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The purpose of this case report is to present a deviation analysis made to evaluate the accuracy and reproducibility of virtual surgical planning—computer-aided design—computer-aided manufacturing (CAD/CAM) technology.These techniques were used to programme and perform both demolitive and reconstructive surgery in an 18-year-old man treated for a mandibular ameloblastoma. Total body CT scan and CT angiography were performed before the surgery. DICOM-format data were captured and a planning was performed using CAD/CAM technology. After the surgery, DICOM files of a postoperative CT scan were evaluated to assess the accuracy of the reconstruction. The deviation of the postoperative result from what was planned was indicated with different colours in a mandible mapper and changes in condylar and angular position between 0.5 mm and 2 mm were observed. A standardised method to evaluate accuracy or efficiency of CAD/CAM technology is still not available, nevertheless, since the patient has a good functional or aesthetic recover, the authors are satisfied with the results.

Reconstructing a well-defined nasal tip is a big challenge for East Asian patients, especially with nasal tip irregularities or short noses in revision rhinoplasty. This study aims to report our experience with a modified large-cap graft for improving the contour of the nasal tip in revision rhinoplasty.A retrospective review was conducted for 91 patients (81 females, 10 males; mean age, 26.8 ± 6.7 years) who underwent revision rhinoplasty with a modified large-cap graft. The rhinoplasty outcome evaluation (ROE) was used for investigating patient satisfaction. The aesthetic outcomes were assessed by preoperative and postoperative photographs by two blinded plastic surgeons using the Independent Rhinoplasty Outcome Score.Most patients reported satisfactory aesthetic outcomes with overall ROE score increasing from preoperative 11.66 ± 3.98 to postoperative 17.30 ± 5.03 (p lt; 0.001). The doctors' evaluations on the improved contour of the nose rendered an overall score of 3.77 ± 0.42. The complication rate was 3.3% (pleural tear, 1.1%; hypertrophic scar, 2.2%) at the donor site, and 7.7% at the recipient site (warping, 3.3%; extrusion, 1.1%; deviation, 2.2%; infection, 1.1%). No other complications were observed during follow-up.Large-cap graft may be safe and efficient for reconstructing contour of the nasal tip in revision rhinoplasty for East Asian patients.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: Mastectomy is the most common and sometimes the only surgery performed in FtM transgender individuals. In this study, it was aimed to evaluate the improvement in life standards of patients who underwent double incision mastectomy with free nipple-areolar complex graft and periareolar mastectomy by using TRANS-Q in trans men. Materials and Methods: TRANS-Q was performed in 71 trans men at the preoperative and postoperative 1st year, and the revision and complication rates in both groups were compared. Results: A statistically significant difference was observed in the postoperative satisfaction rates in both groups. We observed that the patients who underwent periareolar mastectomy had significantly higher satisfaction rates than the patients who underwent double incision mastectomy with free nipple areolar complex graft. In both groups, postoperative satisfaction rates were found to be significantly higher. Conclusion: Improvement in life standards has been observed in trans men who underwent mastectomy, and late results should be evaluated with further prospective studies. 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. © 2022, Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.

Perioral rhytides are a common reason for presentation to the cosmetic dermatologist. Various treatment options exist, and it can be challenging to determine the optimal technique to use in a given patient encounter. We herein provide a review article highlighting various treatment options in the correction of perioral rhytides, focusing on the roles of neurotoxin, filler, microneedling (with and without radiofrequency), fractional resurfacing (nonablative and ablative), and fully ablative lasers, with a brief mention of deep chemical peels. For each modality, we review the evidence behind the specific technique, its advantages and disadvantages, post-procedural effects, expected downtime, as well as the onset and duration of desired effects. Despite longstanding debate regarding the "best" modality to use, we instead propose that the best approach is a combination approach which takes into account he patient's treatment goals while staying consistent with the expected amount of downtime. Importantly, we share clinical pearls based on the senior authors direct patient experience as Director of Laser and Cosmetic Dermatology at University of California, San Diego (UCSD).

The reason behind the spread of penis enlargement practices over time is rooted in the virility that the appearance of the genitals can give a man, as well as an altered perception of his own body. The approach should be to modulate the interventions on the real needs of patients, carefully evaluating the history, the psychological picture, and possible surgical advantages. The aim of this study was to shed light on cosmetic surgery of male genitalia through minimally invasive and more radical techniques, with the purpose of laying the foundation for possible indications and recommendations for the future. A non-systematic literature review using the PubMed and Scopus databases was conducted to retrieve papers written in English on cosmetic surgery of the penis published over the past 15 years. Papers discussing cosmetic surgery in patients with concomitant pathologies associated with sexual dysfunction were excluded. The main outcomes recorded were change in penile dimensions in term of length and girth and surgical complications.

Background Surgical excision remains the gold-standard therapy for arm skin laxity. However, many patients refuse surgical treatment for fear of the prominent long scars associated with brachioplasty. Objectives The objective of the study was to compare the aesthetic outcome of 2 energy-assisted liposuction arm-contouring techniques, radiofrequency-assisted liposuction (RFAL; Group A) and Renuvion helium subdermal coagulation (Group B), with a control group treated with VASER-assisted liposuction (VAL) alone (Group C). Methods This is a randomized controlled study of 176 patients seeking arm contouring, who were treated between February 2017 and December 2020. All of the patients underwent VAL, followed by either RFAL (53 patients, Group A) with the BodyTite RF platform or subdermal coagulation (66 patients, Group B) with the Renuvion platform; 57 patients in the control group (Group C) received VAL alone. Patient data, marking techniques, operative details, complications (and tips and tricks to avoid them), and aesthetic outcomes were recorded and tabulated. Surgical team, third-party, and patient satisfaction surveys were conducted 6 months postoperatively. Results The study included 176 patients (153 female and 23 male) with a mean age of 32 years (range, 20-59 years). All patients were followed up for a minimum of 6 months. In total, 96 (80.6%) patients reported their satisfaction with the overall technique. An independent plastic surgeon considered the result good to excellent in 97 of 119 cases of the studied group. Conclusions The umbrella of nonexcisional arm contouring can be extended to include treatment of difficult cases of arm laxity with energy-producing machines. The procedure can achieve a reduction in fat deposits and significant improvements in skin laxity. Level of Evidence: 4

