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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

There is a lack of an accurate standardised objective method to assess aesthetic outcome after breast surgery. In this methodological study, we investigated the intra- and inter-observer reproducibility of breast symmetry and volume assessed using three-dimensional surface imaging (3D-SI), evaluated the reproducibility depending on imaging posture, and proposed a new combined volume-shape-symmetry (VSS) parameter. Images were acquired using the VECTRA XT 3D imaging system, and analysed by two observers using VECTRA Analysis Module. Breast symmetry was measured through the root mean square distance. All women had undergone bilateral risk-reducing mastectomy and immediate breast reconstruction. The reproducibility and correlations of breast symmetry and volume measurements were compared using Bland-Altman's plots and tested with Spearman's rank correlation coefficient. 3D surface images of 58 women were analysed (348 symmetry measurements, 696 volume measurements). The intra-observer reproducibility of breast symmetry measurements was substantial-excellent, the inter-observer reproducibility was substantial, and the inter-posture reproducibility was substantial. For measurements of breast volumes, the intra-observer reproducibility was excellent, the inter-observer reproducibility was moderate-substantial, and the inter-posture reproducibility was substantial-excellent. The intra-observer reproducibility of VSSVSS was excellent while the inter-observer reproducibility was substantial for both observers, independent of posture. There were no statistically strong correlations between breast symmetry and volume differences. The intra-observer reproducibility was found to be substantial-excellent for several 3D-SI measurements independent of imaging posture. However, the inter-observer reproducibility was lower than the intra-observer reproducibility, indicating that 3D-SI in its present form is not a great assessment for symmetry.

The aim of this study was to evaluate the efficacy of CRB modification of retromandibular approach to gain surgical access for open reduction and internal fixation of mandibular subcondylar fractures. A total number of 264 sustained extra-capsular subcondylar fractures from 230 patients were selected for the study over the period of 5 years. Evaluation of intraoperative accessibility, postoperative facial nerve function, postoperative complications and scar was carried out. All the patients were treated using CRB Curvilinear approach. Patient follow up was recorded for 1 year on a regular interval basis. Symptoms of postoperative facial nerve injury were seen in 2 patients which recovered with time, postoperative complications were not encountered in any case and minimum scar mark hidden in the cervical skin crease. Hence open reduction and internal fixation for Subcondylar fracture of mandible by using the CRB modification of retromandibular approach is a good alternative for other conventional approaches in having ease of access, ease of fixation, reduced incidences of injury to facial nerve and its branches with good aesthetic outcome.

Objective: To evaluate functional and aesthetic outcomes of the reconstruction of soft-tissue defects of the heel with microsurgical techniques using a free radial forearm flap and an anterolateral thigh flap. Patients and methods: The study included 25 patients, 15 males and 10 females, with a mean age of 34.3 ± 10.4 years, with soft-tissue defects of the heel. Of them, 11 patients whose defects were of size between 5 and 10 cm in their largest dimension were treated using a free radial forearm flap, and 14 patients whose defects were of size larger than 10 cm in their largest dimension were treated using a free anterolateral thigh flap.Post-operatively, avoidance of weight-bearing and walking was required for 8 to 10 weeks. At the end of the follow-up, all patients underwent functional, aesthetic and sensation evaluation in addition to assessment of patient satisfaction. Results: The median follow-up period was 24 months. The causes of the defect were trauma (14 patients), neuropathic ulcer (8 patients) and neoplasia (3 patients). The size of the defect ranged from 5 × 6 cm to 14 × 24 cm. Four patients had calcaneal fracture. By the end of the follow-up period, 21 cases showed complete success, whereas 2 flaps failed, one in each flap type, and the remaining two flaps showed partial loss of the edges (anterolateral thigh flaps). Failure was due to venous congestion (one patient) and ischaemia (one patient). Eighteen patients were satisfied with their aesthetic appearance, functional outcome and flap sensation. Conclusion: Reconstruction of large heel defects, using radial forearm and anterolateral thigh free flaps, provides acceptable functional and aesthetic outcomes. Keywords: Soft-tissue defect of heel, Reconstruction, Free flap, Functional, Aesthetic outcome

