Comparison of Aesthetic and Functional Rhinoplasty Outcomes Between Patients with Body Dysmorphic Disorder and Normal Individuals.

BACKGROUND: Rhinoplasty is among the top five most popular cosmetic surgical procedures worldwide. Among rhinoplasty candidates, the most common mental health disorder is body dysmorphic disorder. (BDD). The present study aimed to assess the prevalence of BDD among rhinoplasty candidates, its association with the patient's self-assessment of aesthetic outcome and nasal functional, post-rhinoplasty compared to applicants with negative screening for BDD. METHODS: The following study is a cross-sectional, comparative study. Out of the 209 rhinoplasty candidates screened by the BDDQ questionnaire, 39 were positive for BDD. From the remaining 170 patients who screened negative for BDD, 39 participants were randomly selected as the control group for the comparative analysis. Rhinoplasty outcome evaluation (ROE) and standardized cosmesis and health nasal outcomes survey-cosmetic (SCHNOS-C) questionnaires were used for assessment of patient satisfaction with the cosmetic outcome of rhinoplasty. Nasal obstruction symptom evaluation (NOSE) and standardized cosmesis and health nasal outcomes survey-obstruction (SCHNOS-O) were used for the assessment of satisfaction with functional outcomes between groups of patients screened positive and negative for BDD. RESULTS: The prevalence of BDD was 18.66% among rhinoplasty candidates. The average age of patients screened positive for BDD was 31.41. The mean ROE score was significantly lower (i.e. lower satisfaction) in patients screened positive for BDD (15.69 versus 19.08, P = 0.001), regardless of confounding variables, such as age, sex, and marital status. SCHNOS-C score was higher (i.e. less satisfaction) among patients with BDD (47.01 versus 34.96, P = 0.021) and was significantly associated with higher odds of severe aesthetic concern post-rhinoplasty (OR (95%CI) = 5.000 (1.135-22.022), P = 0.033). Patients screened positive for BDD had significantly higher NOSE scores (i.e. less satisfaction with functional outcome) compared to participants negative for BDD (49.74 versus 37.82, P = 0.012). SCHNOS-O score had no significant association with BDD (P = 0.053). Furthermore, there was no significant association between BDD and NOSE or SCHNOS-O score after adjustment for the confounders. CONCLUSION: Patients screened positive for BDD were significantly less satisfied with the cosmetic outcome of the rhinoplasty compared to those screened negative for BDD. Assessment of BDD among rhinoplasty candidates before surgery, could potentially be beneficial for both patients and surgeons. 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 .

Fixation of Superolateral Platysma Flap to the Mastoid Fascia: A Novel Isolated Neck Lift Technique.

BACKGROUND: This study aimed to evaluate the utility of a novel neck lift technique based on fixation of superolateral platysma flap to the mastoid fascia in terms of postoperative aesthetic outcome and patient satisfaction within an 18-month follow-up period. METHODS: A total of 145 female patients who underwent isolated neck lift operation with the superolateral platysma flap technique were included. Global Aesthetic Improvement Scale (GAIS) scores (by the investigator) and the patient reported outcomes were recorded in terms of improvement in the cervicofacial angle, jowls, platysmal bands and malpositioned cervical fats, at 6 and 18 months, postoperatively. The complications were recorded at early postoperative period and at 1, 6 and 18 months, postoperatively. RESULTS: The median duration of follow-up was 18 months (range, 6-48 months). GAIS scores at 18th months, revealed exceptional improvement in the cervicofacial angle (82.8%), the jowls (93.1%), platysmal bands (93.1%) and malpositioned cervical fat (97.2%). Majority of patients were very satisfied with the treatment in terms of the aesthetic improvement. Complications involved the minor ecchymosis (17.2%) and minor skin circulatory problem (11.7%) in the early postoperative period, suture exposure (12.4%) in the postoperative 1st month, and cervical band reformation in the 6th (0.7%) and 18th (1.4%) months. CONCLUSION: In conclusion, lateral displacement and fixation of superolateral platysma flap to the mastoid fascia seems to be a useful neck lift technique for correction of platysma- and skin-derived aging sings with minor and manageable complications, immediate return to everyday activities and a high patient 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 .

Assessing the Effect of Enzymatic Debridement on the Scar Quality in Partial-Thickness Burns to Deep Dermal Burns of the Hand: A Long-Term Evaluation.