The application of piezoelectric instruments (PEIs), which made the work with the nasal pyramid a predictable and controlled stage of rhinoplasty, is still more often related to the open approach. The intranasal approach is constantly associated with standard methods of osteotomies, including percutaneous techniques, which represent certain limitations in working with the bony vault without managing the surface and thickness of its walls and the risk of uncontrolled fractures.The authors apply PEIs for osteotomies and reshaping of the nasal pyramid through the closed approach with preservation rhinoplasty and complete subperichondrial and subperiosteal dissection.The technique of working with the nasal pyramid using PEIs with the closed approach is described. The patients were grouped according to the methods of nasal pyramid surgery-Push Down (PD), Let Down (LD) with Rhinosculpture (Rs), or the combinations. The results of the surgeries with the application of PEIs on 134 patients were retrospectively analyzed before the surgery and 12 months after it according to the "Rhinoplasty Outcome Evaluation" (ROE).The average age of the patients was 28, 125 were female and 9 were male. The patients' satisfaction was excellent in 96% of all the cases included. There were two cases with residual humps and four cases with residual asymmetries in cases of severe deviations.Via intranasal approach, it is possible to use PEIs for managing the bony vault in primary rhinoplasty. The limitations for this technique are underdevelopment of the nasal dorsum, cleft lip nose situations, post-traumatic and previous rhinoplasty cases.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 .

Rhinoplasty is a challenging procedure, and the ultimate goal is not only to restore the function and youthful appearance, but also to improve the quality of life (QoL). Little is known about the QoL after preservation rhinoplasty (PR). The aim of this study was to assess patient satisfaction after PR by using a validated questionnaire.Patients undergoing primary PR were included in this prospective cohort single-centre (private) study. Overall, 58 patients (41 female and 17 male patients, mean age 32 ± 9.7 years) were operated on between 2017 and 2021. Patient assessment regarding their outcome was evaluated before surgery and at final follow-up using a validated questionnaire (Rhinoplasty Outcomes Evaluation Questionnaire = ROE). Subgroup analyses were performed between the ROE questions and radiological analysis by using the cone-beam computed tomography (CT) before surgery and at final follow-up.After a mean follow-up of 19.7 ± 7.9 months (range = 1-50 months), a high overall patient satisfaction was observed (37.9 ± 9.2 vs. 81.25 ± 14.17, plt; 0.0001). Subgroup analysis showed the highest improvement in nose appearance, breathing, and self-confidence after surgery. The improvement of subjective breathing (1.471 ± 0.90 vs. 3.1 ± 0.88; plt;0.0001) goes in line with an overall improved internal nasal valve (INV) angle (19.88° ± 3.3° vs. 22.04° ± 4.1°, p = 0.0231).Our study showed a high patient satisfaction after PR as evaluated by the ROE, which goes in line with aesthetics and function.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 .

Rhinoplasty is 1 of the most applied procedures among aesthetic and plastic surgery areas. Dorsal hump deformity is a common deformity among Caucasians based on the natural anatomy of the nose. Dorsal preservation techniques arose as a necessity for overcoming the negative outcomes of traditional hump reduction surgery in patients with hump deformity. Beside the strong advantages of dorsal preservation techniques such as push-down and let-down techniques in the fixation of dorsal hump deformity, innovations on these procedures would bring better outcomes in terms of aesthetic and functional manners. In present research, the author defines a new technique, which combines new procedures as mix-down and semi let-down and semi push-down techniques. This study was designed as a retrospective. According to the inclusion and exclusion criteria, 36 patients (26 females and 10 males) were included in the study. The author applied to patients hybrid preservation rhinoplasty approach, which is a combination of mix-down and semi let-down and semi push-down techniques. All patients completed the Rhinoplasty Outcome Evaluation (ROE) questionnaire before surgery and at their 1-year follow-up appointment. The follow-up period ranged between 13 and 28 months (median of 19.8months). The initial median ROE score was 55.5, and it increased to 91.00 points at 12 months after surgery ( P0.001). According to the ROE scale, patients' satisfaction was found as excellent in 91.6% of patients. Present study showed satisfactory outcomes of hybrid dorsal preservation technique, which is a combination of mix-down and semi-let down and semi-push down approaches. This new approach will be suitable for selected patients and easy to perform by the surgeons. Moreover, patients who have concomitant hump and deviation deformities will benefit from hybrid dorsal preservation technique.Level of Evidence: 3.

Background Gynecomastia is nowadays a very common disease, affecting a large cohort of patients with different ages. The aim of this literature review is to assess the incidence of complications with all proposed techniques and for combined procedures versus single approach procedures in gynecomastia correction. Materials and Methods A systematic review of the literature was performed to identify all reported techniques for gynecomastia correction covering a period from January 1, 1987 to November 1, 2020. For all selected papers, demographic data, proposed technique, and complications’ incidence have been recorded. Results A total number of 3970 results was obtained from database analysis. A final total number of 94 articles was obtained for 7294 patients analyzed. Patients have been divided into three groups: aspiration techniques, consisting in 874 patients (11,98%), surgical excision techniques, consisting in 2764 patients (37,90%), and combined techniques, consisting in 3656 patients (50,12%). Complications have been recorded for all groups, for a total number of 1407, of which 130 among “Aspiration techniques” group (14,87%), 847 among “Surgical excision techniques” group (30,64%), and 430 in “Combined techniques” group (11,76%). Conclusions Several techniques have been proposed in the literature to address gynecomastia, with the potential to greatly improve self-confidence and overall appearance of affected patients. The combined use of surgical excision and aspiration techniques seems to reduce the rate of complications compared to surgical excision alone, but the lack of unique classification and the presence of several surgical techniques still represents a bias in the literature review. Level of Evidence III 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.

