Optimizing Postoperative Care in Rhinoplasty and Septoplasty: A Review of the Role of Nasal Packing and Alternatives in Complication Management.

Rhinoplasty, a common surgical procedure for nose reshaping, demands meticulous preoperative evaluation and precise execution. When coupled with septoplasty to address medical issues stemming from a deviated nasal septum, these procedures can lead to noteworthy postoperative complications. These encompass early issues like epistaxis and hematoma, as well as long-term challenges such as scarring and aesthetic deformities. Strategies like steroids and tranexamic acid are employed to prevent and manage these complications. A contentious aspect in postoperative care is the use of nasal packing. While some argue it aids healing and hemostasis, others avoid it due to patient discomfort. This review assesses the pros and cons of postoperative nasal packing following rhinoplasty and septoplasty. A thorough literature review spanning 2000-2023 yielded 30 relevant articles from 62. Discussion reveals that nasal packing offers limited benefits in reducing bleeding, edema and ecchymosis. In conclusion, the decision to employ nasal packing in rhinoplasty and septoplasty should be made carefully, considering patient comfort and surgical context. Evidence suggests that nasal packing may not consistently provide significant advantages and could lead to adverse outcomes. Nasal splints offer similar advantages and may be considered viable alternatives. Surgeons should tailor their approach to individual patient needs, with further research needed to refine postoperative management for these procedures.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 .

Rejuvenation in Men Facial Aging: A Combined Approach.

Facelift surgery, also known as rhytidectomy, is a popular cosmetic procedure aimed at reversing the signs of facial aging. While facelift surgery is more commonly performed in women, an increasing number of men are seeking this procedure to maintain a youthful appearance. The long recovery period conflicts the overall primary outcome anticipated by men undergoing rhytidectomy, i.e., appear younger, youthful, and ready to reaffirm their value in the working environment. Anterior direct neck lift, blepharoplasty (upper and lower eyelid blepharoplasty), and lipofilling are three techniques that have been shown to be effective in improving facial rejuvenation outcomes in elderly male patients. However, there is little to no evidence of the safety and efficacy of these techniques when used in combination. By combining these techniques, we hypothesized that we could achieve outcomes comparable to traditional facelift surgery, but with a lower risk of complications and a shorter recovery time. We conducted a retrospective case series study of 18 male patients who underwent facial rejuvenation surgery using the combination of anterior direct neck lift, blepharoplasty (upper and lower eyelid blepharoplasty), and lipofilling at our institution between 2018 and 2021. All 18 patients completed the study, with an average follow-up of 12 months. No major complications were observed, and all patients reported a high level of satisfaction with their outcomes.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 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.

Comment on "Reverse Expansion Following Nipple Sparing Mastectomy: A Natural, Safe and Effective Autologous Technique for Breast Reconstruction".

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 .

Literature Review: Venous Thromboembolism Prophylaxis in Plastic Surgery.

Venous thromboembolism (VTE) is a postoperative complication experienced in all branches of surgery, including plastic surgery. Its occurrence can be lowered with adequate prophylaxis in the light of the patient's risk category and the type of surgery that will be performed. Nevertheless, thromboembolic prophylaxis is not routinely administered in plastic surgery. The prevention of VTE has gained significant attention in the past 5 years due to increased knowledge about the disease process and the alarming incidence rates. This literature review is specifically aimed at carrying out a synopsis of VTE prophylaxis trials conducted on plastic surgery patients. Antithrombotic agents have generally been avoided by plastic surgeons due to the increased risk of bleeding or hematomas; however, the prevalence of clinically important bleeding has not been found to increase with their use, as it emerges from numerous studies. VTE events can lead to increased morbidity and mortality rates, as well as a rise in healthcare costs. As it emerges from multiple studies, as a preventive measure against VTE, it is strongly advised to use mechanical prophylaxis along with low-molecular-weight heparin as the primary treatment option for plastic surgery patients who are at a greater risk. Up to date though, this practice is not commonly embraced by physicians. Preventing VTE is crucial, and measures to do so are necessary. However, there is no clear evidence to support the use of anticoagulation for plastic surgery patients, and some surgeons are hesitant to use it due to potential bleeding in extensive dissection areas.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 the Histological Features of Tuberous Breast.

