Implementation of a Machine Learning Approach Evaluating Risk Factors for Complications after Single-Stage Augmentation Mastopexy.

BACKGROUND: Single-stage mastopexy augmentation is a much-debated intervention due to its complexity and the associated relatively high complication rates. This study aimed to reevaluate the risk factors for these complications using a novel approach based on artificial intelligence and to demonstrate its possible limitations. PATIENTS AND METHODS: Complete datasets of patients who underwent single-staged augmentation mastopexy during 2014-2023 at one institution by a single surgeon were collected retrospectively. These were subsequently processed and analyzed by CART, RF and XGBoost algorithms. RESULTS: A total of 342 patients were included in the study, of which 43 (12.57%) reported surgery-associated complications, whereby capsular contracture (n = 19) was the most common. BMI represented the most important variable for the development of complications (FIS = 0.44 in CART). 2.9% of the patients expressed the desire for implant change in the course, with absence of any complications. A statistically significant correlation between smoking and the desire for implant change (p < 0.001) was revealed. CONCLUSION: The importance of implementing artificial intelligence into clinical research could be underpinned by this study, as risk variables can be reclassified based on factors previously considered less or even irrelevant. Thereby we encountered limitations using ML approaches. Further studies will be needed to investigate the association between smoking, BMI and the current implant size with the desire for implant change without any complications. Moreover, we could show that the procedure can be performed safely without high risk of developing major 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.

Four-Layer Wound Closure Technique with Barbed Sutures for Inframammary Fold in Mastopexy Augmentation.

BACKGROUND: The inframammary fold (IMF) is an important landmark in breast aesthetic surgery. In augmentation mastopexy procedures, secure and accurate placement of the IMF is essential to aesthetic outcomes and to allow the new IMF to heal in the correct position without displacement. The authors present a simple and efficient four-layer wound closure technique using barbed sutures for closure of the repositioned IMF in augmentation mastopexy procedures. This method was previously described by the first author for reset of the IMF in breast augmentation surgery and has been adapted to the longer IMF incision in augmentation mastopexy procedures. METHODS: A retrospective review was undertaken of 335 patients who underwent bilateral breast augmentation mastopexy procedures with a Wise pattern technique at a single unit. The newly reset IMF was closed using barbed sutures and a four-layer closure technique. RESULTS: There were no cases of complications related to wound healing or wound dehiscence. One patient required explantation for an infected implant. CONCLUSION: The four-layer wound closure technique with barbed sutures provides a quick and efficient method for accurate closure of the newly reset IMF, with positive outcomes related to wound healing. Secure and accurate placement of the inframammary fold is crucial in augmentation mastopexy procedures. The use of a four-layer wound closure technique with barbed sutures provides an efficient method for accurate closure of the newly reset inframammary fold. This method was previously described by the first author for reset of the IMF in breast augmentation surgery and has been adapted to the longer IMF incision in augmentation mastopexy procedures. 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 .

Tailor-Made Mastopexy Plus Implant, A Safe Journey Toward Breast Reshaping and Augmentation.

BACKGROUND: Augmentation/mastopexy represents one of the most complex procedures in the setting of cosmetic surgery, and there is still an ongoing debate about the most suitable approach to undertake to avoid major complications and deliver the desired result. The present study aims to offer a further contribute to the topic by presenting our personal experience with an implant-guided tailor-made mastopexy technique to manage moderate breast ptosis and hypotrophy. METHODS: A retrospective analysis of our database was carried out, and a total of 194 women who underwent a tailor-made resection pattern mastopexy plus implant from November 2016 to December 2021 were enrolled. All patients included in the study presented breast hypoplasia and ptosis classified as Regnault grade II. At the first-year follow-up visit, patients received an anonymous written questionnaire that addressed their self-perception of cosmetic results and overall satisfaction. RESULTS: The technique presented in the study showed a favorable safety profile with a total complication rate accounting for an 8.2% and an overall reoperation rate as low as 4.6%. Major concerns including wound dehiscence, implant exposure, and nipple necrosis are not reported. Patients' self-reported outcomes revealed high satisfaction rates and stable results in the long-term follow-up. CONCLUSIONS: The described approach ensures proper reshaping together with the desired increased breast volume minimizing the chance of implant exposure due to wound dehiscence or any sort of tissue necrosis from devascularized skin edges. The surgical procedure described herein is safe and reliable. 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 .