The human face is an important human structure, often judged by its esthetics. It serves great purpose, as it is and always has been involved in both cultural matters, such as art, as well as biological matters, such as exhibition of emotion and mate selection. Throughout history, there have been multiple studies on what makes a face attractive. Despite the myriad ways in which the face has been explored academically, there has been a lack of reports on which craniofacial elements are deemed the most important for attractiveness subjectively. To fill up this gap on the perception of the esthetics of the human face, as well as to provide a contemporary view on the matter, this research was conducted. Participants were asked to fill out a questionnaire with a visual analogue scale for each craniofacial element and questions about appearance satisfaction. A total of 299 participants were enrolled in this study. Eyes, hair and teeth were deemed to be the most important craniofacial elements for attractiveness. Women scored teeth, hair, and eyebrows significantly higher than men, men scored higher in satisfaction with their own appearance than women. Older people, married people and people in a relationship care less about the opinion of others regarding their appearance. The results from this study can be used to identify a focus in the future development of esthetically related matters, such as plastic surgery or art and will add to the academic knowledge on the perception of craniofacial beauty.

The transoral endoscopic thyroidectomy vestibular approach has been demonstrated to have similar surgical outcomes as open thyroidectomy for selected papillary thyroid carcinomas. This study aimed to evaluate and compare the surgical outcomes and safety of the transoral endoscopic thyroidectomy vestibular approach with those of open thyroidectomy in the treatment of papillary thyroid carcinoma with a diameter between1 cm and ≤3.5cm.We retrospectively reviewed all patients who had papillary thyroid carcinoma that was between1 cm and ≤3.5 cm in diameter and who had undergone the transoral endoscopic thyroidectomy vestibular approach (n = 96) or an open thyroidectomy (n = 425) from January 2017 to June 2020. We then performed 1:1 propensity score matching, yielding 78 matched pairs. Afterward, surgical outcomes and follow-up data were compared between the 2 matched groups.Compared with the matched open thyroidectomy group, the papillary thyroid carcinoma group had a significantly longer operative time (P.001), more blood loss (P.05), higher postoperative white blood cell count (P.05), higher C-reactive protein (P.001), more total drainage volume (P.001), increased surgical cost (P.05), better cosmetic satisfaction (P.001), lower scar self-consciousness (P.001), and better quality of life (P.001). We observed no significant differences in the incidence of other outcomes, including the number of retrieved lymph nodes and metastatic central lymph nodes, the rate of intraoperative recurrent laryngeal nerve signal weakened and parathyroid autotransplantation, visual analog scale scores for pain, drainage duration, postoperative hospital stay, rate of complications, and oncologic completeness. We observed no conversion to open thyroidectomy and no intraoperative capsular disruption in the transoral endoscopic thyroidectomy vestibular approach group. There was 1 case of persistent nodal disease in the transoral endoscopic thyroidectomy vestibular approach group. No recurrence was observed in the 2 groups during the follow-up period.The transoral endoscopic thyroidectomy vestibular approach is feasible in selected patients with papillary thyroid carcinoma, not only because it is cosmetically advantageous but also because it is surgical and oncologically safe and may be an optional surgical method for treating papillary thyroid carcinomas having a diameter between1 cm and ≤3.5 cm.

Background The cleft lip-nose deformity in unilateral cleft lip and palate is one of the most challenging problem for surgeons to correct. Although nasoalveolar molding has been shown to be effective in improving presurgical symmetry in patients with complete unilateral cleft lip and palate, there is need for better evidence regarding the long-term nasolabial aesthetics of patients who have received this therapy. Methods Thirty-eight patients treated with nasoalveolar molding and 48 patients not treated with nasoalveolar molding (but otherwise treated similarly) with unilateral cleft lip and palate were studied to assess and compare the nasolabial aesthetics. The objective evaluation of the nasal symmetry was performed on the basal view of two-dimensional photographs and the subjective nasolabial aesthetic evaluation was performed using the Asher-McDade scale. Results At 5-year postoperative follow-up, nasoalveolar molding group patients had better mean values on the objective scores; however, these were not statically significant. The nasoalveolar molding group of patients had a statistically significant improvement in the subjective evaluation in comparison to the non-nasoalveolar molding-treated patients. The number of lip revisions was also statistically higher in the non-nasoalveolar molding-treated group of patients. Conclusions In this retrospective, single-center study, the authors found that at 5-year postoperative follow-up, nasoalveolar molding-treated patients had improved nasolabial aesthetics and fewer revision operations. These are, however, preliminary results and the patients will be followed up until the end of growth to assess the longer term effects of nasoalveolar molding on the nasolabial aesthetics in unilateral cleft lip and palate. Clinical question/level of evidence Therapeutic, III.

This study evaluated the efficacy of botulinum toxin A (BTX A) in improving the aesthetic appearance of lips. Twenty-four outpatients with clinical evidence indicating decreased fullness of lips or gummy smile were selected and received BTX A injection on the orbicularis oris. We observed a significant decrease in wrinkles and improvement in gummy smile in all patients 4 weeks after the injection. Aesthetic lines also changed significantly. Local injection of BTX A on the orbicularis oris could simultaneously achieve mild lip enhancement, improvement in fine wrinkles around lips, and mild gummy smile.

The main objectives of rhinoplasty in African descendants are to improve the definition and projection of the nasal tip, augment the dorsum, and reduce the alar base. Open rhinoplasty using costal cartilage graft, with lateral crural tensioning and septal extension graft associated with en bloc dorsal augmentation is the workhorse. Cartilage resections should be minimal. Oral isotretinoin and triamcinolone injection may improve tip definition. Surgical success ultimately depends on the ability of the surgeon to accurately identify the anatomic variables and reconcile these anatomic realities with the patient's aesthetic expectations and his or her sense of ethnic identity.

