Immediate Prepectoral Breast Reconstruction in Suboptimal Patients Using an Air-filled Spacer Introduction: Immediate prepectoral breast reconstruction offers excellent aesthetic results with less pain and elimination of animation deformity due to avoidance of pectoralis dissection and subpectoral implant placement. Concerns about the effects of prostheses on flap perfusion have limited use of the technique to highly selected patients. We present a series of “suboptimal” patients that have undergone immediate prepectoral breast reconstruction utilizing an air-filled “spacer” implant. Methods: A single surgeon’s experience with immediate, single-stage prepectoral breast reconstruction using a Spectrum implant was retrospectively reviewed. Patient demographics, adjuvant therapies, risk factors for threatened flaps, and complications, including those that required subsequent intervention, were evaluated. Results: Twenty-five patients (39 breasts) underwent immediate prepectoral reconstruction with a Spectrum implant. Ten patients had minor complications, 6 of whom required intervention with successful correction. There was a single case of implant loss in the series; this patient had prior radiation. Conclusions: Utilizing the spacer concept, immediate single-stage prepectoral breast reconstruction is a viable alternative to subpectoral implant placement or delay procedures. The technique delivers aesthetic results with less postoperative pain, quicker operative times, and avoidance of animation deformity. It can be considered for any patient, including high-risk patients such as those with radiation exposure, thin/threatened skin flaps, significant ptosis, and obesity.

Novel Surface Anatomic Landmarks of the Jowl to Guide Treatment with ATX-101 Summary: Facial appearance is critical to physical attractiveness, and maintaining a youthful face and neck is a major motivation for individuals seeking facial cosmetic procedures. A strong mandibular border without prominent jowls is one sign of a youthful face as jowling occurs with age, contributing to squaring of the face and loss of jawline definition. Excess jowl fat has traditionally been reduced with surgical liposuction when jowling is caused by fat flow across the mandible. The approval of ATX-101 (deoxycholic acid injection) for submental fat reduction provides a minimally invasive technique that may also be suitable for jowl fat reduction. The author has developed novel facial markings that consistently isolate the jowl fat area of concern at the mandible for treatment with ATX-101. The current work refreshes physicians on important jowl anatomical structures, defines the facial markings that consistently isolate the jowl, and describes an injection technique to safely treat excess jowl fat with ATX-101.

Association of Body Dysmorphic Disorder with Leptin Levels in Patients with Normal Weight Undergoing Liposuction: A Matched Case Study Background: Liposuction is the most common aesthetic surgical procedure performed globally. Some of the patients with normal weight who seek liposuction may suffer from body dysmorphic disorder (BDD). Leptin, which is mainly produced by adipose tissue, may be associated with this condition. The aim of this study was to determine the prevalence of BDD and leptin levels in patients with normal weight seeking liposuction. Methods: Thirty-two nonobese women who sought liposuction were matched with 32 healthy volunteers by age and body mass index. Blood biochemistry, leptin levels, and BDD-Yale–Brown Obsessive-Compulsive Scale (BDD-YBOCS) questionnaires were evaluated and compared between the groups. Results: Patients who underwent liposuction had significantly higher median (interquartile range) of total BDD-YBOCS scores than healthy volunteers [25 (22–27) versus 12 (8–20); P < 0.001]. Overall, 28 (87.5%) patients had total BDD-YBOCS scores of >20, whereas 10 (31.5%) volunteers had scores of >20. Patients with total BDD-YBOCS scores of >20 had significantly lower levels of serum leptin [12.43 (7.15–16.98) ng/ml versus 15.57 (9.59–22.28) ng/ml; P = 0.043]. Conclusions: Patients who underwent liposuction had a significantly higher total score of BDD-YBOCS than healthy volunteers matched by sex, age, and body mass index. Subjects with higher BDD-YBOCS scores had significantly lower serum leptin levels.

