performed with a double-blinded randomized design; both the patients and two of the authors measuring outcomes were blinded to the treatment methods. All patients were asked to answer the FACE-Q satisfaction with the nose postoperative scale. Two plastic surgeons reviewed all postoperative photographs, rating the outcome on a 1-5 VAS scale. RESULTS: One hundred and twelve patients were enrolled, 47 males and 65 females, aged between 20 and 50 years. Patients were randomly divided in three groups: group 1, ligament reconstruction and grafts; group 2, only grafts (shield, single and double onlay, umbrella); and group 3, only ligament reconstruction with columellar strut. All rhinoplasties were performed with an open approach. Both the FACE-Q and VAS scores were in groups 1 and 2, which were also the ones undergoing fewer secondary procedures compared to group 3. CONCLUSIONS: The best surgical option appears to be the combination of ligament repair and grafts. It reduces dead space and enables a better redraping of soft tissues, obtaining a better control of tip projection, position, and rotation. 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 .

Before-and-After Photography on Social Media: The Pursuit of Impossible Beauty.

Plastic surgeons and aesthetic medicine professionals often share "before" and "after" clinical cases on social media, but this practice can lead to unintended consequences, such as dysmorphophobia and unrealistic expectations. These before-and-after images, frequently posted on social media, tend to promote unreachable, sometimes retouched, beauty standards, downplaying the complexities of the surgical process, omitting details about postoperative care, recovery, and potential complications. This can create the illusion that perfection is easily attainable through surgery, fostering unrealistic ideals and negatively impacting viewers' self-image and self-worth. Dysmorphophobia, characterized by an excessive preoccupation with perceived flaws in one's appearance, is closely linked to social media usage, especially among Caucasian women. Plastic surgeons hold the responsibility to provide honest insights into cosmetic procedures on social media, emphasizing the healing process, potential risks, and limitations. Celebrating diversity in appearance and sharing genuine patient stories can combat idealized beauty standards and reduce the stigma surrounding cosmetic surgery. They must prioritize honesty, provide comprehensive context for their images, and promote a broader view of beauty that includes mental health and individual diversity. Their ethical responsibility extends beyond the operating room and should guide all aspects of their professional 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 .

Minimally Invasive Facial Rejuvenation with the Hybrid Filler HArmonyCa™.

There is an increasing request of minimally invasive procedures for facial rejuvenation, allowing a fast recovery while still offering satisfying outcomes. Hyaluronic Acid (HA) fillers are very useful to restore facial hollows and have a mild lifting effect, but are not effective in increasing dermal thickness and improving skin texture, which are amongst the main features of the aging face.Evidences in literature support the winning combination between HA and calcium hydroxyapatite (CaHa) in facial rejuvenation thanks to the hydrating and volumizing effect of HA and the neocollagenesis and lifting properties following CaHa injection Fakih-Gomez (Facial Plast Surg Clin North Am 13(3):371-80, 2005), Amiri (Front Med 10:1195934, 2023).HArmonyCa™ (Allergan Aesthetics an AbbVie Company) is a hybrid filler that combines HA (20 mg/mL) and CaHa 55.7% (microspheres 25-45 µm) with 0.3% lidocaine in a 1.25 ml syringe.Studies performed specifically with HArmonyCa™, showed very encouraging data on both safety and efficacy of this treatment Urdiales-Gálvez (J Cosmet Dermatol 22(8):2186-2197, 2023). In fact, besides its volumizing properties, HArmonyCa™ showed both a lifting and tightening effect on the skin visible throughout the 6-month follow-up period Urdiales-Gálvez (J Cosmet Dermatol 22(8):2186-2197, 2023).We hereby present the clinical case of a 56-year-old woman presenting moderate skin laxity, reduced skin thickness and turgor and negative eyelid vector with hollowness in the malar region bilaterally. She was treated with injection of 2.5 ml of HArmonyCa™ (Allergan Aesthetics an AbbVie Company) and 1 ml of Voluma™(Allergan Aesthetics an AbbVie Company) per side. The malar region regained its anatomical fullness, skin elasticity and turgor of both cheeks improved significantly and the patient was very satisfied with her outcome.The literature concerning patient satisfaction after treatments with HA and CaHA hybrid fillers is very poor as reported by Rivers (in: Rivers (ed) Forty-fourth Congress of the Italian Society of Aesthetic Medicine, Rome, Italy, 2023). This is one of the first contributes to the existing literature, but large and systematic studies are necessary in order to better assess a very important aspect of this very promising treatment for non-invasive facial rejuvenation.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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Could Social Network Influence the Body Perception and Develop Dysmorphophobia?