Background Liposuction is the most accepted technique for treatment of gynecomastia at present with or without residual gland tissue excision. Conventional liposuction uses incisions for introduction of cannula, made usually at the inframammary crease or axilla resulting in consequent scars. Cross-chest liposuction technique was introduced to avoid these additional scars and improve the aesthetic outcome. This study aimed to evaluate the difference between aesthetic outcome of conventional liposuction and cross-chest liposuction in treatment of gynecomastia. Method A prospective comparative study between 2 groups with 15 patients in each was conducted, one with conventional and the other cross-chest liposuction. Excision of residual gland tissue was performed through circum-areolar incision in both the groups. Aesthetic outcome was evaluated in both the groups using Likert scale and compared. Result The mean age of the patients was 22.6 years and the mean duration of presentation was 8.13 years. Satisfaction rate with conventional and cross-chest liposuction was 80% and 86%, respectively, as assessed by the patients. The rate was 80% and 77%, respectively, in both the groups as assessed by independent observer. The complication rate was 13.3% in conventional and 20% in cross-chest group. The difference in outcome was not statistically significant between two groups. Difference between the mean Likert scores of pre-operative and post-operative satisfaction was statistically significant for both the techniques. Conclusion The conventional and the cross-chest liposuction, both yield comparable results when used for treatment of gynecomastia in terms of aesthetic outcome. Level of Evidence III 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 Minimally invasive and noninvasive facial aesthetic treatments are increasingly popular, and a greater understanding of patient perspectives on facial aesthetic priorities is needed. Objectives The authors surveyed facial aesthetic concerns, desires, and treatment goals of aesthetically conscious men and women, and physicians, in 18 countries. Methods This was a global, internet-based survey on desired appearance and experiences with, or interest in, facial aesthetic treatments. Eligible respondents were aesthetically conscious adults (21-75 years). Eligible aesthetic physicians were required to see ≥30 patients per month for aesthetic reasons, have 2 to 30 years of experience in clinical practice, and spend ≥70% of their time in direct patient care. Results A total of 14,584 aesthetically conscious adults (mean age, 41 years; 70% women) and 1315 aesthetic physicians (mean age, 45 years; 68% men) completed the survey. Most respondents (68%) reported that aesthetic procedures should be sought in their 30s to 40s; physicians recommended patients seek treatment earlier. Respondents expressed greatest concern over crow’s feet lines, forehead lines, facial skin issues, hair-related concerns, and under-eye bags or dark circles; in contrast, physicians tended to underestimate concerns about under-eye bags or dark circles, mid-face volume deficits, and skin quality. Although both physicians and respondents cited cost as a major barrier to seeking aesthetic treatments, respondents also emphasized safety, fear of injections or procedure-related pain, and concern about unnatural-looking outcomes. Conclusions This global survey provides valuable insight into facial aesthetic concerns and perspectives that may be implemented in patient education and consultations to improve patient satisfaction following aesthetic treatments.

Beauty is not race neutral. It is a racialized category/ perception which emerged through centuries of European colonization, Indigenous genocide, African/Black enslavement and indenture resulting in an aesthetic hierarchy with Blackness at the bottom. The coloniality of aesthetics means that still today hair perceived as Black in texture and styling and darker skin on African descent bodies are the repositories of anti-Blackness. However, Black women, children and men continue to fight back by (re)creating Black antiracist aesthetics focused on valorizing Black skin and hair.

LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Identify common negative outcomes that arise with conventional nasal reconstruction. 2. Understand the technical refinements that help avoid and reduce negative outcomes in nasal reconstruction. 3. Learn about the utility of regional axial island flaps for nasal reconstruction, in particular, the lateral nasal artery flap. SUMMARY Nasal reconstruction has been a preoccupation of surgeons dating to before 600 bc. The nose is the central focal point of the face and a key identifying facial feature, and surgery to the nose can prove to be challenging to even the most experienced surgeon. The objective of this CME article is to outline the most commonly used surgical options for each nasal aesthetic subunit, and the specific complications observed for each. The best surgical options and technical refinements are highlighted, and principles that may help restore the nose are outlined.

BACKGROUND Osseous genioplasty is a powerful procedure that can correct chin dysmorphology; however, traditional techniques may result in chin ptosis or a "witch's chin" deformity. Iatrogenic chin ptosis is thought to be caused by excessive degloving of soft tissue with a failure to reattach the mentalis muscle. In the authors' study, they compared the "no-degloving" technique (using a 90-degree plate with lag-screw fixation) to the "traditional" technique, for minimization of chin ptosis. METHODS The authors compared genioplasty techniques for consecutive patients: group 1 (traditional) underwent degloving for fixation of a stair-step plate, whereas group 2 (no-degloving) underwent lag-screw fixation (n = 50; 25 patients per group). The authors compared operating room time, advancement, complications, preoperative-to-postoperative vertical height change of the pogonion and menton (obtained through cone beam computed tomographic scans), surgeons' assessment of witch's chin, and FACE-Q surveys. RESULTS No-degloving versus traditional groups had similar age and sex distributions, horizontal/vertical change (5 mm/2 mm versus 6 mm/2 mm), length of surgery, and complication rate (5 percent). The traditional group had more deviation from expected position for both the pogonion (3.4 mm versus 1.2 mm; p ≤ 0.05) and menton (2.9 mm versus 0.8 mm; p ≤ 0.05), and more occurrences of witch's chin (six versus zero). No-degloving was superior for several FACE-Q scales, including Chin Appearance, Quality of Life, Satisfaction with Decision to Undergo Procedure, and Satisfaction with Outcome. CONCLUSION No-degloving osseous genioplasty is a safe, reproducible technique that results in decreased soft-tissue ptosis and increased patient satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Summary Purpose Central polydactyly of the foot is rare, with few reports on surgical methods and treatment indications. In this study, based on the experience of central polydactyly in our department, we will consider morphological classification and describe our treatment plan. Method In this retrospective study, 11 patients (11 digits) with central polydactyly were identified among 136 patients of polydactyly of the foot (2009–2018). They were classified according to morphologic characteristics: type I, the duplicated digits are independent of each other; type II, digits of the same size are duplicated; and type III, digits of different sizes are duplicated. Results In morphologic classification, there were 4 cases of type II and 7 cases of type III, but there was no case of type I. For type II, surgery was performed using the Bilhaut-Cloquet (BC) procedure in 2 patients, bone-removing flap (flap) method in 1 patient, and simple ablation in 1 patient. For type III, surgery was performed using the BC procedure in 1 patient, flap method in 3 patients, simple ablation in 2 patients, and ligation in 1 patient with floating type. Conclusion In order to obtain good cosmetic results in digits of morphologic classifications type II and III, it is necessary to select the surgical approach with careful consideration of every feature.

