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Background: Breast augmentation and breast reconstruction with implants are among the most performed surgery worldwide., Objective: In the search for an ideal implant in terms of safety, shape and consistency, the authors report their experience with a subtype of breast implant, the Diagon\Gel 4Two implants, in both cosmetic and reconstructive cases by analyzing their experience on 116 consecutive patients., Methods: One hundred and sixteen consecutive patients undergoing both aesthetic and reconstructive breast surgery using Diagon\Gel 4Two Implants between January 2021 and December 2022 were retrospectively reviewed. The analysis was performed dividing the patients in aesthetic and reconstructive cohort. Early and late complications, cosmetic outcome analysis and patients' satisfaction were registered for both cohorts., Results: On a total of 116 patients, 99 were cosmetic patients and 17 reconstructive cases. The follow-up time was 18 to 24 months. No major early and late complications were experienced. The outcomes were graded as very good to excellent in over 80% for the cosmetic cohort and in 72% of the reconstructive cohort. Patients' satisfaction was high to very high., Conclusion: Diagon\Gel Implants is a subtype of anatomical silicone-gel filled implant with peculiar dual gel construct, unique three-dimensional configuration and available with micropolyurethane shell. In our experience, this implant resulted safe, with very low complication rate and very versatile for both primary and secondary cosmetic and reconstructive breast surgery., 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 ., Competing Interests: Declarations. Conflict of interest: The authors declare that they have no conflicts of interest to disclose. Human or Animal Rights: This article does not contain any studies with human participants or animals performed by any of the authors. Consent to Participate: For this type of study informed consent is not required, (© 2024. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.)

Background: Over the latest 15 years, breast augmentation with implant has been progressively refined technically and artistically. However, little attention is usually given to the intermammary space. The aim of this article is to report author's experience and technique in the safe reduction of the intermammary space in breast augmentation with implants without fat grafting., Patients and Methods: From July 2019 to July 2021, 62 consecutive patients undergoing cosmetic breast enhancement with implant and requesting a reduction of the intermammary space were retrospectively evaluated. Preoperatively, breast features were registered for all patients. Preoperative intermammary distance ranged from 2.3 to 7 cm (5.4 ± 0.74)., Results: The average follow-up time was 20 months (range 12 to 36 months). All implants were anatomical silicon-gel filled implants with micropolyurethane foam shell. No major early and late complications were experienced. The outcomes were graded as excellent in 45 breasts (72.6 %), very good in 15 (24.2%), good in the two cases (3.2%) with minor delayed wound healing (less than 1 cm) which solved conservatively within 1 month. Patients' satisfaction was high to very high. Postoperative intermammary distance was reduced in all cases and ranged from 1 to 4.5 (mean 2.6 ± 0.52 cm) CONCLUSION: The intermammary distance can be safely reduced with implant only in all cases who seek it, both via submuscular and via subfascial approach by a precise medial pocket dissection and implantation of micropolyurethane foam-coated implant, which guarantee device's stability during the healing process avoiding malposition., 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 ., (© 2023. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.)

Background: The lateral thoracic area is a known source for perforator flaps for partial breast reconstruction. In this paper, we report our experience in designing and harvesting lateral thoracic perforator flaps for partial and total breast reconstruction with the introduction of the "propuller" concept., Patients and Methods: Between September 2013 and August 2021, 95 flaps were performed for immediate, partial and total breast reconstruction. On a total of 95 flaps, 30 (19 thoracodorsal artery perforator(TDAP) flaps, 10 lateral intercostal artery perforator(LICAP) flaps and 1 lateral thoracic artery perforator(LTAP) flap) were harvested in the traditional fashion (control group) and 65 (57 LICAP, 2 LTAP and 6 TDAP flaps) according to the propeller concept (study group). All cases were preoperatively planned with Color-Coded Duplex Ultrasound., Results: No flap losses were experienced in both groups. The mean operative time was 156 minutes (range 118-234) for the control group and 75 minutes (range 53-125) for the study group (p < 0.0001). A significantly higher number of LICAP flaps were chosen in the study group compared to control group. None of the patients had donor site complications. Patients' and Surgeons' satisfaction was high to very high., Conclusion: The ultrasound preoperative planning led to the development of an easier and safer method of local perforator flap harvesting, that we named as propuller design. Its novelty lies in that perforator intraoperative selection and fully skeletonization are not needed and a more efficient flap movement (propeller plus advancement) which transfers more tissue into the new breast can be achieved safely, faster and easier., (© 2022. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.)

