Polyurethane Implants in Revisional Breast Augmentation: A Prospective 5-Year Study.

BACKGROUND: Revisional surgery for aesthetic breast augmentation remains a challenging procedure. Polyurethane (PU) implants have been found to avoid capsular contracture recurrence as well as to prevent implant displacement by bio-integrating with the pocket. OBJECTIVES: Our study aimed to assess the use of PU implants in breast revisional surgery and to provide an algorithm. METHODS: Over a 5-year period, a prospective study was conducted involving consecutive patients undergoing implant revision. Patient demographics, previous breast procedures, and specific surgical details were documented. Postoperative outcomes were followed up. RESULTS: Out of 92 patients (184 breasts), 78 (156 breasts) were included in the analysis. The average age was 47.5, with a BMI of 22.3 and a mean follow-up of 5 years. A majority (63%) represented secondary revisional cases, while 37% were tertiary cases. Implant size averaged 296 cc, with 53% placed in retropectoral position and 47% prepectoral. Significantly more implants in secondary cases were changed from prepectoral to retropectoral (P = .005), and in tertiary changed from retropectoral to prepectoral (P = .002). Complete capsulectomy was performed in 61.5% and partial in 25.6%. Additional lipofilling was performed in 32%, and concurrent mastopexy in 40%. Revisional surgery in our series had a 1.9% acute complication rate, 4.5% longer-term reoperation rate for corrections, 0.6% implant exchange rate, and no recurrent capsular contracture. CONCLUSIONS: This is the first study to provide data on outcomes of revisional breast augmentation surgery with PU implants. It shows that polyurethane implants offer consistent stability and have low rates of recurrent capsular contracture in revisional surgery.

Push-Through Filtration of Emulsified Adipose Tissue Over a 500-µm Mesh Significantly Reduces the Amount of Stromal Vascular Fraction and Mesenchymal Stem Cells.

BACKGROUND: Mechanical isolation of the stromal vascular fraction (SVF) separates the stromal component from the parenchymal cells. Emulsification is currently the most commonly used disaggregation method and is effective in disrupting adipocytes and fragmenting the extracellular matrix (ECM). Subsequent push-through filtration of emulsified adipose tissue removes parts of the ECM that are not sufficiently micronized, thereby further liquifying the tissue. OBJECTIVES: The aim of this study was to investigate whether filtration over a 500-µm mesh filter might affect the SVF and adipose-derived mesenchymal stem cell (MSC) quantity in emulsified lipoaspirate samples by removing ECM fragments. METHODS: Eleven lipoaspirate samples from healthy nonobese women were harvested and emulsified in 30 passes. One-half of the sample was filtered through a 500-µm mesh filter and the other half was left unfiltered. Paired samples were processed and analyzed by flow cytometry to identify cellular viability, and SVF and MSC yield. RESULTS: Push-through filtration reduced the number of SVF cells by a mean [standard deviation] of 39.65% [5.67%] (P < .01). It also significantly reduced MSC counts by 48.28% [6.72%] (P < .01). Filtration did not significantly affect viability (P = .118). CONCLUSIONS: Retention of fibrous remnants by push-through filters removed ECM containing the SVF and MSCs from emulsified lipoaspirates. Processing methods should aim either to further micronize the lipoaspirate before filtering or not to filter the samples at all, to preserve both the cellular component carried within the ECM and the inductive properties of the ECM itself.

Decreasing donor site morbidity after groin vascularized lymph node transfer with lessons learned from a 12-year experience and review of the literature.

INTRODUCTION: Donor site morbidity related to vascularized lymph node transfer (VLNT) remains a cause of worry among surgeons. As such, our study explores donor site morbidity after VLNT with or without concomitant deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. Furthermore, we evaluate our surgical approach to ascertain whether it reduces the morbidity rate. MATERIALS AND METHODS: A retrospective chart review of donor site complications and surgical techniques was performed from 2006 to 2018. The patients' medical histories and demographic data were analyzed for risk factors. Patients were contacted by telephone for a long-term follow-up questionnaire. A literature review was implemented to evaluate the reported donor site complications and surgical strategies in literature. Complications were evaluated with and without concomitant autologous breast reconstruction (DIEP flap). RESULTS: Eighty-nine patients were included in our case series. Sixty-five cases (73%) were combined with DIEP flap breast reconstruction. Seroma rate diminished from 60% in the first 39 cases to 18% in the last five years (50 cases) (p < 0,001). Lymphedema of the afferent lower limb is described in the literature but did not occur in our series. CONCLUSIONS: Seroma formation is the most common donor site morbidity after groin VLNT flap harvest, particularly when combined with DIEP flap breast reconstruction. This paper contains the largest reported series of combined VLNT + DIEP flaps and describes surgical strategies on how to decrease seroma formation and avoid iatrogenic lymphedema of the lower limb.

Nanofat Needling: A Novel Method for Uniform Delivery of Adipose-Derived Stromal Vascular Fraction into the Skin.

A novel method for delivering nanofat into the skin is presented. The principle is based on documented experience with introduction of agents into the skin by means of microneedling.

Aging of the Upper Lip: Part II. Evidence-Based Rejuvenation of the Upper Lip-A Review of 500 Consecutive Cases.