Summary Background The CLEFT-Q includes 12 independently functioning scales that measure appearance (face, nose, nostrils, teeth, lips, jaws), health-related quality of life (psychological, social, school, speech distress), and speech function, and an eating/drinking checklist. Previous qualitative research revealed that the CLEFT-Q has content validity in noncleft craniofacial conditions. This study aimed to examine the psychometric performance of the CLEFT-Q in an international sample of patients with a broad range of facial conditions. Methods Data were collected between October 2016 and December 2019 from 2132 patients aged 8 to 29 years with noncleft facial conditions. Rasch measurement theory (RMT) analysis was used to examine Differential Item Function (DIF) by comparing the original CLEFT-Q sample and the new FACE-Q craniofacial sample. Reliability and validity of the scales in a combined cleft and craniofacial sample (n=4743) were examined. Results DIF was found for 23 CLEFT-Q items when the datasets for the two samples were compared. When items with DIF were split by sample, correlations between the original and split person locations showed that DIF had negligible impact on scale scoring (correlations ≥0.995). In the combined sample, RMT analysis led to the retention of original content for ten CLEFT-Q scales, modification of the Teeth scale, and the addition of an Eating/Drinking scale. Data obtained fit with the Rasch model for 11 scales (exception School, p=0.04). Person Separation Index and Cronbach alpha values met the criteria. Conclusion The scales described in this study can be used to measure outcomes in children and young adults with cleft and noncleft craniofacial conditions.

Summary Background There is currently a lack of patient-reported outcome measures for ear reconstruction. We developed the EAR-Q to measure ear appearance and post-operative adverse effects from the patient perspective. Methods Field-test data were collected from children and young adults in eight countries between 13 May 2016 and 12 December 2019. Rasch measurement theory (RMT) analysis was used to refine the scales and to examine their psychometric properties. Results Participants had microtia (n = 607), prominent ears (n = 145) or another ear condition (n = 111), and provided 960 assessments for the Appearance scale (e.g., size, shape, photos), and 137 assessments for the Adverse Effects scale (e.g., itchy, painful, numb). RMT analysis led to the reduction of each scale to 10-items. Data fit the Rasch model for the Appearance (X2(80) = 90.9, p = 0.19) and Adverse Effects (X2(20) = 24.5, p = 0.22) scales. All items in each scale had ordered thresholds and good item fit. There was no evidence of differential item function for the Appearance scale by age, gender, language, or type of ear condition. Reliability was high for the Appearance scale, with person separation index (PSI) and Cronbach alpha values with and without extremes ≥0.92. Reliability for the Adverse Effects scale was adequate (i.e., PSI and Cronbach alpha values ≥0.71). Higher scores (liked appearance more) correlated with higher scores (better) on Psychological, Social and School scales. Interpretation The EAR-Q can be used in those 8–29 years of age to understand the patient perspective in clinical practice and research, and in addition, can be used to benchmark outcomes for ear reconstruction internationally.

Objective Three-dimensional assessment of nasal morphology in patients with unilateral cleft lip nose treated by cartilage graft augmentation. Design Retrospective study. Patients and Intervention Thirteen patients with unilateral cleft lip nose underwent definitive secondary rhinoplasty and postsurgical changes were examined using a three-dimensional (3D) laser scan. Main Outcome Measure Nasal dorsum length, nasal tip, alar width, and alar base width in frontal view; nasion depth, nasal tip projection, nasal dorsal angle, and nasal tip angle in lateral view; nostril width, nostril height, and nasal tip height in basal view were measured at preoperative (T1: within 6 months), short follow-up (T2: 2-10 weeks), and long follow-up (T3: 9-14 months). Results A significant change in alar width, alar base width, nostril width, and nostril height at the cleft side, nasal dorsum length, nasion depth, nasal tip projection, and nasal tip height was observed from T1 to T3 follow-up after rhinoplasty ( P Conclusions 3D imaging evaluation after secondary cleft rhinoplasty demonstrated improved functional and aesthetic outcomes using a septal or conchal graft.

Objective: To develop and validate a novel patient-reported measure to assess internally and externally driven expectations for change after a cosmetic procedure, termed the aesthetic procedure exp...

Summary Purpose Rhinoplasty is one of the most commonly performed aesthetic surgeries among patients who are admitted to plastic surgeons. Recent research has focused on dorsal preservation in hump reduction and consequently dorsal preservation techniques have become more popular. The current study aimed to revise the push down technique by adding ostectomy. Patients and methods In the present retrospective study, data from patients who underwent rhinoplasty to fix a nasal hump were assessed. All patients were administered the push down technique with ostectomy. Following these inclusion and exclusion criteria, the records of 52 patients were assessed (45 females and 7 males). The median age of the patients was 22.2 years. Patients were evaluated using the “Rhinoplasty Outcome Evaluation” (ROE) questionnaire both before surgery and 12 months after surgery. The follow-up period ranged between 13 and 21 months (median of 15.1 months). Results Patients were evaluated before surgery and after one year of surgery by the ROE scale. The median of the ROE score before surgery was 63.4. The median score after one year of surgery was 91.6. Thus, the ROE score significantly increased 12 months after surgery (P Conclusions This study was the first to demonstrate the benefits of performing the push down technique with ostectomy in terms of obtaining a wider nasal cavity. In addition, it can be assumed that the disadvantage of using the push down technique can be overcome with ostectomy.