Background: Many types of brachioplasty techniques have been described in the literature, and the main focus has been scar aesthetics, reproducibility and safety. Little attention has been given to other two aspects of the procedure: overall aesthetic with a focus on the torso-brachial angle and on the lymphatic distress related to the procedure. In this paper, we described a novel technique of brachioplasty called lipobrachiopexy, a lymph-sparing procedure which includes tendon suspension suture to improve cosmetics ., Patients and Methods: Over 18 months, 22 consecutive patients underwent bilateral lipobrachioplasty with circumferential liposuction sparing brachial artery perforators, J-scar dermolipectomy and superficial fascia suspension to the pectoralis major tendon. Aesthetic outcomes, lymphatic function, sensory function and patient's satisfaction were evaluated at 1-year follow-up. The correction of the bat wing deformity and the shape of the transition of the upper arm to the chest was evaluated by quantifying the torso-brachial angle using Photoshop. Lymphatic function was analysed pre-operatively at 1, 6 and 12 months after surgery by indocyanine green lymphography (PDE, Hamamatsu Photonics, Japan)., Results: An average of 447.5 cc (range, 350-550 cc) of fat was aspirated for each side. No major complications were experienced. Patients' and surgeons' satisfaction was high to very high in all cases. The lymphatic function was found preserved, with the same physiological linear patterns and tracer progression pre-operatively and 1 year after surgery. The torso-brachial angles showed significant improvements (86.7 ± 14.7-100.7 ± 10.2 right side and 85.4 ± 16.3-101.5 ± 9.9 left side)., Conclusion: Lipobrachiopexy is a safe and effective technique that adds to the recent trends in brachioplasty, a reestablishment of the brachial fascial systems and addressing the anatomical etiological factor of the bat wing deformity., 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 ., (© 2021. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.)

Background: The increasing demand for further aesthetic outcome improvement in implant-based breast reconstruction after nipple-sparing mastectomy (NSM) leads to major novelties, including endoscopic and robotic NSM with the aim to limit scar visibility. In this paper, we report our experience with a novel and simplified surgical approach-single-axillary-incision non-endoscopic NSM and node surgery followed by an endoscopic DTI breast reconstruction-by focusing on reconstructive indications, technical refinements and aesthetic outcomes., Methods: Between June 2016 and October 2019, 14 women underwent this novel technique using definitive anatomical silicone gel filled, totaling 20 breasts. Reconstructive evaluation methods were clinically and photography-based assessment. Breast-Q has been used to quantify patient satisfaction. Feasibility and safety data are also provided., Results: The average follow-up time was 11 months (range 3-42 months). No local-regional recurrence occurred during follow-up. Median operation time was 340 min; mean hospital stay was 4.1 days. The average mastectomy specimen weight was on average 139 g (ranging from 98 to 182 g). The average implant volume for the reconstructed side was 306 cc (ranging from 165 to 550 cc). Patients' satisfaction was high to very high., Conclusion: Authors' experience suggests that non-endoscopic transaxillary NSM, node surgery and endoscopic direct-to-implant breast reconstruction is a valid, oncological safe, aesthetically sound scarless option in breast cancer patients with small to moderate breast size. It should represent the incision of choice in patient with previous breast surgery with scars that may compromise flap/NAC vascularity using traditional NSM incisions., 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 .

Background: Single-stage augmentation mastopexy is considered a challenging procedure, and its safety and efficacy remain controversial for breasts with grade-2 and grade-3 ptosis. In this paper, we report our experience in single-stage augmentation mastopexy with implants, using a short-scar technique, outlining the four-step principles of our technique which maximizes the cosmetic outcomes though being safe, reliable and reproducible., Patients and Methods: Forty consecutive massive-weight loss (MWL) patients undergoing short-scar augmentation mastopexy with implants between September 2010 and August 2018 were retrospectively analysed. The preoperative evaluation and our four-step surgical principles are presented in detail. Breast shape analysis was performed separately by a blinded group of plastic surgeons and by the attending surgeon using a standardized evaluation method. Breast-Q was used to evaluate patients' satisfaction., Results: Patients' average age was 43 (range from 29 to 54). Among the 40 patients, 2 patients were rated as grade 1 (5%), 21 cases (52.5%) grade 2 and 17 (42.5%) grade 3 according to Pittsburgh Rating Scale. The average follow-up time was 40 months (ranging from 3 to 96 months). No major postoperative complications were experienced. Patients' satisfaction was high to very high., Conclusions: Augmentation mastopexy with implant in the MWL population remains a challenging procedure, especially in Pittsburgh grade-3 breasts. A bilamellar approach using proper footprint reconstruction allows for very satisfying cosmetic results using the short-scar mastopexy pattern with a very low complication rate. Our four-step surgical principles are provided, which may aid in the surgical planning and execution of such demanding cases., 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.