Aesthetic Surgery Fellowship at Akademikliniken Stockholm: Survey among Graduates.

BACKGROUND: Aesthetic Surgery is one of the most competitive fields of plastic surgery. Although there is a certain demand for highly educated surgeons in this field, training in cosmetic procedures remains challenging. Akademikliniken Stockholm offers a highly appreciated fellowship program for aesthetic plastic surgeons and trained more than 200 surgeons from all over the world. OBJECTIVES: The aim of the present work was to provide insights into this fellowship program, analyze what graduates have learned and if this had implications on their further professional orientation. METHODS: Participants of the Akademikliniken fellowship program, who graduated between 10/2008 and 10/2018 (n = 66) were invited to take part in an online survey which included 30 questions about general demographics and about experience before, during and after the fellowship. RESULTS: Thirty-four graduates participated in the survey (52%). Twenty-four graduates (71%) had been already specialists in plastic surgery before commencing the fellowship program. Mean length of fellowship was 7 months (range 3-24months). Numbers of aesthetic procedures performed by the applicants significantly increased after the fellowship, and moreover, the scope of daily clinical practice shifted toward aesthetics in almost all applicants. CONCLUSIONS: A well-designed dedicated aesthetic surgery fellowship can improve the lack of training, aesthetic surgeons have during their residency. Graduates of our fellowship program reported great improvements in confidence in performing aesthetic procedures and a benefit for their future career. 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 .

Comparison of POLYTECH MESMO and Motiva Ergonomix Breast Implants With Focus on Displacement Issues: A Single Surgeon's Experience with 329 Patients.

BACKGROUND: Nanotextured breast implants (classified as smooth implants by the latest ISO 14607:2018) have been described as possibly reducing major textured implant-related complications such as capsular contracture and breast implant-associated anaplastic large cell lymphoma. On the other hand, microtextured breast implants benefit from an optimal safety profile based on a much larger body of literature. OBJECTIVES: The aim of this study was to directly compare the incidence of complications between Motiva Ergonomix (Establishment Labs Holdings, Inc., Alajuela, Costa Rica) and POLYTECH MESMO (POLYTECH Health & Aesthetics GmbH, Dieburg, Germany) breast implants, especially regarding the displacement issues that might arise after breast augmentation. METHODS: Consecutive patients who previously underwent surgery by the same physician for placement of Motiva Ergonomix and POLYTECH MESMO implants were included in this study. They were divided into 2 groups according to the type of implant. The onset of complications was assessed through survival analysis. RESULTS: Data were collected from 329 patients, 185 (56.2%) with POLYTECH MESMO and 144 (43.8%) with Motiva Ergonomix implants. The median follow-up was 8 months for both groups. Of the 42 women (12.8%) who experienced at least one complication, 26 belonged to the Motiva Ergonomix subgroup (P = .013). The most represented complications during this period resulted from displacement issues, with a clear prevalence of bottoming out in the Motiva Ergonomix cohort: 15 cases vs 0 cases in the POLYTECH MESMO cohort (P < .001). For 7 patients, a reoperation was required, more frequently for patients with Motiva Ergonomix implants (4.2% vs 0.5%; P = .046). CONCLUSIONS: POLYTECH MESMO devices provided a more favorable outcome. Motiva Ergonomix devices revealed a concerning incidence of displacement issues during the first postsurgery years, with no advantage over other major complications.

Devil's Advocate: Evidence-Based Recommendation for "One Breast-One Insertion Funnel" Policy.

BACKGROUND: Rates of capsular contracture have reduced significantly since the use of insertion funnels to place breast implants became routine. However, due to financial constraints, the same funnel is usually used for implantation of both sides. OBJECTIVES: The aim of this study was to determine whether the risk of capsular contracture is higher for the second breast when the same insertion funnel is used for both breasts. METHODS: The authors collected a sample of the insertion funnel tip immediately after removing the funnel from its sterile packaging and another tip sample after the funnel had been used to insert the first implant. These samples were sent for microbiological culture evaluations. Capsular contracture rates in the first implanted breast vs the second implanted breast were then retrospectively analyzed. RESULTS: All samples taken from the funnel before the first implantation showed no bacterial growth. All 10 samples taken from the funnel after the first implantation showed organism growth (8 were positive for Staphylococcus epidermidis and 2 for Cutibacterium acnes). Retrospective analysis of the results revealed that the overall capsular contracture rate had reduced after the authors began to use insertion funnels. However, this complication was still more common on the second implanted breast. CONCLUSIONS: Surgeons should consider the use of separate insertion funnels for each breast. This might help to slightly reduce the incidence of capsular contracture.See the abstract translated into Hindi, Portuguese, Korean, German, Italian, Arabic, and Chinese (Simplified and Traditional) online here: https://doi.org/10.1093/asj/sjad288.