The concept of body beauty has evolved significantly over the years, reflecting cultural shifts, societal norms, and changing ideals. Unlike the gradual evolution of body perception seen in the past eras, the advent of social media has accelerated the pace of change dramatically. The virtual realm, while offering platforms for self-expression, has also bred a culture of comparison, unrealistic standards, and heightened self-consciousness. Scientific literature agrees on the increased prevalence of body dysmorphic disorder (BDD), particularly in Caucasian women, finding a strong association between this and the use of social media. COVID-19 made this scenario even worse, particularly in young people, increasing the request for cosmetic treatments aiming to obtain unachievable results. Being aware of what social media are, it is crucial for our mental well-being to engage in introspection and self-awareness. In a world of digital facades, genuine self-reflection becomes a powerful tool for preserving our mental equilibrium and fostering a positive self-perception.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 .

Does a High-Quality Scar Overcome its Length? Italian Validation of the SCAR-Q Questionnaire.

Scars play a pivotal role in plastic surgery: as surgeons, we continuously seek the best approach to perform a surgical procedure through a minimal access, possibly hidden in natural creases of the body, in order to create a scar less noticeable as possible. This behavior is explained by the fact that commonly, both patients and surgeons believe that the smaller the scar, the better the result. However, this is not always true and the quality of the scar is as important as its length (Barone in Aesthetic Plast Surg, 2022. https://doi.org/10.1007/s00266-022-03081-5 ). A small but widened scar can be less tolerated than a longer linear scar. Scar appearance is an important aspect influencing patient satisfaction after a surgical procedure that is often unaddressed (Barone in Aesthetic Plast Surg 42(6):1506-1518, 2018). The SCAR-Q represents the first validated comprehensive patient-reported outcome measure (PROM) designed for children and adults to assess scars (Klassen in Plast Reconstr Surg Glob Open 6(4):e1672, 2018). It is composed of three domains: scar appearance, scar symptoms, and psychosocial impact. The scar appearance scale investigates how bothered the patient is about his/her scar and consists of 12 items asking about length, width, color, shape, and size of the scar, as well as how it looks up close and from different angles. The symptoms scale investigates how bothered are patients by how their scar has felt in the past week and it consists of 12 items asking whether the scar is painful, numb, itchy, hard or firm, tight, and sensitive when touched, as well as whether the scar makes it hard to move parts of the face or body or do some activities. The psychosocial impact scale investigates how the patient feels about his/her scar and involves 5 items asking about feeling upset, embarrassed, or unhappy about the scar, as well as how they feel when someone sees their scar. The three scales are independent and can also be administered separately. Scores for SCAR-Q scales range from 0 to 100, with higher scores representing a better outcome. Following a rigorous five-step process in cooperation with the developers, our team translated and validated the SCAR-Q questionnaire in Italian in order to allow Italian surgeons to use it in their clinical practice overcoming the language barrier that was often encountered with patients who are not fluent in English. We believe this is a precious tool for plastic surgeon to assess patient satisfaction, any issues related specifically to the scar and analyze the outcomes of the procedure performed.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 https://www.springer.com/00266 .

The Effect of Adjuvant Radiotherapy on One- and Two-Stage Prosthetic Breast Reconstruction and on Autologous Reconstruction: A Multicenter Italian Study among 18 Senonetwork Breast Centres.