Summary The nasal aesthetic subunit principle has been widely accepted as the standard for nasal reconstruction with forehead flaps. However, in our experience, one's impression of a reconstructed face can easily be represented by the nose's entire appearance rather than a single nasal component. Accordingly, we hypothesized that total nasal reconstruction focusing more on the facial aesthetic subunit principle would be superior to focal nasal subunit partial reconstruction. Here, we investigated the indication range of total nasal reconstruction and analyzed its effectiveness. Between July 2006 and December 2017, 32 patients who underwent total or subtotal nasal reconstruction were recruited. The total nasal reconstruction group (n = 20) was treated according to our modified facial aesthetic unit concept, while the subtotal reconstruction group (n = 16) was treated according to the nasal aesthetic subunit principle. Using retrospective reviews, we compared surgical details and aesthetic, and functional outcomes with visual analog scale scores. In aesthetic evaluation, nose contour (p = 0.009), nasal symmetry (p = 0.001), and nostril shape (p = 0.041) were superior in the total nasal reconstruction group. Satisfaction regarding the nose (p = 0.036) was significantly higher than that regarding the forehead and labial folds in the total group. Regarding function, there were no significant intergroup differences in nasal airflow, snoring, or olfaction. We suggest that total nasal reconstruction is not a strategy to avoid because of its aggressive nature. For selected suitable patients, the use of the total nose reconstruction focusing on our one nose concept can be a successful surgical option, and the reconstructed nose can be visualized as a real part of the face.

Successful microtia reconstruction involves fabrication of a framework with well-defined ear subunits. Tragal definition and deep conchal bowl are key elements to produce a natural well-defined and contoured ear. We describe a modification in the cartilage framework with the purpose of increasing framework stability, tragal definition and conchal bowl depth.The tragus is placed on two cartilaginous bars (L-shaped), which are fixed to the framework base block creating a complete ring. These increase tragal projection and conchal depth. The tragus is carved angled posteriorly to have a shadowing effect on the absent auditory canal. Aesthetic outcome was assessed, at least 6 months after the second stage, on a 5-point ordinal scale (1-5) using the scoring system published in the UK microtia care standards and agreed on by the International Society for Auricular Reconstruction (ISAR).A total of 406 auricular reconstructions were performed in 363 patients (206 right, 114 left, 43 bilateral). After excluding cases who did not have second stage and those without complete photographs, 290 cases were assessed. The described modification in the framework carving was performed in 255 ears out of these 290 ears. The mean aesthetic score before and after the modification was 2.4 and 3.09 respectively for the tragus (p0.001), 2.2 and 2.95 for the intertragal notch (p0.001) and 2.77 and 3.49 for the concha (p0.001).This technical refinement has resulted in increased permanence and definition of the tragus and deeper and more aesthetic concha.

SUMMARY The intermediate cleft tip rhinoplasty is frequently performed during childhood to address nasal tip anomalies in cleft patients before the most critical period of psychosocial development. The authors previously described the component restoration intermediate cleft tip rhinoplasty technique for the unilateral cleft nose, which was developed to systematically address the lining deficiency, cleft lower lateral cartilage malpositioning, and cleft lateral cartilage weakness using a combination of lower lateral cartilage release, lateral cartilage repositioning, and placement of an auricular composite chondrocutaneous graft. In this work, the authors evaluate the utility of this technique to the bilateral cleft nose. Preoperative and postoperative (mean ± SD, 18.6 ± 10.8 months) photographs of bilateral cleft patients treated with the component restoration intermediate cleft tip rhinoplasty (n = 7) were evaluated using photogrammetric measurements and aesthetic assessments. From preoperatively to postoperatively, the columella length-to-alar width ratio on basal photographs increased (0.19 ± 0.05 versus 0.28 ± 0.05; p = 0.001). On lateral view, the columella-labial angle decreased from preoperatively to postoperatively [138 degrees (interquartile range, 132 to 144 degrees) versus 123 degrees (interquartile range, 122 to 139 degrees); p = 0.04]. Aesthetic ratings performed by four blinded observers also improved from preoperatively to postoperatively (1.6 ± 0.8 versus 2.4 ± 0.7; p = 0.004). As a comparison, bilateral cleft nose patients who did not undergo intermediate cleft tip rhinoplasty (n = 3) of similar ages were subjected to the same photogrammetric and aesthetic analyses, which showed no differences from preoperatively to postoperatively. In combination, the current work suggests that the component restoration technique in the bilateral intermediate cleft tip rhinoplasty improves nasal tip support and aesthetic outcomes.

The present study aimed to describe and critically discuss the current evidence regarding the penile girth enhancement procedures for aesthetic purposes. We designed a narrative review of the literature. A comprehensive search in the MEDLINE database was performed. Original articles in English-language, published until March 2021, were selected. A total of 29 studies were included (3 reporting non-invasive approaches, 11 injection therapies, and 15 surgical procedures). The vast majority of articles (26, 89.7%) were not randomized controlled trials, with overall low quality and limited level of evidence. Only 1 (33.3%) paper regarding non-invasive approaches reported a minimal (+0.03 cm) but a significant increase of penile girth (p = 0.034). A low rate (11.2-14.4%) of mild, temporary adverse events and poor-to-moderate patient satisfaction were found. Eight (72.7%) articles concerning injection therapies showed a significant increase in penile girth (p < 0.05). A low rate of mild complications, generally at the injection site, and a high patient satisfaction rate (75-100%) were highlighted. Nine (60%) papers on surgical treatments found a significant increase in penile girth (p < 0.05), while the other 6 (40%) studies reported a generic improvement in penile circumference. Skin necrosis or ulcers, wound infections, or need for reoperation were reported in 8 (53.3%) studies. A high patient satisfaction rate (60-100%) was reported. Our review highlighted the overall positive results of injection procedures, the poor outcomes associated with non-invasive techniques, and the good efficacy and satisfaction with a non-negligible risk of complications in patients undergoing surgical treatments. However, the adverse events are probably largely under-reported and these procedures should still be considered under investigation due to the limited evidence available and the lack of guidelines.