Background: Double-bubble and bottoming-out deformities represent the second most common reason for revision surgery in breast augmentation. Etiopathogenesis of these complications is still unclear. The aim of this paper is to report our findings in breast cadaver dissections focusing on the inframammary fold (IMF) applied anatomy and to critically review our ten-year experience in breast augmentation., Methods: A cadaveric study has been performed on four consecutive embalmed cadavers. A retrospective review of 207 consecutive women who underwent breast augmentation, using the submuscular dual-plane technique with a periareolar approach, between January 2003 and January 2013, was performed., Results: According to our dissections, the IMF is a complex osseo-fascio-cutaneous structure in which the superficial pectoralis fascia represents a key structure in breast augmentation surgery. Hence, a critical analysis of the IMF relationship with surrounding breast structures helps to understand the etiology of double-bubble and bottoming-out deformities and gives the anatomical basis to prevent them. In our early clinical experience, we experienced 3% of double-bubble and 6% of bottoming-out deformities. Those complications were avoided later by dissection in the inferior pole according to the anatomical findings., Conclusions: Bottoming-out and double-bubble deformities can be avoided if an anatomical approach is used during pocket dissection at the level of the IMF, paying attention to avoid disrupting the superficial and deep attachments of the superficial pectoralis fascia at the IMF. A comprehensive understanding of IMF anatomy and the key surgical maneuvers to avoid these complications must be taken into account for each route of dissection., 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 .

Introduction: The navel contributes to abdominal surface identity and beauty. In Western societies, the display of the navel in women's fashion has grown and, nowadays, women are much more concerned about its shape and position. Despite this, few studies are available on navel surface anatomy and there is no standardization regarding its proper placement in cosmetic abdominoplasty., Materials and Methods: In this observational study, we analyzed navel shape and position on 81 high quality pictures, having been chosen as top 2013 bikini models by editors of mass media. An on-line survey on navel shape and position has been made via facebook.com, involving 1,682 people., Results: The analysis revealed that navel position is quite variable based on the proportions analyzed with an acceptable narrow data spread of the xiphoid-umbilicus:umbilicus-abdominal mean crease ratio of 1.62 ± 0.16. The data dispersion for the other three ratios was wider, making them less reliable as references. The most appreciated navel shape was the vertical oval with superior hooding (82 %), and the less appreciated ones were the horizontal oval (29 %) and the protruding shape (47 %). When comparing navel position on the same body, the majority of participants choose the one with the navel relocated according to the golden ratio (i.e., 1.618) CONCLUSION: The most attractive navel position is located at the xiphoid-umbilicus:umbilicus-abdominal crease golden ratio. Bony landmarks seem to be not reliable as references for proper navel positioning. The use of the Fibonacci (golden mean) caliper intraoperatively might aid in proper positioning of the navel in abdominoplasty.

Background: The new indications for radiotherapy in the cure of breast cancer lead to an increasing number of candidates for this adjuvant treatment. However, it raises some concerns with respect to the prosthetic reconstruction of the breast. In fact, the use of implants in the irradiated breast is discouraged by many authors because of the high rate of complications. In these cases autologous tissue reconstruction is being recommended. However, not every patient is a candidate for autologous tissue reconstruction. Furthermore, not all radiotherapies are comparable in dose, timing, and patient tolerance. In this article we present the preliminary results of an alternative surgical management in oncoplastic breast surgery consisting of fat injections before implant placement., Methods: Six months after the last radiation treatment, a lumpectomy patient and a modified radical mastectomy patient each underwent two sessions of fat injection prior to implant placement, with a 3-month interval in between sessions. The implants were placed 3 months after the last fat injection., Results: There was a 12-month follow-up for the modified radical mastectomy case and a 18-month follow-up for the lumpectomy case. In both cases we report no postoperative complications, Baker grade 1 capsule contracture, good aesthetic outcome, and high patient satisfaction., Conclusion: The preliminary results show that fat injection in irradiated tissue prior to breast alloplastic reconstruction may reduce the radiation-related complications on implants. Benefits from fat grafting are in keeping with the theoretical basis of this surgery. Larger studies are needed to confirm our observations.

Background: Ectopic primary carcinoma of breast tissue is a rare entity, and its diagnosis often is delayed. The axilla is the most common site involved. The Limberg flap as a random flap is easy and practicable for coverage of many defects including those involving the axilla. In the reported case, the vascularity of the flap was improved by including a thoracodorsal artery perforator., Methods: This report presents the clinical features of a case of ectopic breast carcinoma in the axilla and an alternative tension-free Limberg thoracodorsal artery perforator flap for reconstruction of the extended defect after excision of the tumor., Results: The flap survived and healed without further problems. A good functional and aesthetic result was obtained., Conclusion: Ectopic primary carcinoma of breast tissue is a rare entity. Correct early diagnosis should be made. A tension-free fasciocutaneous flap according to Limberg, supercharged using a thoracodorsal artery perforator, can provide skin and soft tissue coverage for extended defects in the axilla with a satisfactory outcome. The operative procedure is easy and reliable. This is a further surgical option for soft tissue extended reconstruction in the armpit.