Augmentation Mastopexy: A Five-step Standardized Strategy Approach.

Planning a combined procedure requires ensuring an optimal fill of the reduced breast skin envelope, which in turn requires a system to quantify skin excess to ensure that the selected implant achieves that optimal fill. This has led us to develop a five-step approach that a surgical team can use to assess patients scheduled to undergo an augmentation mastopexy and arrive at an optimal surgical strategy. Methods: This retrospective study included 50 consecutive cases where layered mastopexies combined with augmentation mammaplasties were performed. Step 1 entailed a preoperative examination and evaluation of the breasts. In step 2, the breast volume was assessed. The pocket plane was determined in step 3. The choice of which surgical technique to use was done in step 4, and in step 5, the horizontal skin excess was assessed. Results: The average implant size was 300 cm3 (range: 170-350 cm3). The overall revision rate was 4%: on average, revision surgeries were performed 24 months after the first surgery. The average implant size was 300 cm3 (range: 170-350 cm3). Conclusions: Early results of single-stage augmentation with mastopexy have shown that the design of this systematic five-step approach demonstrates a great potential for producing reliable results with minimal risk. Using this five-step approach will improve patient and surgeon satisfaction and help to replace the old concept of "fill and re-drape" with a new one of "plan, reduce, fill, and re-drape."

Mastopexy: with or without Acellular Dermal Matrix?

In the years after unilateral breast reconstruction, the reconstructed breast resists ptosis more than natural breast tissue in the native contralateral breast. As acellular dermal matrix (ADM) becomes fully incorporated into the recipient's anatomy, thus reinforcing the inferior pole of the uplifted breast, we combined our mastopexy cases with ADM in an attempt to reduce the rate of recurrent ptosis. Method: This was a prospective randomized analysis of a cohort of 24 patients, divided into two groups (A and B); all underwent primary unilateral mastopexy to correct grade III breast ptosis. Our patients had previously undergone contralateral skin sparing mastectomy with immediate breast reconstruction, for invasive breast cancer or ductal carcinoma in situ that originally was symmetrical to their native breast. The symmetrization mastopexy in half of our patients was carried out with the addition of an ADM sling to the inferior pole of the breast, to act as an internal, subcutaneous supportive "bra" (A). The other half of patients received a standard symmetrization mastopexy, without the addition of an ADM support (B). Patients were followed up for 36 months. Results: The difference between control arm and study groups revealed a statistical difference (P < 0.05), when comparing the follow-up period. From the sixth postoperative month onward, the measurements for group A revealed a statistically significant difference (P < 0.05) when compared with group B. Conclusion: The additional ADM sling acts as an added layer of support, thus delaying reoccurrence of ptosis following mastopexy.

Lower Pole Breast Reconstruction Using Muscle-sparing Latissimus Dorsi Flap in Postburn Breast Deformity.

BACKGROUND: Full-thickness burns of the anterior chest wall during childhood are a devastating problem that results in significant distortion of the developing breast. This deformed burnt breast represents a serious aesthetic problem, and can lead to functional impairment as well as severe emotional trauma for patients. METHODS: Patients with postburn scarring affecting the lower pole of the breast were included. Only patients with small to medium-sized breasts were targeted. The lower breast pole was reconstructed using muscle-sparing latissimus dorsi flap. All patients had been subjectively assessed, including overall patient satisfaction regarding breast aesthetics, donor site morbidity, and functional deficits of latissimus dorsi muscle, 3 months postoperatively. RESULTS: Six patients (seven breasts) were included in this study. Muscle-sparing latissimus dorsi flap was used to reconstruct lower breast pole in all patients. A horizontally-oriented skin paddle was used in five patients, whereas a vertically oriented skin paddle was used in one patient. Average patient satisfaction was 9.1 (SD 0.6) for the reconstructed lower breast pole. For the donor site, average overall satisfaction was 9.1 (SD 0.8). Latissimus dorsi muscle function was objectively confirmed in 90% of cases after 3 months postoperatively. Patients had an average score of 3.9 (SD 0.4) for the activity score as well. CONCLUSIONS: The muscle-sparing latissimus dorsi flap is a good reconstructive tool for lower breast pole in postburn breast reconstruction. It has a reliable versatile skin paddle that can resurface the whole lower breast pole, while avoiding many of the latissimus flap morbidities.