Hyperbaric Oxygen Preconditioning Can Reduce Postabdominoplasty Complications: A Retrospective Cohort Study Background: Hyperbaric oxygen therapy (HBOT) can improve wound healing and has been found to have positive preconditioning effects in animal models. Among esthetic surgical procedures, abdominoplasty poses the highest rate of postoperative complications. The aim of this study was to evaluate the effect of preoperative HBOT as a preconditioning treatment for expected postsurgical complications. Methods: We conducted a retrospective cohort study among patients who underwent abdominoplasty at our institute and private practice between January 2012 and November 2017. Patients who received preoperative HBOT were compared with patients who did not receive HBOT. Surgical complication data and demographic, preoperative and postoperative data from patient records were collected. Results: The study included 356 patients. Of them, 83 underwent HBOT preoperatively. Using preoperative HBOT, postoperative complications were significantly reduced from 32.6% (89 patients) to 8.4% (7 patients), P <0.001. Moreover, 17 (6.2%) patients in the comparison group and none in the HBOT group experienced necrosis (P = 0.016). In the multivariate analysis, preoperative HBOT was an independent protective factor against postoperative complications (odds ratio, 0.188; 95% CI, 0.082–0.432; P < 0.001). After propensity score matching, the study results remained the same. Conclusions: Preoperative HBOT can reduce postoperative complication rate in abdominoplasty patients. Further prospective studies are necessary to validate the findings and characterize patients who benefit the most from this treatment.

Integrating Fat Graft with Blepharoplasty to Rejuvenate the Asian Periorbita Background: Contemporary periorbital rejuvenation is undergoing a paradigm shift to an approach that prioritizes volume preservation and/or augmentation. However, the technical difficulties of using traditional fat grafting techniques in this area and the distinct ethnic features make periorbital rejuvenation in Asians especially challenging. Here, the authors present their approach to enhance the periorbita and outcomes. Methods: A retrospective chart review was performed for 33 consecutive patients who underwent microautologous fat transplantation (MAFT) to the periorbita using the MAFT gun device combined with excisional blepharoplasty. Additionally, preoperative and postoperative photographs were analyzed by external evaluators to grade the aesthetic outcomes and fat resorption rates. Results: Three months after surgery, patients looked on average 5.4 ± 3.4 years younger, and the aesthetic result was graded 7.4 ± 2 in a one-to-ten scale. The fat resorption rate was 19.6% ± 3.5% at 3 months and 32.2% ± 3.9% after 12 months (range: 12–24 months; P = 0.007). The overall morbidity rate was 12% (4 patients), including 1 visible lump (3%), an overcorrection case (3%) in the lower eyelid, and 2 palpable lumps in the upper eyelid (6%) which were not visible. One case of lower eyelid hollowness required secondary fat grafting. Conclusions: Traditional blepharoplasty procedures can be combined with fat grafting techniques to address volume loss and tissue descend while keeping ethnic identity. A fat injection device like the MAFT gun is safe and effective and provides long-term predictable outcomes for fat grafting around the periorbital thin skin.

Oncoplastic Volume Replacement for Breast Cancer: Latissimus Dorsi Flap versus Thoracodorsal Artery Perforator Flap Background: Volume replacement oncoplastic breast techniques have become one of the standard lines in the treatment of early breast cancer. They have better cosmetic outcome and patient satisfaction. Latissimus dorsi (LD) flap is one of the most commonly used flaps for these techniques. Although it shows satisfactory surgical outcomes, postoperative shoulder dysfunction is an obvious drawback. The aim of this study was to compare LD flap with thoracodorsal artery perforator (TDAP) flap after breast-conserving surgery regarding surgical outcomes, patient satisfaction, and impact on shoulder function. Methods: The study included 42 adult female patients with early breast cancer who were eligible for conservative breast surgery and immediate breast reconstruction. Patients were divided into 2 equal groups: group A where patients underwent immediate reconstruction using LD flap and group B where patients underwent reconstruction using TDAP flap. Follow-up was designed for 12 months for early outcome, patient satisfaction, and shoulder functions. Results: The mean age of the included patients in group A and group B was 40.95 ± 5.06 and 40.33± 5.25 years, respectively. There was no significant difference in flap dimensions, postoperative complications, or cosmetic outcome in both groups. However, significantly less shoulder dysfunction was documented in cases of TDAP compared to LD flap at 3, 6, and 12 months postoperatively. Conclusions: TDAP flap is as reliable a technique as LD flap regarding the feasibility, postoperative complications, and the cosmetic outcome with significantly better functional outcome of the shoulder.