Background and Objectives: Burn surgery on the hands is a difficult procedure due to the complex anatomy and fragility of the area. Enzymatic debridement has been shown to effectively remove burn eschar while minimizing damage to the surrounding tissue and has therefore become a standard procedure in many burn centers worldwide over the past decade. However, surprisingly, our recent literature review showed limited valid data on the long-term scarring after the enzymatic debridement of the hands. Therefore, we decided to present our study on this topic to fill this gap. Materials and Methods: This study analyzed partial-thickness to deep dermal burns on the hands that had undergone enzymatic debridement at least 12 months prior. Objective measures, like flexibility, trans-epidermal water loss, erythema, pigmentation, and microcirculation, were recorded and compared intraindividually to the uninjured skin in the same area of the other hand to assess the regenerative potential of the skin after EDNX. The subjective scar quality was evaluated using the patient and observer scar assessment scale (POSAS), the Vancouver Scar Scale (VSS), and the "Disabilities of the Arm, Shoulder, and Hand" (DASH) questionnaire and compared interindividually to a control group of 15 patients who had received traditional surgical debridement for hand burns of the same depth. Results: Between January 2014 and December 2015, 31 hand burns in 28 male and 3 female patients were treated with enzymatic debridement. After 12 months, the treated wounds showed no significant differences compared to the untreated skin in terms of flexibility, trans-epidermal water loss, pigmentation, and skin surface. However, the treated wounds still exhibited significantly increased blood circulation and erythema compared to the untreated areas. In comparison to the control group who received traditional surgical debridement, scarring was rated as significantly superior. Conclusions: In summary, it can be concluded that the objective skin quality following enzymatic debridement is comparable to that of healthy skin after 12 months and subjectively fares better than that after tangential excision. This confirms the superiority of enzymatic debridement in the treatment of deep dermal burns of the hand and solidifies its position as the gold standard.

Comparative Analysis of Sterile Freeze-Dried Versus Sterile Pre-Hydration Acellular Dermal Matrix in Implant-Based Breast Reconstruction.

INTRODUCTION: Implant-based breast reconstruction currently represents the most popular form of breast reconstruction. Acellular dermal matrix (ADM) is a biological scaffold which is used for inferolateral implant coverage in implant-based breast reconstruction. There are two types in the way when using ADM, freeze-dried type and pre-hydrated type. In this study, we focused on complication and aesthetic outcome resulting from freeze-dried type or pre-hydrated type. PATIENTS AND METHOD: Through retrospective chart review, we analysed 78 patients (using 26 freeze-dried type, 52 pre-hydrated type, MegaDerm; L&C BIO, Seongnam, Korea) from January 2016 to February 2019. Complications such as skin inflammation, wound dehiscence, skin necrosis, infection, nipple-areolar necrosis were assessed with medical chart review with post-operative photographic findings by two independent assessors. Drainage amount of operative site and retention period of drainage was checked. Assessment for aesthetic outcome categorized into five parts, shape, volume, symmetry, nipple-areolar complex and scar. Two independent assessors undertook visual analogue scale of 1 (very dissatisfied) to 5(very satisfied) at 1 year after the surgery. And the symmetry of breast was evaluated subjectively by the patient for the same scale. If the implant was removed, aesthetic outcome assessment has not been implemented. RESULTS: In aesthetic assessment, the category of shape assessed by clinician and symmetry assessed by patient showed higher in pre-hydrated type group with significant differences. In the pre-hydrated type group, the other aesthetic outcomes including the categories of shape, size, symmetry and texture were not statistically significant, but higher. In complication, the result showed no significant difference between the two groups. In addition, there was no difference in the amount of drainage. CONCLUSIONS: Pre-hydrated type ADM is designed to be softer than freeze-dried type. We could predict pre-hydrated type would provide better texture of breast. Indeed, in this study, the shape showed better in pre-hydrated group, which was related to the nature of texture. Also, it also showed better results in the volume, symmetry, nipple-areolar complex and scar and may be related to skin thickness or remaining soft tissue after mastectomy procedure. In future studies, it should be conducted with consideration of post-mastectomy factors. 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 Evaluation of Breast Reconstruction with Autologous Fat Transfer vs. Implants.