Rotating the Tip in Long Noses: A Strategy rather than a Single Technique.

BACKGROUND: Rhinoplasty is one of the most commonly performed aesthetic surgical procedures in plastic surgery, the incidence of which has increased up to approximately 1 million cases in 2016 according to the recent International Society of Aesthetic Plastic Surgery survey. This study aimed at defining the importance of each sequential procedure within the same surgery, the extent to which a procedure can be performed, and those that can be omitted. METHODS: In this descriptive study, 27 candidates (18 women; nine men; age range, 20-48 years) for primary rhinoplasty between September 2016 and September 2019 were included. All had long noses, their main concern was reduction of nasal tip projection and all were seeking cranial tip rotation to enhance their tip aesthetics. Those who required revision rhinoplasty or who had nasal deformities due to congenital defects, and those older than 60 or younger than 18 years of age, were excluded. RESULTS: The average nasolabial angle in women preoperatively was 88.2 ± 6.6 and postoperatively 102.8 ± 5.6. In men, the average average nasolabial angle preoperatively was 79.6 ± 5.4 and postoperatively 92.3 ± 2.3. In both men and women, the P value was <0.001, which indicates high significance. Tip rotation was achieved in all patients, with 81% achieving ideal rotation, and 19% exceeding the ideal range. CONCLUSIONS: Rotating the tip in long noses is a complex procedure. It can be achieved by many described techniques, but not all are required. A general strategy should be followed during which variable techniques, with varying efficacy, can be utilized.

Systematic Approach for Management and Prevention of Boxy Breast.

BACKGROUND: Although a boxy breast is a common aesthetic problem following breast reduction and mastopexy, literature regarding this deformity is scarce. It is vaguely described as a definitive postreduction deformity. To address this complication, it is important to fully analyze the problem, understand and predict its causes, and then try to prevent it. METHODS: This study included two groups. Group 1 included 14 patients presenting with boxy postoperative breasts. Revision surgeries were conducted for all patients, and the first algorithm was created for quantifying breast surgery in revision cases. Group 2 included 37 cases of primary mammaplasty reduction/mastopexy performed between 2016 and 2019. All the patients in this group were treated as per the study algorithm. RESULTS: Patient satisfaction was measured on a scale of one to 10, with one being extremely dissatisfied and 10 being extremely satisfied. The results indicated overall satisfaction, with average scores of 9.5 and 9.1 in groups 1 and 2, respectively; the scores of surgeon satisfaction were 8.2 and 8.6, respectively. CONCLUSIONS: The proposed algorithm, preoperative markings, intraoperative techniques, and postoperative orientation may help achieve optimal results and prevent undesired deformities or asymmetry. Applying a flexible and simplified algorithm provided a more objective plan, which enabled surgeons to attain more satisfactory results. Following a preset quantified plan supported and shortened learning curves and objectively addressed the common postoperative complication, breast boxing.

Alar Flare Preservation Using the Sandwich Technique as an Adjunct to Alar Base Reduction.

Achieving an aesthetic balance and natural appearance when modifying soft tissues of the nasal tip, alae, and nostrils is fundamental to the success of rhinoplasty surgery. The present study aimed to investigate the ability of a simple "sandwich" technique combined with external alar base reduction to preserve the alar flare and achieve a natural and appealing alar contour. METHODS: The study included 40 patients who reported dissatisfaction due to excessive nasal flaring. Cartilaginous grafts were harvested from the septum in cases of primary rhinoplasty. Grafts were harvested from the conchal cartilage in cases of secondary rhinoplasty to ensure adequacy of the grafts. The grafts were inserted from the alar wedge excision point along the created pocket to be "sandwiched" in the soft tissue of the alar rim. RESULTS: The average preoperative alar flare was 35.2 mm (SD ±1.9 mm), with an average postoperative reduction of 3 mm. Difference between intercanthal distance and postoperative alar flare distance showed a mean of (-0.4 mm) (SD ±1.2 mm) and was highly significant with P < 0.05. A comparison between nasal base width and alar flare measurements was done. Difference between nasal base width and preoperative alar flare distance was (-9.2 mm) (SD ±2.6), and between nasal base width and postoperative alar flare was (-6.3 mm) (SD ±2.1). Postoperatively, overall patient satisfaction was scored 4.1 of 5. CONCLUSION: The use of a trapezoidal graft, in combination with external alar base reduction, markedly improves the basal view while maintaining the natural alar flare and curvature.