INTRODUCTION: Tuberous breast deformity (TB) is a condition mostly characterized by breast stenosis, areolar widening and glandular asymmetry. The most accredited hypothesis describes an abnormal thickening of the fascia corporis that might influence an alteration in the glandular development, limiting the horizontal growth of breast parenchyma. Alterations in the extracellular matrix components (ECM) might be involved in the abnormal breast development. PATIENTS: The aim of our case control study is to use histological specimens to analyze qualitative and quantitative differences in collagen fibers, elastic fibers and vessel densities in TB and normal breasts of 20 patients using a software for digital pathology. RESULTS: The quantitative findings showed increasing concentrations of collagen fibers and decreasing elastic fibers in TB, compared to normal breasts. No difference was seen in vessel density among the two groups. The qualitative findings highlighted differences in the distribution of the ECM among the TB specimens. Collagen fibers showed a packed appearance rather a scattered distribution, while elastic fibers visibly presented a reduction and a focal distribution of their concentration. CONCLUSIONS: The study proposes a correlation between abnormalities in ECM concentrations and TB, resulting in a higher degree of fibrosis and in the characteristic stenotic and less elastic morphology of the deformity. 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 .

Implant-Based Breast Reconstruction: Impact of Body Mass Index on Postoperative Complications and Aesthetic Results: A 5-Year, Single-Center Study.

BACKGROUND: Increasing adoption of implant-based breast reconstruction (IBR) has raised expectations regarding postoperative outcomes and aesthetic results. BMI has been extensively explored as a predictor of complications. This study is the first to examine complication rates in underweight subjects, and compares these rates among underweight, normal weight, overweight, and obese patients. OBJECTIVES: The aim of this study was to investigate the influence of BMI on postoperative complications and aesthetic results in IBR following mastectomy. METHODS: Retrospective analysis encompassed patients undergoing mastectomy with subsequent IBR, performed by a collaborative team of breast and plastic surgeons. Demographics, treatment specifics, and outcomes were evaluated by univariate and multivariate regression models. Significance was determined at P < .05. RESULTS: In total, 1046 IBRs were performed in 921 patients, of whom 63 had a BMI <18.5 kg/m2, 572 were normal weight, 215 were overweight, and 71 were obese. Significantly higher complication rates were observed in both obese and overweight patients compared with normal-weight patients (P < .001). Each unit increase in BMI correlated to 7% increased odds of overall complications and 13% increased odds of reconstructive failure. Underweight individuals had higher capsular contracture rates than normal-weight patients, 14.3% vs 3.65%, respectively (P = .001). In addition, aesthetic complications rates in underweight patients were higher than in normal-weight patients, 36.4% vs 25.7%, respectively (P < .05). CONCLUSIONS: This study confirmed BMI to be a strong predictor of postoperative complications and aesthetic outcomes, and demonstrates that low BMI has a significant impact on the incidence of capsular contracture and aesthetic complications.

Safety of autologous fat grafting in breast cancer: a multicenter Italian study among 17 senonetwork breast units autologous fat grafting safety: a multicenter Italian retrospective study.

BACKGROUND: Autologous fat grafting (AFG), defined as the re-implant to the breast of fat tissue from different body areas, has been firstly applied to esthetic plastic surgery and then has moved to reconstructive surgery, mainly used for scar correction and opposite breast altering. Nevertheless, due to the potentially unsafe stem-like properties of adipocytes at the tumoral bed level, no clear evidence of the procedure's oncological safety has been clearly documented at present. PATIENTS AND METHODS: We retrospectively collected data of early breast cancer (BC) patients from 17 Italian Breast Units and assessed differences in terms of locoregional recurrence rate (LRR) and locoregional recurrence-free survival (LRFS) between patients who underwent AFG and patients who did not. Differences were analyzed in the entire cohort of invasive tumors and in different subgroups, according to prognostic biological subtypes. RESULTS: With a median follow-up time of 60 months, LRR was 5.3% (n = 71) in the matched population, 3.9% (n = 18) in the AFG group, and 6.1% (n = 53) in the non-AFG group, suggesting non-inferiority of AFG (p = 0.084). Building Kaplan-Meier curves confirmed non-inferiority of the AFG procedure for LRFS (aHR 0.73, 95% CI 0.41-1.30, p = 0.291). The same effect, in terms of LRFS, was also documented among different biological subtypes (luminal-like group, aHR 0.76, 95% CI 0.34-1.68, p = 0.493; HER2 enriched-like, aHR 0.89, 95% CI 0.19-4.22, p = 0.882; and TNBC, aHR 0.61, 95% CI 0.12-2.98, p = 0.543). CONCLUSIONS: Our study confirms in a very large, multicenter cohort of early BC patients that, aside the well-known benefits on the esthetic result, AFG do not interfere negatively with cancer prognosis.

Secondary Treatment of Cleft Lip Correction Sequelae With Percutaneous Needleotomy, Autologous Fat Grafting, and Local Flaps: An Integrated Approach.