Breast Augmentation in the Digital Era: The Power of Social Media in a Surgeon's New Practice.

BACKGROUND: Opening a new practice is always challenging, and one of the main problems is how to engage patients. Most of them use social media to gather information about surgery and surgeons. OBJECTIVES: The aim was to evaluate social media's impact on a new practice, compared with a long-standing practice run by the same surgeon. Furthermore, changes in patients' and surgeons' perspectives regarding social media in recent years were studied. METHODS: In the 2 aforementioned practices, a questionnaire was administered to patients seen in consultation for primary breast augmentation regarding their interaction with social media before booking the visit. Another questionnaire was administered to 152 surgeons to assess their perceptions of social media. RESULTS: Two hundred forty-seven patients in Italy and 129 in Sweden answered the questionnaire. In the first year of the Italian practice, 97.2% of patients booked a consultation with the surgeon thanks to social media; after 3 years, the percentage dropped to 68.02%. Comparing Italian and Swedish patients, 68.02% vs 28.68%, respectively, booked a consultation with the surgeon specifically thanks to social media, 91.09% vs 79.84% did research about the surgeon before booking a consultation, and 36.03% vs 10.08% contacted the surgeon before booking an appointment. One hundred fifty-two surgeons from 24 different countries answered the questionnaire, and 77.9% opined that social media positively affected their practice. CONCLUSIONS: Social media is fundamental in patient-surgeon interaction and can strongly influence patient inflow, especially at the beginning of a new practice. Surgeons should be capable of using these tools to engage patients, bearing in mind the important role of these media in patients' education.

Silicone Migration From Breast Implants: A Case of Ocular Siliconoma and Literature Review.

BACKGROUND: Breast augmentation with implants is one of the most popular cosmetic surgery operations performed worldwide. Complications of breast implants are well recognized, and include capsular contracture, implant rupture, and infrequently distant migration of silicone, resulting in siliconoma. Distant migration of silicone can present many years after implantation with a wide variety of signs and symptoms. OBJECTIVES: The aim of this study was to describe the authors' experience of orbital silicone migration and to review the literature describing documented cases of distant silicon migration from breast implants, both ocular and nonocular. METHODS: In January 2022, a case of breast implant augmentation presented with silicone migration into the right orbit. This rare case was monitored and diagnosed with ocular muscle palsy and diplopia. Here, the authors present the patient's presenting complaint, symptomatology, working investigations, and outcomes. A comprehensive report of all available cases of distant silicone migration is presented along with their associated complications and more specifically ocular silicone migration. RESULTS: Systemic migration of silicone from breast implants to the orbital region is extremely rare: a total of 4 previous cases of ocular silicone migration from breast implants have been described previously; the authors describe the fifth case herein. CONCLUSIONS: Silicone implant rupture can present with a wide variety of clinical symptoms that may mimic different clinical pathologies. In every patient with a history of breast augmentation with silicone implants, the possibility of silicone migration should be always taken into consideration during the differential diagnosis process.

A Machine Learning Approach to Identify Previously Unconsidered Causes for Complications in Aesthetic Breast Augmentation.

INTRODUCTION: Primary breast augmentation is one of the most commonly requested aesthetic procedures. Considering the large number of procedures performed in connection with a high demand, it is crucial to prevent complications. For this reason, finding and avoiding possible sources of complications is decisive. METHODS: Between January 2010 and December 2021, 1625 female patients underwent an aesthetic breast augmentation performed by a single surgeon. The data collected were analyzed through a machine learning technique for binary recursive partitioning. This made it possible to detect unknown sources of a complication and determine a vertex for the various features. RESULTS: When analyzing the data, for most features a high importance score with low entropy was achieved, concluding a high significance. In addition, reproducibility was demonstrated through detailed testing and training accuracies in the algorithm. With this procedure, in addition to known risks such as a high BMI and round implant shape, a larger than A preoperative bra-cup size (OR: 2.7) and a taller body could also be identified as most significant influencing factors for complications. DISCUSSION: Preoperative breast size plays an exceptionally important role in the occurrence of complications and should be a factor held in a surgeon's considerations. In addition, this study shows ways to transfer artificial intelligence into plastic surgery to increase medical quality. 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 Search for the Ideal Female Breast: A Nationally Representative United-States-Census Study.