BACKGROUND: Autologous fat transfer (AFT) seems to be a new minimal invasive method for total breast reconstruction, yet how patients, surgeons, and laymen evaluate cosmesis is lacking. The aim of this study was to evaluate the aesthetic outcome of AFT (intervention group) for total breast reconstruction post-mastectomy, as compared to implant-based reconstruction (IBR) (control group). METHODS: A random and blinded 3D photographic aesthetic outcome study was performed on a selection of 50 patients, scored by three panels: plastic surgeons, breast cancer patients, and laymen. Secondary outcomes included agreement within groups and possible patient characteristics influencing scoring. RESULTS: Breast cancer patients and plastic surgeons did not differ in the aesthetic scores between the treatment groups. In contrast, the laymen group scored AFT patients lower than IBR patients (- 1.04, p < 0.001). Remarkably, mean given scores were low for all groups and overall agreement within groups was poor (ICC < 0.50). Higher scores were given when subjects underwent a bilateral reconstruction and if a mamilla was present. CONCLUSION: Evaluation of aesthetic outcomes varies greatly. Hence, aesthetic outcome remains a very personal measure and this emphasizes the importance of thorough patient counseling including information on achievable aesthetic results before starting a reconstructive procedure. 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 .

A 5-year randomized controlled trial comparing zirconia-based versus metal-based implant-supported single-tooth restorations in the premolar region.

OBJECTIVE: To compare 5-year biological, technical, aesthetic, and patient-reported outcomes of single-tooth implant-supported all-ceramic versus metal-ceramic restorations. MATERIALS AND METHODS: Thirty patients with 63 premolar agenesis participated in the 5-year follow-up. The prosthetic treatment on single-tooth implants was randomly assigned to all-ceramic crowns on zirconia abutments (AC = 31) or metal-ceramic crowns on metal abutments (MC = 32). All patients were recalled to clinical examinations at baseline, 1, 3, and 5 years after prosthetic treatments. Biological, technical, and aesthetic outcomes including complications were clinically and radiographically registered. The patient-reported outcomes were recorded using OHIP-49 questionnaire before treatment and at each follow-up examination. RESULTS: At the 5-year examination, the survival rate was 100% for implants and 100% for AC and 97% for MC crowns and abutments. The marginal bone loss after 5 years was minor and not significantly different (p = .056) between AC (mean: 0.3, SD: 1.1) and MC (mean: -0.1, SD: 0.4) restorations. The success rate of the implants based on marginal bone loss was 77.4% for AC- and 93.7% for MC restorations. The marginal adaptation was significantly better for MC than for AC restorations (p = .025). The aesthetic outcomes and patient-reported outcomes between AC and MC restorations were not significantly different. CONCLUSIONS: The biological, aesthetic and patient-reported outcomes for implant-supported AC and MC restorations were successful and with no significant difference after 5-years. The marginal adaptation of the MC crowns cemented on titanium abutments showed a significantly better fit than restorations based on zirconia crowns cemented on zirconia abutments.

Aesthetic Outcome of Gynecomastia Management with Conventional Liposuction and Cross-Chest Liposuction: A Prospective Comparative Study.

BACKGROUND: Liposuction is the most accepted technique for treatment of gynecomastia at present with or without residual gland tissue excision. Conventional liposuction uses incisions for introduction of cannula, made usually at the inframammary crease or axilla resulting in consequent scars. Cross-chest liposuction technique was introduced to avoid these additional scars and improve the aesthetic outcome. This study aimed to evaluate the difference between aesthetic outcome of conventional liposuction and cross-chest liposuction in treatment of gynecomastia. METHOD: A prospective comparative study between 2 groups with 15 patients in each was conducted, one with conventional and the other cross-chest liposuction. Excision of residual gland tissue was performed through circum-areolar incision in both the groups. Aesthetic outcome was evaluated in both the groups using Likert scale and compared. RESULT: The mean age of the patients was 22.6 years and the mean duration of presentation was 8.13 years. Satisfaction rate with conventional and cross-chest liposuction was 80% and 86%, respectively, as assessed by the patients. The rate was 80% and 77%, respectively, in both the groups as assessed by independent observer. The complication rate was 13.3% in conventional and 20% in cross-chest group. The difference in outcome was not statistically significant between two groups. Difference between the mean Likert scores of pre-operative and post-operative satisfaction was statistically significant for both the techniques. CONCLUSION: The conventional and the cross-chest liposuction, both yield comparable results when used for treatment of gynecomastia in terms of aesthetic outcome. 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.