Purpose: In modern breast cancer treatment, a growing role has been observed for breast reconstruction together with an increase in clinical indications for postmastectomy radiotherapy (PMRT). Choosing the optimum type of reconstructive technique is a clinical challenge. We therefore conducted a national multicenter study to analyze the impact of PMRT on breast reconstruction. Methods: We conducted a retrospective case-control multicenter study on women undergoing breast reconstruction. Data were collected from 18 Italian Breast Centres and stored in a cumulative database which included the following: autologous reconstruction, direct-to-implant (DTI), and tissue expander/immediate (TE/I). For all patients, we described complications and surgical endpoints to complications such as reconstruction failure, explant, change in type of reconstruction, and reintervention. Results: From 2001 to April 2020, 3116 patients were evaluated. The risk for any complication was significantly increased in patients receiving PMRT (aOR, 1.73; 95% CI, 1.33-2.24; p < 0.001). PMRT was associated with a significant increase in the risk of capsular contracture in the DTI and TE/I groups (aOR, 2.24; 95% CI, 1.57-3.20; p < 0.001). Comparing type of procedures, the risk of failure (aOR, 1.82; 95% CI, 1.06-3.12, p=0.030), explant (aOR, 3.34; 95% CI, 3.85-7.83, p < 0.001), and severe complications (aOR, 2.54; 95% CI, 1.88-3.43, p < 0.001) were significantly higher in the group undergoing DTI reconstruction as compared to TE/I reconstruction. Conclusion: Our study confirms that autologous reconstruction is the procedure least impacted by PMRT, while DTI appears to be the most impacted by PMRT, when compared with TE/I which shows a lower rate of explant and reconstruction failure. The trial is registered with NCT04783818, and the date of registration is 1 March, 2021, retrospectively registered.

Prepectoral Versus Subpectoral Direct-to-Implant Breast Reconstruction: Evaluation of Patient's Quality of Life and Satisfaction with BREAST-Q.

BACKGROUND: Over the years, plastic surgery has acquired a central role in the integrated treatment of breast cancer. Direct-to-implant (DTI) reconstruction using the prepectoral approach has emerged as an alternative to reconstruction using the subpectoral technique to overcome the complications arising from this type of surgery resulting as a consequence of muscle elevation. The satisfaction and quality of life of patients undergoing DTI breast reconstruction were evaluated using the BREAST-Q questionnaire, comparing the prepectoral and the subpectoral technique. METHODS: A single-center cross-sectional study on patients who underwent mastectomy and DTI breast reconstruction at our institution between 2013 and 2021 was conducted. Eighty-one patients were included and mainly divided into two groups based on the surgical procedure: 52 patients undergoing a subpectoral breast reconstruction approach and 29 patients receiving a prepectoral breast reconstruction. In order to assess the quality of life, the postoperative BREAST-Q module was administered electronically to the enrolled patients. RESULTS: Higher scores in BREAST-Q domains were recorded from patients who underwent mastectomy and breast reconstruction with prepectoral technique: psychosocial well-being (P<0.0085), sexual well-being (P<0.0120), physical well-being: lymphoedema (P<0.0001) and satisfaction with information received (P<0.0045). There were further statistically significant differences between the two groups with regard to postoperative complications (p<0.0465) and the need for reoperation (p<0.0275). CONCLUSIONS: Patients who underwent DTI breast reconstruction with prepectoral technique were more satisfied in terms of psychosocial, sexual and also physical well-being. These patients also had statistically lower complications and reoperations compared to patients who received breast reconstruction with the subpectoral technique. LEVEL OF EVIDENCE IV: This journal requires that authors 38 assign a level of evidence to each article. For a full 39 description of these Evidence-Based Medicine ratings, 40 please refer to the Table of Contents or the online 41 Instructions to Authors www.springer.com/00266 .

Effects of an exercise program plus manual therapy in a patient with failed neck surgery syndrome: A case report.