INTRODUCTION: Many studies have started to search for the perfect aesthetic breast in order to create a pars-pro-toto for reconstruction, but especially for aesthetic surgery. To date, no representative study with anatomically accurate models was performed. METHODS: In an online based United-States-census-representative survey with 1049 participants, questions regarding the preferred breast were asked utilizing lifelike morphed 3D-generated female models for the first time. Attributes such as breast pole ratio, areola size, breast direction and projection were asked. RESULTS: The results show that, contrary to what has been claimed in previous studies, an upper-pole-to-lower-pole ratio of 55:45 is preferred by both female and male participants. When it comes to breast size, on the other hand, there are clear gender-specific differences. While women opted for a cup size around B, the men preferred larger cup sizes. Moreover, the smallest depicted areola size of 30 mm was favored among all groups in the survey. DISCUSSION: Most publications used rather detrimental models for their surveys. We therefore opted for computer-generated 3D models and varied their naturalness. This enabled us to ensure a more aesthetic and accurate illustration and thus obtained more comparable and reliable results paired with the representation of the US-population. Taken together this study unveiled unexpected insights into the population favored breast attributes that might change operative planning in breast surgery. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

The Dual Vascular Pedicle: A Novel Method to Approach Challenging Cases in Single-Stage Mastopexy/Augmentation.

BACKGROUND: Age, pregnancy and weight change can affect the shape of the female breast. Various mastopexy/augmentation techniques have been described to address these changes which work well in primary and uncomplicated cases. However, there is a distinctive category of high-risk patients which includes post-bariatric, active smokers, those with poor skin quality, wanting larger implants or undergoing secondary surgery. The complications reported in this group of patients are as high as 32%. MATERIALS AND METHODS: We describe a new technique of one-stage mastopexy/augmentation, using a wide dermo-glandular pedicle, and our early results with 51 consecutive patients. RESULTS: Fifty-one patients were operated between January 2016 and September 2018, with a mean age of 40.0 years. Ten patients were smokers, eight were post-massive weight loss, six had previous mastopexy. At a mean follow-up of 22 months, only two patients had a unilateral bottoming out. There were no incidents of hematoma, seroma, capsular contracture or major tissue-related complications. CONCLUSION: Plastic surgery has been described as a struggle between beauty and blood supply. We have performed a one-stage mastopexy/augmentation using a wide and thick dermo-glandular glandular pedicle to maximize the blood supply in a range of challenging patients with promising 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 .

Controllable Factors to Reduce the Rate of Complications in Primary Breast Augmentation: A Review of the Literature.

BACKGROUND: Aesthetic augmentation mammoplasties are one of the most demanded procedures performed in the aesthetic surgical sector. Because of the high epidemiological impact, the evaluation of measures to reduce the risk of complications is highly needed. The goal of this review is to evaluate the current literature for successful actions to reduce the risk of complications in aesthetic breast augmentation. METHODS: We searched Medline-listed journals for "complications primary breast augmentation" and defined surgeon-dependent and patient-dependent factors within those. RESULTS: Most of the strategies to reduce the risk of any complication are based on meticulous hygienic precautions and adequate training of the surgeon. The current literature suggests complications such as capsular contracture, infection and BIA-ALCL are closely linked with bacterial contamination and therefore can be avoided with different hygienic measures. 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 .

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.

The Evolution of Patients' and Surgeons' Perspectives Towards the Role of the Internet and Social Media in Breast Augmentation Over 5 Years.