INTRODUCTION: Cleft lip and/or palate (CL/P) is the most common congenital craniofacial malformation. The severity of the anatomic deformity is highly variable and different techniques can be employed depending on whether the defect is unilateral or bilateral, complete or incomplete. Patients usually undergo multiple steps of reconstruction throughout childhood and adolescence and, for this reason, secondary deformities of the nasolabial region of the midface may ensue. Considering our experience in the treatment of scars, we opted to correct the cleft lip surgery sequelae not only with local flaps/scar revisions, but we decided to add the use of the autologous fat grafting (AFG) to induce a regenerative effect in these young patients. MATERIALS AND METHODS: In this study we present the results obtained from a series of 12 consecutive Caucasian patients aged from 23 to 44 years with widened paramedian lip scars secondary to cleft lip reconstruction surgery, treated with a combination of needle-induced lysis of the scar tissue and AFG from January 2013 to December 2018. RESULTS: After the procedure we observed an overall improvement in the quality of the scar tissue, in the function of mimic features, in the symmetry and cosmetics of the lower third of the nose. Patients' satisfaction was excellent. Results were long lasting and remained virtually unchanged after 1 year of follow-up. CONCLUSIONS: Scar release by needle, AFG and local flaps are excellent tools for the treatment of cleft lip correction sequelae, but the combination of these surgical techniques can lead to even better results.Level of Evidence: Level V.

Gynecomastia: Ultrasound-Confirmed Classification Pertainent to Surgical Correction.

BACKGROUND: Gynecomastia is the most common form of breast alteration in men, due to proliferation of the gland ducts and stromal components, including fat. In addition to the most obvious indications (weight loss, pharmacotherapy, and drugs suspension), the surgical treatment is needed for long-standing gynecomastia, combining liposuction, adenectomy, partial mammary adenectomy, periareolar skin resection, and round-block suture. MATERIALS AND METHODS: A retrospective study was conducted on 148 patients undergoing gynecomastia correction from May 2012 to April 2018. Follow-up ranged from 9 to 14 months. The authors propose a new ultrasound-confirmed classification system, dividing patients into six categories. The authors analyzed immediate complications, revision, recurrence, and minor aesthetic problems (retracted/depressed areas) and introduced a way to correct the irregularities with fat grafting and needles. RESULTS: The total complication rate was 11.5% (17/148). Most of the complications (11) were observed in patients who underwent glandular resection and 3 after liposuction only. Retrospective surveys about patients' and surgeons' satisfaction were performed, showing excellent feedbacks regarding the results accomplished. CONCLUSIONS: The simple classification helps surgeons choose the most suitable approach, avoiding insufficient or invasive treatments and undesirable scars. Moreover, the analysis of the type of sequelae and their correction allow high patients' satisfaction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Dorsal Augmentation with Diced Conchal Cartilage Wrapped in Retroauricular Fascia.

BACKGROUND: Dorsal augmentation is of primary importance to shape an ideal nose. Although costal cartilage is still used for this purpose, diced cartilage grafts wrapped in autogenous fascia became more and more popular in recent decades. In this paper, the authors report their experience with a new combination made by diced conchal cartilage wrapped in retroauricular fascia in primary and secondary cases. METHODS: The clinical records of the first 19 patients to undergo dorsal augmentation with this technique were reviewed. The entire concha has been harvested and, once diced, wrapped in a sleeve of retroauricular fascia obtained using the same incision. Quilting reabsorbable sutures closed the mastoid dead space and prevented the risk of hematoma. The graft has been used in all the cases through a closed approach. CONCLUSION: The use of diced cartilage is nowadays considered one of the best options among the available procedures for dorsal augmentation. Diced conchal cartilage wrapped in posterior auricular fascial graft is a new, simple and safe procedure that eliminates the necessity of a secondary donor site (temple or thorax), speeds up the operation and leaves a well-concealed scar behind the ear. Its main disadvantages toward costal diced cartilage wrapped in rectus abdominis fascia are the minor quantity of cartilage that can be obtained, even in case of bilateral harvest, and compared to temporal fascia a longer postoperative swelling (6-8 weeks). 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 .

Fat Graft in Composite Breast Augmentation with Round Implants: A New Concept for Breast Reshaping.

BACKGROUND: Breast augmentation surgery with implants is one of the most common aesthetic surgical procedures. Round and anatomical textured implants are employed very often, and fat grafting has proven to be a very useful complementary procedure in breast augmentation. Many authors report a more natural result with anatomical compared to round implants. Nevertheless, anatomical implants can be associated with complications such as implant rotation with subsequent shape distortion. In this article, we propose a combination of high-profile round implants and fat grafting to obtain a natural result analyzing its impact on the aesthetic outcome and patient satisfaction. METHODS: In this study, we report our personal approach on 31 consecutive patients undergoing primary aesthetic breast augmentation with high-profile round implants and fat grafting. We describe our personal technique of breast augmentation via the periareolar approach and fat grafting. We evaluated short- and medium-term aesthetic outcomes and patient satisfaction using a 10-point VAS scale. RESULTS: We achieved in all cases high patient satisfaction and good aesthetic outcomes with a "natural" breast shape and a "smoothened" upper pole with low complication rates. The technique is safe, simple, fast, and it leads to high levels of patient satisfaction. CONCLUSIONS: Our observations show that the combination of high-profile round implants and fat grafting in aesthetic breast augmentation can improve the aesthetic outcome and patient satisfaction as with anatomical implants eliminating the risk of implant rotation. 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 .