Consultation for female esthetic genital concerns is unique in that the topic is shrouded in secrecy. Few opportunities exist for the improvement of female sexual health and well-being when compared with male counterparts. Women concerned with the appearance of their genitalia seek help with improving their confidence and reducing mental and physical discomfort attributed to large labia minora. Validated questionnaires given to patients beforehand, a detailed sexual history, and a comprehensive vulvar examination help define the esthetic and functional issues. Providing informed consent and setting realistic expectations are the key final steps to a successful esthetic genital consultation.

Defects involving the glabella and nasal root require an optimal cosmetic outcome due to its critical position in the mid-face. Glabellar defects often involve multiple cosmetic subunits, hair variations, and various skin thicknesses (forehead superiorly, eyebrows / eyelids laterally, nasal root and dorsum inferiorly), further complicating the reconstruction. The eyebrows and natural concavity of this area must be preserved if possible. Repair options in this location vary by personal preference and experience rather than literature-based outcomes. Key considerations include the location of the defect (glabella vs nasal root +/- brow +/- medial canthus), the position of the defect (midline or off-center) and the texture/thickness of the skin (thick glabellar skin or thin skin of medial canthus). The rich blood supply in this area has made local flaps the preferred option for moderate to large defects. However, two pitfalls for local flaps are pincushioning resulting in aldquo;bull noserdquo; and the possibility of causing synophrys. Often, a combination of flaps, grafts, and/or primary closures are necessary to adequately close large glabellar/nasal root defects. There is a paucity of literature for reconstructive options of the glabella and nasal root, and in the authorsrsquo; experience, even experienced surgeons struggle to decide on these. We present a series of reconstructive approaches for the majority of moderate to large cutaneous glabellar and nasal root defects with excellent functional and aesthetic results. J Drugs Dermatol. 2022;21(9):983-988. doi:10.36849/JDD.6132.

Genital aesthetic procedures have increased in popularity among women and men. Many clinicians tried to expand the application of fill injection by using it for genital aesthetic injection. However, this procedure is not so safe as imagined and may lead to a fatal complication of pulmonary embolism. This article summarizes the clinical manifestations and proposed mechanism of the filler-induced non-thrombotic pulmonary embolism (FINTPE) cases. A literature review was performed with the search keywords including "genital aesthetic injection, vaginal injection, vaginoplasty, vaginal tightening, penile augmentation, penis injection, hyaluronic acid, fat grafting, pulmonary embolism, alveolar hemorrhage, hypoxemia, and dyspnea." Among the 14 cases from 11 articles enrolled, 12 patients were female, and two were male. Eight patients received silicone injection, followed by two received fat grafting and hyaluronic acid injection, respectively. All the female patients had one single injection site, including 11 cases for the vaginal wall and one for G-spot, while all the male patients received injections into the penis and scrotum. The main symptoms were dyspnea and chest pain. Almost 60% of FINTPE patients presented respiratory disorders within 12 hours post-operation. Treatment includes oxygen therapy, corticosteroids, and anticoagulation. Five patients improved with an average of 14.6-day treatment, and seven died due to organ failures. Genital aesthetic filler injections are experimental procedures without being strictly reviewed or approved. As a severe complication following these procedures, FINTPE requires cautious performance, careful prevention, timely identification, and treatment to decrease its incidence and mortality.

BACKGROUND The primary element of a crooked nose is a midline deviation of the nasal pyramid. To date, no surgical strategies have been described as compatible with the philosophy of dorsal preservation. The dorsal preservation technique differs from the Joseph structured rhinoplasty because it preserves both the keystone area and the continuity of the cartilaginous vault. The authors focused on the versatility of the dorsal preservation technique even for the deviated nose, introducing the "Pisa Tower concept." METHODS From January of 2015 to June of 2019, 280 patients diagnosed as having a crooked nose underwent primary septorhinoplasty with dorsal preservation through an asymmetric bony wedge resection and lowering of the bony pyramid onto the frontal process of the maxilla (the let-down osteotomy), in accordance with the Pisa Tower concept. Inclusion criteria were a preoperative computed tomography examination, nasal axis deviation, a complete photographic examination preoperatively, and at least a 1-year follow-up. RESULTS The mean nasal axis deviation was 7.62 degrees preoperatively and 1.15 degrees postoperatively (p < 0.05). Of the 84 patients, 47 (55.95 percent) were very satisfied, 33 (39.28 percent) were satisfied, and four (4.76 percent) were unsatisfied with surgical results and required revision surgery. CONCLUSIONS The authors' opinion is that the association of "swinging door" septoplasty with the Pisa Tower concept can be a valid alterative to other techniques when working with the structured rhinoplasty philosophy in patients with a crooked nose. Although this is only a preliminary study, the decreased use of spreaders graft and less aggressive reconstructive methods look very promising. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.

BACKGROUND Male tuberous breast is an exceedingly rare condition that not fit properly into the majority of existing classifications of gynecomastia. This deformity has been categorized by Cordova and Moschella as gynecomastia grade III; however, they do not make any reference to the isolated tuberous deformity of the nipple-areola complex (NAC). Considering that the areolar area is the main ''esthetic unit'' in the male chest, surgical correction of the isolated tuberous NAC deformity can be challenging. There is a belief that this deformity is unsuccessfully corrected when approached through a limited periareolar incision at the lower pole. A complete periareolar incision, with a concentric excision of excess areolar skin, is usually required leaving an unnatural-looking round periareolar scar on the male thorax. METHODS We describe a variation of a surgical technique for the correction of a male tuberous NAC deformity in a teenager who rejected a conspicuous round periareolar scar after surgery. This modification combines a conventional lower hemiareolar approach with a percutaneous intradermal purse-string suture in the superior areolar margin to reduce the areolar diameter, avoiding an evident circumareolar scar. RESULT At the six-month follow-up, areolar widening or tuberous deformity relapse was not observed. The patient felt satisfied with the outcome. CONCLUSION The use of percutaneous intradermal purse-string periareolar suture for correction of this rare deformity is a simple and reproducible surgical technique that could help to obtain a better cosmetic result by restoring the contour of the male chest while minimizing the visibility of the residual scar. 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 .