BACKGROUND: The influence of the internet and social media (SoMe) in the decision-making of patients is recognized. Plastic surgeons are aware of this trend but are entangled between ethics, professionalism, and business acumen. OBJECTIVES: In this study, the authors presented the evolution of perspectives of patients and surgeons recruited through a private clinic over 5 years. METHODS: A questionnaire was administered to patients consulting for primary breast augmentation in 2014, 2017, and 2019. Plastic surgeons who worked at or visited the Akademikliniken in 2014, 2017, and 2019 completed a separate questionnaire. RESULTS: In total, 1646 patient responses were collected. Patients who started their information gathering with the internet increased from 68.0% to 72.9%, and 94.1% of patients looked for information about aesthetic surgery on the internet before their consultation. Patients who read about aesthetic surgery on SoMe increased 29.1%. Of 462 surgeons recruited, 62% opined that the majority of patients had gathered information online before consultation. Fewer surgeons in 2019 thought that the internet and SoMe led to better information (down from 61.7% to 35.2%). An increase from 38.3% to 65.3% of surgeons attributed it to unrealistic expectations. However, only 9.7% of surgeons would support removal of plastic surgery material from SoMe compared with 21.9% in 2014. CONCLUSIONS: The increased utilization and influence of the internet and SoMe on patients and surgeons is rapid. Aesthetic plastic surgeons must equip themselves to cope with the risks and capitalize on the opportunity for patient engagement and public education.

Transitioning From Conventional Textured to Nanotextured Breast Implants: Our Early Experience and Modifications for Optimal Breast Augmentation Outcomes.

BACKGROUND: Nanotextured breast implants were hailed as an innovation that may address capsular contracture and breast implant-associated anaplastic large cell lymphoma and may provide the sweet spot between smooth and conventional textured implants. OBJECTIVES: This study aimed to evaluate the introduction of nanotextured implants alongside conventional textured implants and to compare early complications. METHODS: Patients who underwent breast augmentation from the introduction of nanotextured implants in the author's practice with at least 1 year of follow-up were included. They were divided into nanotextured and conventional textured implant groups and then into 3 chronological subgroups. Patient characteristics, implant specifications, operative factors, and complication rates were compared. RESULTS: A total 415 cases with a mean follow-up of 26.9 months were identified, of which 38.8% utilized nanotextured implants and 61.2% conventional textured implants. Utilization of nanotextured implants increased from 26.9% in period 1 to 54.5% in period 3. Complication rates for the conventional textured group were 0.8% at 1 year and 3.5% on overall follow-up, with mostly capsular contractures; for the nanotextured group, complication rates were 6.8% and 8.7%, respectively, and "bottoming out" was most common. When analyzed across chronological subgroups, complication rates decreased for nanotextured implants by period 3. CONCLUSIONS: A learning curve and associated complications are expected for early adopters of new implants. In our series, nanotextured implants were associated with higher complication rates at 1 year and on overall follow-up. Modifications in patient selection, intraoperative techniques, and postoperative care reduced complications in the later period.

Why Do We Need Anatomical Implants? the Science and Rationale for Maintaining Their Availability and Use in Breast Surgery.

The choice between anatomical and round implants is an important decision in breast augmentation surgery; however, both have their place and the decision between them that should be made on a patient-by-patient basis, taking into account the patient's desires, anatomy, and surgical history. In some individuals, there are clear indications for using either anatomical or round devices, and there is good evidence that aesthetic outcomes are better with anatomical implants in some instances. When both types are an option, anatomical devices may offer increased flexibility and, despite a longer learning curve needed to properly manage them, they are associated with positive long-term outcomes and high levels of patient satisfaction. Concerns about implant rotation can be minimized with proper patient selection and surgical technique, and the overall complication rate may favor anatomical over round devices in appropriate patients. Breast implant-associated anaplastic large-cell lymphoma is an important issue, and while rare, it must be considered in the context of the entire patient risk profile. Both anatomical and round implants remain key elements of a complete surgical toolbox in breast augmentation. 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.

Secondary Breast Augmentation: Is There a Trend for Bigger Implants?

BACKGROUND: Despite novel assessment tools and 3D simulation, patient's desire for implant size change is one of the most common reasons for revision surgery after primary breast augmentation. In this study, we analysed outcomes and predictive indicators for revision surgeries in a cohort of patients operated on by a single surgeon. PATIENTS AND METHODS: All consecutive patients who underwent revision augmentation surgery between 2013 and 2017 by the first author were included in this study. Besides review of medical records, subgroups based on the indication for revision surgery were compared and statistically analysed. RESULTS: A total of 110 patients were included in this study. Revision surgery was performed 97.2 months on average after primary augmentation. Eighty-six per cent of patients received larger implants. Indications for revision surgery and associated subgroups were: (1) wish for bigger implants (38%), (2) complication + wish for bigger implants (26%), (3) complication (29%), (4) complication + wish for smaller implants (3%) and (5) wish for smaller implants (3%). Subgroup analysis showed that patients who underwent revision surgery for bigger implants were significantly younger compared to patients who suffered a complication or desired smaller implants. Time to secondary augmentation was significantly shorter in case of wish for size change compared to complications as reason for revision surgery. Implant sizes differed significantly in patients where volume change was the sole indication for surgery compared to revisions performed due to complications. CONCLUSION: In our cohort of patients, almost all patients who underwent revision surgery after primary breast augmentation received bigger implants. Patients who specifically wished for size change were younger, asked for surgery earlier and received larger volumes compared to patients who underwent revision surgery for other reasons. 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 .