Autologous fat graft in irradiated orbit postenucleation for retinoblastoma.

Autologous fat grafting has been extensively and successfully adopted in a number of pathologic conditions in regenerative surgery especially on irradiated fields in order to improve pain symptoms and tissue trophism promoting scar release. In the present study, we report our experience with autologous fat grafting for the treatment of postirradiation fibrosis and pain on three consecutive patients undergoing orbital enucleation for locally advanced retinoblastoma (RB) and subsequent radiotherapy. We selected three consecutive patients who underwent orbital enucleation for locally advanced RB and subsequent local radiotherapy showing severe reduction in orbital volume and eyelid length and retraction due to fibrosis, spontaneous local pain exacerbated after digital pressure with no possibility to place an ocular implant. They underwent autologous fat grafting in the orbital cavity and results were evaluated by clinical examination at 5 and 14 days, and 1, 3, 6 months, and 1 year after surgery. A significant release of scar retraction, reduction of fibrosis and orbital rim contraction together with an important improvement of pain symptoms was observed in all patients. The local changes observed enabled an ease placement of an ocular prosthetic implant (implant). No local or systemic complication occurred. Fat grafting is a promising treatment for patients showing radiotherapy related complication in the orbital area and it should be adopted by all oculoplastic surgeon in order to improve pain syndrome creating the ideal local conditions for the placement of an ocular prosthetic implant.

Stenotic Breast Malformation and Its Reconstructive Surgical Correction: A New Concept From Minor Deformity to Tuberous Breast.

BACKGROUND: Several classification systems have been reported to define the spectrum of tuberous breast deformity, and a range of surgical techniques has been described. In this paper, we proposed a new classification including tuberous breast and minor deformity based on stenosis type, glandular trophism and ptosis adapting surgical planning to different breast types. METHODS: A total of 246 patients meeting our definition for stenotic breasts asking for surgery were analyzed in this study. We considered eight different types of stenotic breasts analyzing anatomical presentations, and we then proposed eight key-point maneuvers, finalized to the correction of different breast deformities and their possible association according to the stenotic breast type. Results have been evaluated by a group of three surgeons and by patients. In addition, we evaluated the complication incidence in terms of re-intervention rate. RESULTS: Following our classification eight different groups were distinguished. For each one we reported the prevalence and the surgical procedure adopted. Results evaluated by the surgeon group reported a mean aesthetic outcome of 8.2 (range 5-10), whereas patients reported a mean value of 7.9 (range 6-10). During a follow-up period with a mean of 16 months we observed a 4.9% re-intervention rate. CONCLUSIONS: We believe this new classification to be very complete in evaluating breast shape, including most of the breast evaluable features. Our results confirmed the suitability of the approach for appropriate preoperative planning, thus improving the global surgical outcome. 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 .

Optimising aesthetic outcome after nipple-areola complex-sparing mastectomy and immediate one-stage prosthetic reconstruction: A simple surgical trick to fix nipple-areola complex position.

BACKGROUND: Nipple-areola complex (NAC) sparing mastectomy (NSM) is mostly indicated in patients with small-/medium-sized and non-ptotic breasts, while skin-reducing mastectomy is used in patients with medium or large breasts with severe ptosis. NAC location on the reconstructed breast is one of the major factors in determining the final aesthetic result and patients' satisfaction. An optimum result obtained at the end of surgical procedure may be altered and compromised by skin redistribution and consequently NAC depositioning during the post-operative period in patients with medium-sized breasts and a moderate degree of ptosis. AIMS: In the present study, we propose a simple surgical trick to fix the NAC in the desired position with a long-lasting result. METHODS: We selected 35 patients undergoing NAC sparing mastectomy for breast cancer and immediate one-stage prosthetic reconstruction and we performed a single suture to fix NAC in the desired position before closing the skin envelope. We evaluated NAC complex position stability overtime comparing pre-operative standard photographs with early (3 weeks after surgery) and late (1 year after surgery). RESULTS: In all patients, we were able to place the NAC complex on the desired position, and the result was stable at 1 year follow-up. The aesthetic outcome was satisfactory in all patients with no change in the complication rate. CONCLUSIONS: This simple surgical trick has been shown to be safe and effective in optimising the aesthetic outcome in a patient undergoing NAC sparing mastectomy and immediate one-stage prosthetic reconstruction. Level IV: evidence obtained from multiple time series with or without the intervention, such as case studies. Dramatic results in uncontrolled trials might also be regarded as this type of evidence.