Invited Discussion on "Three-Dimensional Volumetric Analysis of the Effect of Interval Time in Autologous Fat Graft Breast Augmentation" by Yan Lin, MA; Dali Mu, MD; Xiaoyu Zhang, MA; Haoran Li, MA; Yu Yao, BA.

Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/00266 .

A Novel Application of the Hemostatic Net in Aesthetic Breast Surgery: A Preliminary Report.

BACKGROUND: Obtaining optimum breast aesthetics can be challenging in secondary aesthetic breast surgery, particularly with poor-quality skin, when downsizing implants, and in cases where patients will not accept additional mastopexy scars. Most techniques described in these cases rely on internal suturing and capsulorrhaphy, which can lack precision in tailoring the skin over the internal pocket. OBJECTIVES: The aim of this study was to present the authors' experience with utilizing the hemostatic net to help address a range of challenging breast cases in their practices. METHODS: A multicentre retrospective analysis of patients undergoing aesthetic and reconstructive breast surgery between 2019 and 2021 was conducted. A database was established to record patient demographics, indications for surgery, surgical technique, and complications. Following capsulorrhaphy, the hemostatic net was applied in as many rows as required with monofilament sutures and removed 3 to 7 days postoperatively. RESULTS: Twenty-four women (aged 23-67 years) underwent aesthetic or reconstructive breast surgery with the hemostatic net. This approach optimized stabilization of the inframammary fold and redraping of lax skin or irregularities in the skin envelope. At follow-up review, only 1 instance of the net failing to successfully redrape the skin was seen. CONCLUSIONS: The application of the hemostatic net is an option for patients who might otherwise require mastopexy but refuse to accept the scars. The technique has now been extended to primary cases where implant malposition or skin tailoring issues are anticipated, thus securing its place as a part of the surgical armamentarium.

Sting Technique: A New Procedure for Hypoplasic Lower Breast Poles.

BACKGROUND: In breast augmentation patients affected by hypoplasic lower poles are a difficult challenge for plastic surgeons. Indeed in these cases it is difficult to create a nice and round contour, especially if a tight thoracic skin is present. Various techniques have been described in the past in order to solve this problem including parenchymal manipulation, fat grafting alone or after subcutaneous release of the stenotic tissue (Rigottomy). Following a large experience with the use of needles to deliver fat grafting in fibrotic tissue of different type of scars the Authors report in this paper their preliminary experience with a new surgical technique consisting of a multiple percutaneous stings of the skin and gland of the inferior breast quadrants associated to an implant to correct a flat, rigid and hypoplasic lower breast pole. METHODS: A total of 24 patients affected by this malformation have been treated during the breast augmentation procedure using the above-mentioned technique. Hypoplasic lower poles (skin and subcutaneous tissues) have been punctured several times using an 18 G needle before inserting the implant. Results have been evaluated by the Authors and patients grading them from 0, extremely poor, to 10, extremely satisfactory outcome. RESULTS: Aesthetic results evaluated by the surgeons group reported a mean outcome of 7.9, whereas the ones of the patients reported a mean value of 8.3. In one case a capsulotomy for monolateral capsular contracture was performed. In another patient the aesthetic result was revised performing a fat grafting in order to further correct the lower pole. In six cases a subcutaneous blood effusion, due to the prick of the skin, was experienced while in two patients with darker skin (Fitzpatrick III) the use of the needle left pigmented spots that completely disappeared after the use of hydroquinone cream 4% for two months. CONCLUSIONS: Even with the limitations of this preliminary study, such as the small number of patients and the short follow-up, the sting technique seems to be an efficacious and safe new tool in the armamentarium of plastic surgeons to treat hypoplasic breasts with stenotic lower poles. 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 .

Correction to: Invited Discussion on: ''Transaxillary Nipple-Sparing Mastectomy and Direct-to-Implant Breast Reconstruction Using a Simplified Endoscopic Approach: Indications, Cosmetic Outcomes and Technical Refinements''.

This erratum is to add reference citation to the original article discussed in this invited commentary. Original reference 1 in the article becomes reference 2. Updated reference list appears below.

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 .

Labia majora labioplasty in HIV-related vaginal lipodystrophy: technique description and literature review.

BACKGROUND: We present a rare case involving severe hypertrophy of the labia majora. This 39-year-old married woman developed a clinically noticeable bilateral lipodystrophy of her labia majora following the administration of chronic antiretroviral therapy. Different combination drug regimens that included drugs like Crixivan(®), Epivir(®), and Zerit(®) were administered to the patient from 1998 to 2005. The patient is currently on a single drug regimen of Atripla(®) with the disease under control and no other comorbidities. The severity of the pubic protuberance created an appearance resembling male genitalia, even when covered by underwear. This anatomical abnormality obviously impaired her social life and forced her to avoid wearing tight pants, swimming garments, and tight clothes in general. She also avoided any sexual activity. METHODS: Her pubic hair was shaved. Crural creases and vulvar mucosa were marked in order not to be violated. The estimated amount of skin and fat to be removed was marked. Intraoperative tailor-tacking suturing was used to mark the extent of the resection of the labia majora. Sutures were left in place to verify the accurate tension of the remaining skin. The procedure was performed with the patient under general anesthesia. Labial skin resection was performed by sharp dissection. Electrocautery was then used to excise the lobulated fat accumulation. Two layers of 3/0 Vicryl(®) sutures were used in the lax subcutaneous tissue. 4/0 Vicryl(®) rapide was used on the skin to approximate wound edges. Suction drains were left in place for 48 h to reduce the dead space and to manage postoperative bleeding. The patient was instructed to keep ice and compression pads on the area for the first 24 h and to keep the area clean. This was followed by the application of antibiotic ointment two times a day on the wounds to avoid blood crust formation and to keep the skin soft. RESULTS: Stitches were removed on POD 14 after an overall uneventful postoperative course. The sensitivity of the labia majora's interior aspect was preserved, even initially. With the legs slightly open, the labia majora just covered the entrance to the vagina. The clitoris and labia minora became visible again, restoring a normal anatomical appearance. Moderate edema was observed for 4 weeks after surgery. CONCLUSION: The surgical technique used provided an excellent result according to the patient, who regained her self-confidence and started having a normal sexual life again. 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 .