BACKGROUND: Patients who have undergone cervical surgery may present pain and dysfunction in the upper limb, which is often referred to as failed neck surgery syndrome. Little is known about the effects of an exercise program plus manual therapy in the treatment of prolonged neuropathic pain of the upper quadrant in a patient with failed neck surgery. CASE DESCRIPTION: A 66-year-old woman consulted for neuropathic pain and dysfunction during grasping activities, as a result of failed neck surgery after 12 months. Clinical, functional, and electromyographic measurements were recorded at baseline and after treatment. The patient underwent a treatment for six weeks based on manual therapy for the upper limb and cervical spine and an exercise program for the scapular muscles, rotator cuff and wrist extensor muscles. OUTCOMES: Positive clinically significant changes were observed in the Neuropathic Pain Questionnaire (DN4) (baseline = 7 points; post-treatment = 4 points), Neck Disability Index (NDI) (baseline = 36; post-treatment = 18 points), QuickDASH (baseline = 78; post- treatment = 32 points), Upper Limb Neurodynamic Test 1 (ULNT-1) (baseline = 75°; post- treatment = 42°) and grip strength (GS) (baseline = 23 kgf; post-treatment = to 32 kgf). Improvements in the surface electromyographic (sEMG) activity of the upper trapezius (UT), infraspinatus (IS) and radial wrist extensors (RWE) muscles also seemed to occur after treatment. CONCLUSION: Treatment helped relieve neuropathic pain, decrease neck disability, and improve general upper limb function.

Direct-to-Implant Breast Reconstruction After Unilateral and Bilateral Mastectomy: Cross-Sectional Study of Patient Satisfaction and Quality of Life with BREAST-Q.

INTRODUCTION: Immediate single stage breast reconstruction is a challenging procedure with the goal of improving the quality of life of patients with breast cancer. The aim of this study is to evaluate using the BREAST-Q patient satisfaction, body perception and quality of life after direct-to-implant breast reconstruction comparing unilateral and bilateral reconstructions. METHODS: In this study we enrolled 56 women who underwent mastectomy and immediate single-stage direct-to-implant (DTI) breast reconstruction at Campus Bio-Medico University of Rome between 2013 and 2020. One year after surgery they were administered electronically the BREAST-Q post-operative module. RESULTS: Our two cohorts of patients consisted in 34 women who received unilateral nipple-sparing mastectomy and DTI breast reconstruction and 22 women who underwent bilateral nipple-sparing mastectomy and DTI breast reconstruction. Twenty-four of the 34 patients belonging to the unilateral group responded to the questionnaire (70.5%), while in the bilateral group responders were 16 out of 22 (72.7%). The BREAST-Q scores were compared between the two groups: patients undergoing bilateral mastectomy and breast reconstruction showed higher scores in every BREAST-Q domain compared to patients undergoing unilateral mastectomy and breast reconstruction with a statistically significant difference in the Satisfaction with breast (P = 0.01), Sexual well-being (P = 0.03), and Satisfaction with implants (P = 0.01) domains. CONCLUSIONS: Patients undergoing bilateral DTI breast reconstruction have a favorable postoperative surgical cosmetic outcome with a better patient's body image perception and a higher post-operative level of satisfaction compared to unilateral DTI reconstruction after nipple-sparing mastectomy. 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.

Reply to: Invited Discussion on: Quality of Life and Outcome After Preservation Rhinoplasty Using the Rhinoplasty Outcome Evaluation Questionnaire.

Rhinoplasty is certainly the most creative and exciting intervention in the field of plastic surgery due to the possibility of associating the technical procedures with the inventiveness and artistic sense of the surgeon. In addition, the position of the nose in the center of the face and the impact of its changes in social relationships have made this intervention the protagonist of all plastic surgery from the very beginning. Most of the publications up to the end of the 90s concerned the closed approach to rhinoplasty. And then there was a lot of discussion about the open approach and the comparison with the closed one. More recently this division into two strands has been lost due to the personalization of each surgeon. Very recently, a third philosophical approach to rhinoplasty has been added, namely "preservation rhinoplasty" which is a more conservative and much less aggressive approach. This trend translates into two techniques, the push down and the let down. The possibility of obtaining a totally smooth nasal contour after the correction of a hump, leaving this area intact, was emphasized by Saban and Ciakir and has garnered the enthusiasm of many surgeons around the world. Apart from the ongoing discussions on the indications for the push down technique and its complications, preservation rhinoplasty has the great merit of having paved the way for a less aggressive rhinoplasty and with the use of a very fine and precise dissection. The idea of my rhinoplasty, the result of daily clinical practice, is always that of a balanced and personalized rhinoplasty in which the imperfections of the nose and functional problems are corrected, but which has as its ultimate goal the maintenance of the patient's characteristics.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 Table of Contents or online Instructions to Authors www.springer.com/00266 .