BACKGROUND: Findings from photometric analysis of soft tissue on cranial magnetic resonance imaging demonstrate that the aging upper lip shows significant lengthening, thinning, volume loss, and deepening of the nasolabial folds. In this study, these findings are implemented in a review of 500 cases of upper lip rejuvenation to propose an evidence-based strategy for surgical rejuvenation of the upper lip. METHODS: The charts of 500 consecutive surgical perioral rejuvenation patients treated by the senior authors (P.L.T. and A.M.V.) from 2014 until 2018 were reviewed. The surgical methods of lip lift and fat grafting were described in relation to the cases and the metric data. RESULTS: Of the 500 patients, 51 had an isolated procedure such as a lip lift (3 percent), lip augmentation (3 percent), augmentation of the nasolabial folds (2 percent), or skin resurfacing (2 percent). The remaining 449 patients underwent combinations of lip lift, augmentation of the lip and nasolabial fold (32 percent), lip lift with augmentation of the lip and nasolabial fold with resurfacing (30 percent), lip augmentation and resurfacing (14 percent), or lip lift and resurfacing (14 percent). CONCLUSIONS: Rejuvenating the upper lip needs to address both lengthening and volume loss. This requires a combination of surgical shortening of the upper lip by a precisely designed lip lift and a differential filling of certain upper lip regions by microfat grafting. The combination of these two modalities works synergistically. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Aging of the Upper Lip: Part I: A Retrospective Analysis of Metric Changes in Soft Tissue on Magnetic Resonance Imaging.

BACKGROUND: In scientific literature, numerous theories on the mechanism of facial aging can be found. The debate about facial sagging versus deflation is still ongoing. In this study, the metric changes in perioral soft tissue were demonstrated. These data can contribute to a better understanding of physical changes in the aging perioral area. METHODS: Upper lip measurements were performed on cranial magnetic resonance images of 200 Caucasian subjects (100 men and 100 women). The study population was aged between 20 to 30 and 65 to 80 years. The upper lip length and soft-tissue thickness were measured on sagittal and parasagittal section. Cross-section surface area of the upper lip was measured in the sagittal section to represent volume. The data were analyzed with a t test and results were considered significant at p < 0.01. RESULTS: The upper lip in the old age group differed significantly in length (19.24 percent in women and 18.24 percent in men), thickness (up to -40.55 percent in women and -32.74 percent in men), and volume (-20.89 percent in women and -17.40 percent in men). Soft-tissue thickness at the alar nasolabial fold was significantly thinner in the old age group (-25 percent in women and -25.7 percent in men) and showed significantly greater tissue loss than elsewhere in the upper lip (p < 0.001). CONCLUSIONS: These results suggest that the aging perioral area is affected with a combination of soft-tissue lengthening, thinning, and volume loss. The clinical implications of this study on perioral rejuvenating strategies will be explained in part II.

Creation of Clitoral Hood and Labia Minora in Penile Inversion Vaginoplasty in Circumcised and Uncircumcised Transwomen.

Gender dysphoria, the incongruence between anatomical sex and gender identity, is estimated to affect 1 percent of the population. Creation of a feminine vulva with labia minora remains a technical challenge for surgeons, especially in circumcised patients. The authors present the technique developed by the senior author (S.M.) that uses prepuce skin in uncircumcised patients or distal shaft skin in circumcised patients for creation of both clitoral hood and labia minora. A retrospective case review was conducted of all penile inversion vaginoplasties performed by the senior author between 2014 and 2016. Patient characteristics, history of circumcision, and revision surgery were recorded. Surgical technique to create and inset the neoclitoris and labia minora in a single-stage penile inversion vaginoplasty is described in detail. A total of 161 penile inversion vaginoplasty operations were performed. Creation of labia minora and clitoral hood was achieved in all patients, with 4.3 percent undergoing an early intervention for bleeding or dehiscence and 5.6 percent requiring late revision surgery for diverted urinary stream. Average length of follow-up was 29 months. Age, hormonal therapy time, body mass index, smoking, and diabetes were the investigated risk factors for postoperative complications, but no significant correlations were found. All patients met the standards of care set forth by the World Professional Association for Transgender Health. Creation of the clitoral hood and labia minora during penile inversion vaginoplasty is achievable in both circumcised and uncircumcised patients, with good aesthetic results and a low revision surgery rate. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Microneedling: Where do we stand now? A systematic review of the literature.

BACKGROUND: Patients who suffer from scars or wrinkles have several therapeutic options to improve the appearance of their skin. The available treatment modalities that provide desirable results are often overtly invasive and entail a risk of undesirable adverse effects. Microneedling has recently emerged as a non-ablative alternative for treating patients who are concerned with the aesthetic changes that result from injury, disease or ageing. OBJECTIVE: This review aims to evaluate the current evidence in the literature on microneedling. METHODS: A systematic literature review was performed by searching the electronic databases PubMed and Google Scholar. The reviewed articles were analysed and compared on study design, treatment protocol, outcome parameters, efficacy measurement and results to evaluate the strength of the current evidence. RESULTS: Microneedling was investigated in experimental settings for its effects on atrophic acne scars, skin rejuvenation, hypertrophic scars, keloids, striae distensae, androgenetic alopecia, melasma and acne vulgaris. Several clinical trials used randomisation and single-blindation to strengthen the validity of the study outcome. Microneedling showed noteworthy results when used on its own and when combined with topical products or radiofrequency. When compared with other treatments, it showed similar results but was preferred due to minimal side effects and shorter downtime. CONCLUSION: This systematic review positions microneedling as a safe and effective therapeutic option for the treatment of scars and wrinkles. The current literature does show some methodological shortcomings, and further research is required to truly establish microneedling as an evidence-based therapeutic option for treating scars, wrinkles and other skin conditions.