Lateral approach is a more aesthetical option for radical resection of BSCC: assessment of its surgical, oncological, functional, and aesthetic outcomes.

BACKGROUND: The purpose of this study was to introduce a modified lateral approach for combined radical resection of buccal squamous cell carcinoma (BSCC) and evaluate its surgical, oncological, functional, and aesthetic outcomes in comparison with the conventional lower-lip splitting approach. METHODS: This single-center study retrospectively reviewed 80 patients with BSCC, of which 37 underwent the lateral approach and 43 underwent the conventional approach. Surgical, functional, oncological, and aesthetic evaluations, as well as follow-ups, were recorded and compared. RESULTS: Compared to the conventional approach group, the lateral approach group had a longer surgical time (P = 0.000), but there was no significant difference in other surgical and oncological parameters. Moreover, the scar in the head and neck had a significantly discreet appearance in the lateral approach group, whose satisfaction was better than those in the conventional approach group (P = 0.000). Other oral function parameters, postoperative mouth-opening, and 3-year survival rate were not significantly different between the two groups. CONCLUSION: The lateral approach could provide superior aesthetic results while maintaining equal surgical, functional, and oncological outcomes compared to the conventional approach for radical resection of BSCC.

Reconstructive outcome analysis of the impact of neoadjuvant chemotherapy on immediate breast reconstruction: a retrospective cross-sectional study.

BACKGROUND: Neoadjuvant chemotherapy (NACT) was initially applied to locally advanced breast cancer to convert advanced lesions to an operable status. Currently, its application has been expanded to enhance overall oncological results, especially in patients with triple-negative or HER-2-positive breast cancer. With more NACT being applied, the role and impact of this approach on breast reconstruction needs to be determined. This study aimed to perform a complete reconstructive outcome analysis of patients receiving NACT who underwent immediate breast reconstruction. METHODS: A retrospective review of a single reconstructive surgeon's immediate breast reconstructions performed from July 2008 to December 2018 was undertaken. The results were stratified by the use of NACT. Patient demographics, delivery of NACT, adjuvant treatment, incidence of surgical complications, and postoperative photographs were analyzed. RESULTS: A total of 269 patients were included. The mean follow-up was 46.3 months. Forty-six out of 269 patients received NACT and were included in the NACT group. The other patients were included in the non-NACT group. When implant-based reconstruction was planned, the NACT group had a higher rate of two-stage tissue expander-implant reconstruction than direct-to-implant reconstruction (p < 0.001). The requirement for postmastectomy radiotherapy was higher in the NACT group (p < 0.001). The surgical complication rates were similar between groups after adjusting for confounding factors. The objective aesthetic outcomes assessed by 6 plastic surgeons were also similar between groups. CONCLUSIONS: Immediate breast reconstruction is a safe and reliable procedure, with an acceptable reconstructive complication rate and satisfactory aesthetic outcomes, for patients treated with NACT.

Purse-string suture versus full-thickness skin graft: An efficacy and safety comparison study.

Purse-string suture (PSS) and full-thickness skin graft (FTSG) are two different approaches to the closure of circular skin defects. In this study, we compare the feasibility and the aesthetic outcome of these two techniques in high operatory risk non-melanoma skin cancer (NMSC) patients. We performed a retrospective study on 65 patients, treated with PSS or FTSG, and evaluated after a minimum follow-up of 6 months. The post-surgery assessment was based on the Vancouver scar scale (VSS) and differences in terms of defect areas, operative and healing times were performed both with parametric and nonparametric tests. Operative times in PSS were significantly lower than those needed for FTSG, without perioperative adverse events; PSS required a waiting time before removing the suture greater than FTSG. After surgery, PSS resulted in a median defect area reduction of 73%. No significant differences were found in the median value for VSS in the two groups. Based on our clinical experience, the PSS advantages in terms of feasibility, rapidity of execution, and mean defect area reduction were confirmed. So, this technique seems to be appropriate for fragile patients affected by NMSC, that cannot hold long surgical sessions.

Use of amniotic membrane for radial forearm free flap donor site coverage: clinical, functional and cosmetic outcomes.