Antia-Buch versus Franssen-Frechner Technique.

We performed a retrospective study comparing 2 patient groups. Each cohort included 22 cases of skin cancer of the external ear. Each patient required resection of the affected part of the external ear, followed by flap reconstruction. METHODS: The patients in Cohort A underwent external ear reconstruction with a classic Antia-Buch flap, as described by Antia and Buch in 1967: The defect was closed by mobilizing an advancement flap from the root of the helix (upper ear), which was closed in a V-Y fashion, after a rim of healthy scaphal cartilage was resected to allow approximation of the skin. The patients in Cohort B underwent external ear reconstruction with a modified Antia-Buch flap, as presented by Franssen and Frechner in 2010. Here, a wedge of skin was removed from the ear lobe (lower ear), to allow mobilization of an advancement flap from the caudal end of the ear, to close the defect. RESULTS: Both techniques allowed tension-free closure. Cohort B, however, required less dissection of the ear. The entire cephalic ear remained unaffected and no scaphal cartilage was sacrificed, thus preserving ear width, with scars that were overall less visible. Also, the loss in ear height associated with Cohort B was easily symmetrized by contralateral ear lobe reduction. CONCLUSIONS: Cohort B achieved closure with less ear dissection, achieving excellent morphological outcomes. The patients in Cohort B had superior levels of satisfaction with scars and ear symmetry than those in Cohort A.

Effect of Platelet Rich Plasma versus Saline Solution as a Preservation Solution for Hair Transplantation.

BACKGROUND: Hair transplantation is the only method available to regrow new hairs; hence, enhancing the results of this procedure using state-of-the-art methods has become mandatory in clinical practice. Recent studies have suggested that significant improvements in hair density and stimulation of hair growth occur when follicular units are pretreated with platelet plasma growth factors before implantation. This study aimed to investigate and compare the outcomes of this procedure using platelet-rich plasma (PRP)-preserved hair grafts and saline-preserved hair grafts. METHODS: This is a randomized controlled study. The study included 27 men and 3 women aged 22-51 years. Clinical examination (general and local) and preoperative marking were performed in these patients. The surgical technique involved graft extraction, PRP preparation, and hair implantation. Postsurgical patient satisfaction and clinical improvement were evaluated. RESULTS: There were significant differences between the groups in hair uptake and hair thickness after 1 year follow-up, with P value <0.05. Using PRP therapy with follicular unit extraction increases the success of follicular unit extraction hair transplantation. All participants in the PRP group had >75% hair regrowth after 6 months. They had more rapid improvements in hair density and skin recovery than those in the non-PRP group. CONCLUSION: Preserving hair grafts in PRP before implantation increases the hair density, the graft uptake, and the hair thickness compared with pretreatment preservation of hair grafts in saline.

Distally-based Peroneus Brevis Turnover Muscle Flap in the Reconstruction of Soft Tissue Defects.

Reconstruction of the distal 3rd of the lower leg requires either local or free flap coverage if tendons or bones are exposed. The distally based, pedicled peroneus brevis (PB) flap has been shown to be a valid option in the management of distal 3rd lower limb injuries. Herein, we present 21 cases treated with distally-based PB muscle flaps between May 2017 and September 2019. The defect location varied, and included defects over the lateral and medial malleolar areas, distal tibia (middle and distal 3rd junction, and the distal 3rd), and Achilles tendon area. METHODS: The PB was dissected from the lateral fibula and intermuscular septa in a cephalic to caudal direction, to a point no lower than 7 cm proximal to the lateral malleolus tip. This preserved most distal vascular perforators to the muscle, and afforded sufficient mobilization to allow successful turn-over of the muscle, with transposition into the defect within 30 minutes of tourniquet time. A meshed skin graft completed the intervention. RESULTS: The metalwork was removed in all chronic cases (10/21), as bone union had occurred. All flaps survived completely. One patient partially lost the skin graft; the wound was healed by secondary intention. No major complications occurred and no significant patient discomfort was noted. All wounds healed completely by 9 weeks of follow-up. CONCLUSION: The PB turnover muscle flap is a versatile flap, ideally suited to manage up to moderately sized defects of the distal 3rd of the lower leg, with negligible postoperative morbidity.