Background Scar revisions have been increasing in number. Patient-reported outcome measures are one tool to aid scar modulation decision-making. The aims of this study were to determine patient, scar, and clinical risk factors for (1) low SCAR-Q Appearance, Symptom, and Psychosocial Impact scores and how this differs for children; and (2) the potential need for future scar revision surgery to better identify such patients in a clinical setting. Methods A multicenter international cross-sectional cohort study based on survey data of participants with traumatic, surgical, and burn scars attending plastic, hand, and burn clinics in four countries was conducted following the Strengthening the Reporting of Observational Studies in Epidemiology checklist. Univariate analysis to identify risk factors and multivariable logistic analysis to select risk factors were completed. Collinearity for nonindependent factors and C statistic for model discrimination were also calculated. Results Seven hundred thirty-one participants completed the study booklet, and 546 participants (74.7 percent) had full data. Independent risk factors were determined to be a bothersome scar and perception of scarring badly for all three scales. Risk factors for self-reporting the need for future surgery included a health condition, scarring badly, scar diagnosis, prior scar revision, and low Psychosocial Impact scores. We did not identify evidence of multicollinearity. C statistics were high (0.81 to 0.84). Conclusions This study is the first multicenter international study to examine independent risk factors for low patient-reported outcome measure scores and the potential need for future scar revision surgery. Patients that perceive themselves as scarring badly and having a bothersome scar were at a higher risk of scar appearance concern, an increased symptom burden, and poorer psychosocial impact scores. Clinical question/level of evidence Risk, III.

Body dysmorphic disorder (BDD) is a controversial topic in the field of plastic surgery. Our aim was to determine whether BDD knowledge, attitude and practice (KAP) are affected by the experience of the surgeon in the field, sex of the surgeon, country of practice, and the number of patients the surgeon sees annually. We were particularly interested in uncovering any significant relations in KAP of BDD between plastic surgeons practicing in developed versus developing countries. We created a two-page survey of 24 questions about the KAP of BDD. The survey was sent to aesthetic plastic surgeons worldwide via ISAPS global email list. The data were collected over a period of 20 days at the end of 2020. A total of 464 plastic surgeons completed the survey. The only factor that determines the awareness of BDD is the experience of the surgeon. The more experienced the surgeon is, the more likely he/she is to be familiar with the clinical picture of BDD. Although aware, the more experienced surgeons tend to dismiss the importance of referring BDD patients to psychiatrists/psychologists. Male surgeons tend to diagnose more patients with BDD than female surgeons. Surgeons who estimated the correct prevalence of BDD among patients seeking surgery acquired knowledge of BDD from scientific journals. The KAP is relatively similar between surgeons practicing in developed and developing countries, and the main statistically significant difference was in the questions used during the course of the interviews to diagnose BDD. We can deduce from the results that most aesthetic surgeons worldwide have got knowledge of the presentation of BDD and are keen to diagnose the disorder in their practice. It is worth noting that surgeons usually have their unique approach in the management of BDD. Our study highlights the importance of not only raising awareness of the best management of BDD, but also of establishing a consensus that BDD is a contraindication to aesthetic treatment. The best methods to raise awareness are through journals and plastic surgery residency. 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 .

BACKGROUND The emergence on the market of non-invasive mechanisms aimed at reducing subcutaneous fat achieving a slimming effect arouses great interest in doctors and patients. Several methods for the destruction of adipocytes are today on the market. AIMS This is a pilot study on body fat reduction treatment, using a novel energy-based device for body shaping. METHODS The study is performed on 42 patients, healthy adults of both sexes, with BMI between 25 and 30 kg/m², indicated for the removal of fatty tissue deposits specifically in the following areas: flanks, abdomen, internal legs, trochanter, buttocks, and arms. A minimum of 5 to a maximum of 6 treatments were performed for each patient, with the device, every two weeks and with a follow-up of 6 weeks. Circumference reduction, side effects, and patient pain were evaluated for all patients. RESULTS A set of 42 patients were evaluated. The mean circumference reduction at 6 weeks was 2.42 ± 0.4 cm (p

Background Men worry disproportionately about potential negative consequences of facial aesthetic treatment with injectable therapies, such as side effects or appearing more feminine. Features of the lower third of the face (eg, prominent chin and jaw) are particularly important in perceptions of masculinity. A strategy has been developed for male patients based on an initial consultation emphasizing the safety and masculinizing potential of injectables, followed by treatment with a high G’ hyaluronic acid filler targeting the lower third. Aims To assess this strategy in routine practice. Methods This was a retrospective analysis of male patients with poor definition of the lower third of the face wishing to undergo non‐surgical correction. Initial consultation focused on detailed patient education and facial masculinization with injectables. Individuals were then treated in the lower third using VYC‐25 based on the standardized MD Codes approach. Follow‐up lasted ≤12 months. Results Forty patients were included (mean age: 40.9 ± 9.6 years). The mean volume of VYC‐25 injected into the lower third was 7.8 ± 1.2 ml. Patient satisfaction was high, as assessed using the FACE‐Q “Satisfaction with outcome” questionnaire (mean Rasch‐transformed score: 88.1 ± 10.3). Complications included the following: soft tissue edema, n = 12 (30.0%); hematoma, n = 6 (15.0%); and telangiectasia, n = 2 (5.0%). All were early, transient, and minor; there were no major or delayed events. Conclusions This approach to male subjects was practical and safe despite the large volumes of filler used. Focusing on the lower third may help to reassure patients and deliver results that respect masculine identity.

It is an open question whether preferences for visual art can be lawfully predicted from the basic constituent elements of a visual image. Here, we developed and tested a computational framework to investigate how aesthetic values are formed. We show that it is possible to explain human preferences for a visual art piece based on a mixture of low- and high-level features of the image. Subjective value ratings could be predicted not only within but also across individuals, with a regression model with the same set of interpretable features. We also show that the features which predict aesthetic preference can emerge hierarchically within a deep convolutional neural network trained only for object recognition. Our findings suggest that human preferences for art can be explained at least in part as a systematic integration over the underlying visual features of an image.