OBJECTIVE: To evaluate the clinical, functional and aesthetic outcomes for radial forearm free flap (RFFF) donor sites covered with amniotic membrane (AM). MATERIAL AND METHODS: The healing process of patients with RFFF donor sites covered with AM was prospectively followed for 1 year. Additionally at the 12-month evaluation, objective scoring systems were used to assess the aesthetic (Vancouver scar scale, VSS: range 1-13) and functional outcome (skin sensibility, hand/wrist functionality [goniometer], grip strength [score 1 = excellent, 5 = poor]). By using a subjective rating system (score 1 = excellent, 5 = poor), the patient-reported aesthetic and functionality outcome was correlated with objective data analysis. RESULTS: Twenty-one out of 23 patients were followed for 12 months (dropout: 2 patients at 3 months). In 17/23 (73.9%) patients RFFF defect covered with AM showed an uneventful healing period (< 3 months). Prolonged healing periods (> 3 months < 6) for 6 patients (26.1%) were attributed to wound infections (4×), seroma (1×) and inflammation (1×). At the 1-year evaluation, there was a significant (p < 0.01) correlation between subjective (2.0 ± 0.71) and objective aesthetic scores (VVS 3.74 ± 2.18), and a successful grip strength (score 1.67 ± 0.86); however, thumb hyposensibility in 76.2% was seen. A high body mass index (BMI) was in conjunction with a negative (p = 0.012) and the use of antihypertensive medications provided positive effects (p = 0.041) on the aesthetic outcome. CONCLUSION: RFFF donor site defects covered using AM show excellent clinical, aesthetic and functional outcome representing patient comorbidities (BMI, antihypertensive drugs) might affect the aesthetic outcome. CLINICAL RELEVANCE: In relation to the excellent outcomes found, the use of AM offers an alternative treatment procedure for RFFF defect covering.

PROMs following breast-conserving therapy for breast cancer: results from a prospective longitudinal monocentric study.

BACKGROUND: Treatment of breast cancer includes many options and shared decision making is becoming standard practice. Within the context of treatment individualization, the omission of radiotherapy (RT) can be considered. It is thereby of great importance to correctly foresee the side effects attributed to RT. Data from longitudinal studies with contemporary techniques however are sparse. The purpose of the present study was to evaluate patient-reported outcome measures (PROMs) and long-term aesthetic outcome (AO) related to RT in the breast-conserving therapy (BCT) setting for breast cancer over time. METHODS: Patients treated with BCT between April 2015 and April 2016 were prospectively included in the cohort. Evaluations were made at six time points: at baseline (before RT), during and at the end of RT, between 3 and 6 months, 1 year and 2 years after RT. AO was scored by the patient and by the BCCT.core software. Further PROMs were measured with the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire QLQ-C30/-BR23 and the Body Image after Breast Cancer Questionnaire BIBCQ. Patients were evaluated over 2 years. First, we assessed the evolution in time. Second, we tested the differences in mean scale scores of the PROMs between patients with a favourable and an unfavourable AO. RESULTS: One hundred seventy-five patients were included in the analysis. At baseline, unsatisfactory levels were already present for several scales. Most unsatisfactory PROMs improved up to 1 year after RT. Complaints of fatigue increased at the start but decreased up to a lower level than that at baseline up to 1 year after RT (mean difference (MD) 7.6, - 12.3, respectively). Cognitive functioning showed a small decrease at the start with no further significant decrease (MD - 4.73, - 0.21, respectively). Breast symptoms significantly increased during RT but decreased afterwards up to 2 years after RT to lower values than those at baseline and were then considered satisfactory (MD 15.6, - 19.7, - 4.1, respectively). AO scored as PROM associated with BCCT.core and with the body image measures. CONCLUSIONS: The study suggests that quality of life and body image are temporarily impaired due to RT. Around one third of patients score their long-term AO as unfavourable. These results should be discussed with the patient and could help in the decision making of the treatment plan and in the clarification of the patient's expectations.

Patterns of care: burr-hole cover application for chronic subdural hematoma trepanation.