Online and Social Media Footprint of All Swedish Aesthetic Plastic Surgeons.

BACKGROUND: The visual nature of the Internet and its newer technologies makes it naturally aligned to plastic and aesthetic surgery. While many studies have looked at the use of social media ('SoMe'), they have been limited by either low response rate or limited scope. Our aim was to analyse a whole community of aesthetic plastic surgeons and their use of the Internet and social media platforms over a period of many years. METHODS: All active members of the Swedish national aesthetic plastic surgery society were identified. Webpages, professional (LinkedIn), social media (Facebook, Twitter, Instagram) and video-sharing (YouTube) accounts as well as online patient forum (Plastikoperationsforum) mentions of the surgeons and their clinics were identified, and corresponding platform-specific metrics were analysed. RESULTS: Of the 85 active members, 67 (78.9%) had a webpage on one of the 34 different clinic websites. The websites of older established clinics had a significantly better Alexa ranking than newer ones. Surgeons with a profile on Facebook or Instagram were significantly younger than those without an account. Twitter was the least preferred social media platform. Each surgeon had a mean 12.8 threads per year as compared to a mean 34.3 threads per clinic per year. CONCLUSION: Most of the new practices established by Swedish aesthetic plastic surgeons in the last 10 years are single-surgeon ones. Instagram and Facebook accounts of their clinics seem to be the most popular SoMe platforms. Younger surgeons were more likely to have a Facebook or Instagram account and to be using two or more social media platforms. These data provide information about all aesthetic plastic surgeons registered with the Swedish national body and their increasing use of SoMe. 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 .

Implant Insertion Time and Incision Length in Breast Augmentation Surgery with the Keller Funnel: Results from a Comparative Study.

BACKGROUND: The Keller funnel is an easy-to-use mechanical device that aids breast implant insertion. This study analyzed implant insertion time and incision length using the Keller funnel versus conventional manual insertion. METHODS: This was an analysis of two cohorts of adult patients undergoing primary breast augmentation with anatomical implants at a single center. In the 'insertion time cohort' (N = 20), implants were inserted with a Keller funnel on one side and manually on the other; follow-up lasted 4 years. In the 'incision length cohort,' both implants were inserted with a Keller funnel (N = 50) or manually (N = 50), with follow-up lasting 12 months. RESULTS: In the insertion time cohort, mean total insertion time (from implant sterile-package opening to final positioning in the pocket) was 35 s (range 13-76 s) with the Keller funnel and 25 s (range 13-43 s) using manual insertion (p = 0.07); the mean time needed to push the implant through the incision was 6 s (range 3-10 s) with the Keller funnel and 16 s (range 13-40 s) with manual insertion (p = 0.04). In the incision length cohort, mean incision length was shorter with the Keller funnel versus manual insertion (35.5 ± 2.1 mm vs. 46.2 ± 3.2 mm; p < 0.001). There were no differences in complications based on insertion method. CONCLUSION: The Keller funnel was associated with decreased incision length and reduced time to push the implant through the incision. This brings potential clinical advantages in minimizing scarring and reducing contamination of the device. 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 .

Aesthetic Training for Plastic Surgeons: Are Residents Getting Enough?

Plastic Surgery is one of the most competitive specialties in the field of medicine. However, this specialty has a unique particularity: the difficulties in Aesthetic Surgery training within the residency program. Despite the fact that the full title of the specialty is Plastic, Reconstructive, and Aesthetic Surgery and that Aesthetic Surgery is a part of the examination syllabus, the actual training in the specific area is limited. One of the solutions to this problem is Fellowships. The first author describes his personal experience with Aesthetic training and how it enhanced his knowledge in the area as well as the status of Fellowships in various training programs. 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.