Impact of Rectus Muscle Injury during Perforator Dissection on Functional Donor Morbidity after Deep Inferior Epigastric Perforator Flap Breast Reconstruction Background: This study aimed to assess the extent of rectus muscle damage in deep inferior epigastric perforator (DIEP) flap harvest and to evaluate its association with functional donor morbidity. Methods: A prospective cohort of 76 patients who underwent DIEP flap breast reconstruction was evaluated preoperatively and followed up for 1 year. Abdominal wall strength was assessed using the upper and lower rectus abdominis manual muscle function tests. Functional weakness was defined as a postoperative decrease in function by at least 2 scores. The effects of patient- and operation-related characteristics on adverse outcomes were also assessed. Results: The mean width of the transected rectus muscle was 2.2 cm (partial thickness, 1.8 cm; full thickness, 0.4 cm). The mean width ratio of the overall injured muscle to the entire bilateral muscle was 0.18. Muscle injury was more severe in the cases with bipedicled flap elevation and in those with 4 or more perforators harvested. Functional weakness was detected in 13 patients (17.1%). Multivariate analyses demonstrated that the width ratio of the muscle injury was an independent predictor of functional weakness. The width ratio achieved maximal discrimination regarding the rate of functional weakness at a threshold value of 0.12, indicating that functional weakness did not develop in all 19 cases with a width ratio of <0.12. Conclusions: The extent of rectus muscle injury during perforator dissection may be associated with functional donor morbidity after DIEP flap harvest. This may be beneficial in achieving proper balance between securing flap perfusion and preserving donor functions.

Cost Utility of Breast Tissue Expansion using Carbon Dioxide versus Saline: An Analysis of Infection Risk Background: The AeroForm System, a needle-free, patient-controlled carbon dioxide-filled tissue expander, represents a novel option for tissue expansion in 2-stage breast reconstruction. This technology has previously been found to decrease time to expansion, health-care utilization, and infection rates. The purpose of this study was to determine the economic impact of the reduced infection rate observed with the AeroForm tissue expander as compared with saline tissue expansion. Methods: A decision model incorporating costs, quality-adjusted life years, and clinical outcomes of infection was designed to evaluate the cost-efficacy of AeroForm tissue expanders versus conventional saline expanders. All statistical calculations were performed in the R statistical computing environment. Results: Pooled infection rates from the published literature following saline and AeroForm tissue expander placement were 5.83% and 2.62%, respectively. Cost-utility analysis resulted in a baseline expected savings of $253.29 and an expected gain of 0.00122 quality-adjusted life years with AeroForm tissue expanders. One-way sensitivity analysis revealed that AeroForm tissue expanders were dominant when the surgical site infection rate was greater than 4.56% with traditional saline expanders. Conclusions: Clinical benefits of an innovation are no longer sufficient to justify its acquisition costs. Novel technologies must also demonstrate favorable economic outcomes. This cost-utility analysis demonstrates that the use of AeroForm expanders is likely a cost-saving technology for 2-stage breast reconstruction.

International Expert Panel Consensus on Fat Grafting of the Breast Background: Autologous fat grafting has broad applications in reconstructive and aesthetic breast surgery as a natural filler and for its regenerative purposes. Despite the widespread use of fat grafting, there remains no shared consensus on what constitutes the optimal fat grafting technique and its oncological safety. For this reason, the authors of this study have organized a Survey and an International Consensus Conference that was held at the Aesthetic Breast Meeting in Milan (December 15, 2018). Methods: All studies on fat grafting, both for breast aesthetic and reconstructive purposes, were electronically screened. The literature review led to 17 “key questions” that were used for the Survey. The authors prepared a set of 10 “key statements” that have been discussed in a dedicated face-to-face session during the meeting. Results: The 10 key statements addressed all the most debated topics on fat grafting of the breast. Levels of evidence for the key statements ranged from III to IV with 2 statements (20%) supported by a level of evidence III and 6 statements (60%) by level of evidence IV. Overall consensus was reached for 2 statements (20%) with >75% agreement reached for 7 statements. Conclusions: The survey demonstrated a diversity of opinion and attitude among the panelists with regard to technique. Clear recommendations for evidence-based clinical practice for fat grafting use both in aesthetic and reconstructive breast surgery could not be defined due to the scarcity of level 1 or 2 studies.

Wise Pattern Direct Implant Breast Reconstruction: A Review and Improved Outcomes Using Dermal Matrix Background: The inverted T (Wise pattern) mastectomy for patients with macromastia or significant breast ptosis has evolved along with generalized techniques for breast reconstruction. We present a review of Wise pattern breast reconstruction along with our technique for direct to implant reconstruction using dermal matrix. Methods: The literature was reviewed and an analysis of techniques and complications was performed. We present our series of patients incorporating dermal matrix and relatively large implants in direct to implant reconstruction. Results: Of 18 breasts reconstructed only 2 failed. One caused by flap necrosis secondary to smoking and one as a result of preoperative radiation. Conclusion: Wise pattern breast reconstruction using relatively large implants and dermal matrix in direct to implant reconstruction is a safe technique in selected patients with macromastia.