OBJECTIVE: Skin depressions may appear as undesired effects after burr-hole trepanation for the evacuation of chronic subdural hematomas (cSDH). Placement of burr-hole covers to reconstruct skull defects can prevent skin depressions, with the potential to improve the aesthetic result and patient satisfaction. The perception of the relevance of this practice, however, appears to vary substantially among neurosurgeons. The authors aimed to identify current practice variations with regard to the application of burr-hole covers after trepanation for cSDH. METHODS: An electronic survey containing 12 questions was sent to resident and faculty neurosurgeons practicing in different parts of the world, as identified by an Internet search. All responses completed between September 2018 and December 2018 were considered. Descriptive statistics and logistic regression were used to analyze the data. RESULTS: A total of 604 responses were obtained, of which 576 (95.4%) provided complete data. The respondents' mean age was 42.4 years (SD 10.5), and 86.5% were male. The sample consisted of residents, fellows, junior/senior consultants, and department chairs from 79 countries (77.4% Europe, 11.8% Asia, 5.4% America, 3.5% Africa, and 1.9% Australasia). Skin depressions were considered a relevant issue by 31.6%, and 76.0% indicated that patients complain about skin depressions more or less frequently. Burr-hole covers are placed by 28.1% in the context of cSDH evacuation more or less frequently. The most frequent reasons for not placing a burr-hole cover were the lack of proven benefit (34.8%), followed by additional costs (21.9%), technical difficulty (19.9%), and fear of increased complications (4.9%). Most respondents (77.5%) stated that they would consider placing burr-hole covers in the future if there was evidence for superiority of the practice. The use of burr-hole covers varied substantially across countries, but a country's gross domestic product per capita was not associated with their placement. CONCLUSIONS: Only a minority of neurosurgeons place burr-hole covers after trepanation for cSDH on a regular basis, even though the majority of participants reported complaints from patients regarding postoperative skin depressions. There are significant differences in the patterns of care among countries. Class I evidence with regard to patient satisfaction and safety of burr-hole cover placement is likely to have an impact on future cSDH management.

Treating skin graft donor sites: a comparative study between remnant skin use and polyurethane foam.

OBJECTIVE: Excess remnant skin is retained for use in additional grafting in case of split-thickness skin graft (STSG) failure. We hypothesise that regrafting with remnant skin offers greater efficacy and advantages in wound healing and donor site appearance. METHODS: Skin graft donor sites were assessed by comparing those regrafted with remnant skin with those treated with polyurethane foam dressing. Healing time, pain, patient satisfaction, itching sensation, skin stiffness and irregularity between regrafting and foam dressing were compared. The aesthetic satisfaction of donor site was evaluated by four board-certified plastic surgeons. The differences were tested statistically. RESULTS: A total of 39 patients received a STSG due to skin or soft tissue wounds caused by burn, trauma and cancer reconstruction. The donor site healing time was shorter with remnant skin regrafting compared with foam dressing. There was no difference with respect to donor site pain between the two treatment groups. At two weeks after skin graft, patient satisfaction was higher in those treated with remnant skin than in those treated with foam dressing. Aesthetic assessment was improved after 12 weeks. CONCLUSION: Donor site dressing using remnant skin appears to improve wound healing and enhance the aesthetic outcome of donor sites.

Validation of the Vectra XT three-dimensional imaging system for measuring breast volume and symmetry following oncological reconstruction.

PURPOSE: Three-dimensional surface imaging (3D-SI) of the breasts enables the measurement of breast volume and shape symmetry. If these measurements were sufficiently accurate and repeatable, they could be used in planning oncological breast surgery and as an objective measure of aesthetic outcome. The aim of this study was to validate the measurements of breast volume and symmetry provided by the Vectra XT imaging system. METHODS: To validate measurements, breast phantom models of true volume between 100 and 1000 cm3 were constructed and varying amounts removed to mimic breast tissue 'resections'. The volumes of the phantoms were measured using 3D-SI by two observers and compared to a gold standard. For intra-observer repeatability and inter-observer reproducibility in vivo, 16 patients who had undergone oncological breast surgery had breast volume and symmetry measured three times by two observers. RESULTS: A mean relative difference of 2.17 and 2.28% for observer 1 and 2 respectively was seen in the phantom measurements compared to the gold standard (n = 45, Bland Altman agreement). Intra-observer variation over ten repeated measurements demonstrated mean coefficients of variation (CV) of 0.58 and 0.49%, respectively. The inter-observer variation demonstrated a mean relative difference of 0.11% between the two observers. In patients, intra-observer variation over three repeated volume measurements for each observer was 3.9 and 3.8% (mean CV); the mean relative difference between observers was 5.78%. For three repeated shape symmetry measurements using RMS projection difference between the two breasts, the intra-observer variations were 8 and 14% (mean CV), the mean relative difference between observers was 0.43 mm for average symmetry values that ranged from about 3.5 to 15.5 mm. CONCLUSION: This first validation of breast volume and shape symmetry measurements using the Vectra XT 3D-SI system suggests that these measurements have the potential to assist in pre-operative planning and also as a measure of aesthetic outcome.

Improving the aesthetic outcome with burr hole cover placement in chronic subdural hematoma evacuation-a retrospective pilot study.

BACKGROUND: The aesthetic outcome after burr hole trepanation for the evacuation of chronic subdural hematomas (cSDH) is often unsatisfactory, as the bony skull defects may cause visible skin depressions. The purpose of this study was to evaluate the efficacy of burr hole cover placement to improve the aesthetic outcome. METHODS: We reviewed consecutive patients treated by burr hole trepanation for cSDH with or without placement of burr hole covers by a single surgeon between October 2016 and May 2018. The clinical data, including complications, were derived from the institution's prospective patient registry. The primary endpoint was the aesthetic outcome, as perceived by patients on the aesthetic numeric analog (ANA) scale, assessed by means of a standardized telephone interview. Secondary endpoints were skin depression rates and wound pain, as well as complications. RESULTS: From n = 33, outcome evaluation was possible in n = 28 patients (n = 24 male; mean age of 70.4 ± 16.1 years) with uni- (n = 20) or bilateral cSDH (n = 8). A total of 14 burr hole covers were placed in 11 patients and compared to 50 burr holes that were not covered. Patient satisfaction with the aesthetic outcome was significantly better for covered burr holes (mean ANA 9.3 ± 0.74 vs. 7.9 ± 1.0; p < 0.001). Skin depressions occurred over 7% (n = 1/14) of covered and over 92% (n = 46/50) of uncovered burr holes (p < 0.001). There was no difference in wound pain (p = 0.903) between covered and uncovered sites. No surgical site infection, cSDH recurrence, or material failure was encountered in patients who had received a burr hole plate. CONCLUSIONS: In this retrospective series, placement of burr hole covers was associated with improved aesthetic outcome, likely due to reduction of skin depressions. A randomized controlled trial is developed to investigate whether adding burr hole covers results in superior aesthetic outcomes, without increasing the risk for complications.

The potential role of three-dimensional surface imaging as a tool to evaluate aesthetic outcome after Breast Conserving Therapy (BCT).

PURPOSE: To establish whether objective measurements of symmetry of volume and shape using three-dimensional surface imaging (3D-SI) can be used as surrogate markers of aesthetic outcome in patients who have undergone breast conserving therapy (BCT). METHODS: Women who had undergone unilateral BCT in the preceding 1-6 years were invited to participate. Participants completed a satisfaction questionnaire (BREAST-Q) and underwent 3D-SI. Volume and surface symmetry were measured on the images. Assessment of aesthetic outcome was undertaken by a panel of clinicians. The Kruskal-Wallis test was used to assess the relationship between volume and shape symmetry measurements with the panel score. Spearman's rho correlations were used to assess the relationship between the measurements and patient satisfaction. RESULTS: 200 women participated. Median volume symmetry was 87% (IQR 78-93) and shape symmetry was 5.9 mm (IQR 4.2-8.0). The participants were grouped according to panel assessment of aesthetic outcome (poor, fair, good, excellent) and the median volume and shape symmetry was calculated for each group. Volume symmetry significantly differed between the groups. Post hoc pairwise comparisons demonstrated that these differences existed between panel scores of fair versus good and good versus excellent. Median shape symmetry also differed according to patient panel groups with four significant pairwise comparisons between poor versus good, poor versus excellent, fair versus good and fair versus excellent. There was a significant but weak correlation of both volume symmetry and surface asymmetry with BREAST-Q scores (correlation coefficients 0.187 and -0.229, respectively). CONCLUSION: Breast volume and shape symmetry are both associated with panel assessment scores and patient satisfaction. The objective volume and shape symmetry measures were strongly associated with panel assessment scores, such that a 3D-SI tool could replace panel assessment as a faster and more objective method of evaluating aesthetic outcomes.

Aesthetic outcome and complications of simple interrupted versus running subcuticular sutures in facial surgery: A randomized controlled trial.

BACKGROUND: The suturing technique and its associated complications could affect cosmetic outcome after facial surgery. Literature on this topic is limited. OBJECTIVE: To compare the cosmetic results 12 months after treatment and complications associated with simple interrupted sutures (SIS) versus running subcuticular sutures (RSS) in facial surgery. METHODS: A randomized, controlled multicenter trial was performed. Adults receiving dermatologic surgery on the face were randomized to receive SIS or RSS for wound closure. The primary outcome was the overall opinion score on the Patient and Observer Scar Assessment Scale (POSAS) 12 months after surgery. Secondary outcomes were the complication rates and scores according to alternative methods for assessment of cosmetic outcome. The observer of cosmetic outcome was blinded to treatment assignment. RESULTS: 142 patients were randomized to receive SIS (n = 73) or RSS (n = 69). Twelve months after surgery, the median score of the overall opinion on the POSAS was 2.0 (range 1-8) according to the patients and 3.0 (range 1-8) according to the observer in both groups. In the RSS group, hyper- or hypoesthesia was reported more often. LIMITATIONS: The cosmetic result was assessed by 1 observer. CONCLUSION: SIS and RSS in facial surgery resulted in comparable cosmetic outcomes. RSS was more often associated with hyper- or hypoesthesia.

Aesthetic outcome of immediately restored single implants placed in extraction sockets and healed sites of the anterior maxilla: a retrospective study on 103 patients with 3 years of follow-up.

OBJECTIVES: The aim of this study was to compare the aesthetic outcome of single implants in extraction sockets and healed ridges of the anterior maxilla by means of the pink aesthetic score/white aesthetic score (PES/WES) index. MATERIALS AND METHODS: This retrospective study was based on data from 103 patients (43 males, 60 females) aged 24-65 years (mean age 41.4 ± 13.8 years) who had been successfully treated with a single implant in the anterior maxilla, in four different clinical centres. Forty-two patients (mean age 46.5 ± 15.1 years) were treated with a single implant in a fresh post-extraction socket (immediate implant treatment, IIT), while 61 patients (mean age 38.0 ± 11.8 years) were treated with a single implant in a healed site (conventional implant treatment, CIT). Two independent calibrated examiners applied the PES/WES index to the 103 single-tooth restorations, respectively 3 months and 3 years after implant placement. RESULTS: A few biological (4.8%) and prosthetic (8.7%) complications were reported. Both IIT and CIT yielded satisfactory aesthetic outcomes. At the delivery of the final restoration, a PES/WES score of 16.6 ± 2.6 and 15.7 ± 3.0 was reported for IIT and CIT, respectively: this difference was not statistically significant. A higher decrease in the PES/WES score was observed with CIT over time. At 3 years, a PES/WES score of 16.4 ± 2.8 and 15.2 ± 3.3 was reported for IIT and CIT, respectively: this difference was statistically significant. IIT seemed to yield better aesthetic outcomes in young patients (≤30 years), with implants placed in central incisor/cuspid areas, in the presence of bone contouring. CONCLUSIONS: Both immediate and conventional single-implant treatment in the anterior maxilla can yield satisfactory aesthetic outcomes, when performed by experienced clinicians in well-selected cases. Further studies are needed to confirm these results.

Comparison of Aesthetic Outcomes Between Vertical and Horizontal Flap Insets in Breast Reconstruction with the TRAM or DIEP Flaps.

BACKGROUND: Tissue transfer, such as use of the transverse rectus abdominis myocutaneous (TRAM) or deep inferior epigastric artery perforator (DIEP) free flaps, is considered a standard method. However, outcomes may vary among inset methods. Here we compared the aesthetic outcomes of breast reconstructions using vertical and horizontal flap inset methods. METHODS: We, respectively, reviewed 274 patients who underwent unilateral post-mastectomy breast reconstruction using TRAM or DIEP free flaps between April 2006 and December 2013. Photographs (frontal and bilateral oblique views) obtained 6 months post-operatively were evaluated. Symmetry scores and regional volume discrepancy scores were compared between the vertical and horizontal inset groups. Symmetry scores were adjusted for 11 potential confounding factors on multivariate regression analysis. RESULTS: The vertical inset method was associated with higher total symmetry scores, projection, and ptotic naturalness scores. On multivariate regression analysis, the inset method was an independent predictor of outcomes. Regional volume discrepancy score analysis showed a greater tendency for more symmetrical volumes in the upper, medial, and lateral poles with the vertical inset. CONCLUSION: The flap inset method is one of the key determinants of aesthetic breast reconstruction outcomes. The vertical inset method was associated with superior aesthetic outcomes and enabled balanced distribution of flap volume to the four poles of the breast. 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 .