Background Treatment of breast cancer includes many options and shared decision making is becoming standard practice. Within the context of treatment individualization, the omission of radiotherapy (RT) can be considered. It is thereby of great importance to correctly foresee the side effects attributed to RT. Data from longitudinal studies with contemporary techniques however are sparse. The purpose of the present study was to evaluate patient-reported outcome measures (PROMs) and long-term aesthetic outcome (AO) related to RT in the breast-conserving therapy (BCT) setting for breast cancer over time. Methods Patients treated with BCT between April 2015 and April 2016 were prospectively included in the cohort. Evaluations were made at six time points: at baseline (before RT), during and at the end of RT, between 3 and 6 months, 1 year and 2 years after RT. AO was scored by the patient and by the BCCT.core software. Further PROMs were measured with the European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire QLQ-C30/-BR23 and the Body Image after Breast Cancer Questionnaire BIBCQ. Patients were evaluated over 2 years. First, we assessed the evolution in time. Second, we tested the differences in mean scale scores of the PROMs between patients with a favourable and an unfavourable AO. Results One hundred seventy-five patients were included in the analysis. At baseline, unsatisfactory levels were already present for several scales. Most unsatisfactory PROMs improved up to 1 year after RT. Complaints of fatigue increased at the start but decreased up to a lower level than that at baseline up to 1 year after RT (mean difference (MD) 7.6, - 12.3, respectively). Cognitive functioning showed a small decrease at the start with no further significant decrease (MD - 4.73, - 0.21, respectively). Breast symptoms significantly increased during RT but decreased afterwards up to 2 years after RT to lower values than those at baseline and were then considered satisfactory (MD 15.6, - 19.7, - 4.1, respectively). AO scored as PROM associated with BCCT.core and with the body image measures. Conclusions The study suggests that quality of life and body image are temporarily impaired due to RT. Around one third of patients score their long-term AO as unfavourable. These results should be discussed with the patient and could help in the decision making of the treatment plan and in the clarification of the patient's expectations.

Background Neoadjuvant chemotherapy (NACT) was initially applied to locally advanced breast cancer to convert advanced lesions to an operable status. Currently, its application has been expanded to enhance overall oncological results, especially in patients with triple-negative or HER-2-positive breast cancer. With more NACT being applied, the role and impact of this approach on breast reconstruction needs to be determined. This study aimed to perform a complete reconstructive outcome analysis of patients receiving NACT who underwent immediate breast reconstruction. Methods A retrospective review of a single reconstructive surgeon’s immediate breast reconstructions performed from July 2008 to December 2018 was undertaken. The results were stratified by the use of NACT. Patient demographics, delivery of NACT, adjuvant treatment, incidence of surgical complications, and postoperative photographs were analyzed. Results A total of 269 patients were included. The mean follow-up was 46.3 months. Forty-six out of 269 patients received NACT and were included in the NACT group. The other patients were included in the non-NACT group. When implant-based reconstruction was planned, the NACT group had a higher rate of two-stage tissue expander-implant reconstruction than direct-to-implant reconstruction (p p Conclusions Immediate breast reconstruction is a safe and reliable procedure, with an acceptable reconstructive complication rate and satisfactory aesthetic outcomes, for patients treated with NACT.

Background: The use of acellular dermal matrix (ADM) in one-stage immediate implant-based breast reconstruction (BR) may offer advantages over the two-stage expander-to-implant technique, but literature shows conflicting results. The aim of the present study was to compare these two techniques for immediate implant-based BR regarding postoperative complications, aesthetic correction procedures and aesthetic outcome. Methods! The study was designed as an observational cohort study with 44 participants admitted for immediate implant-based BR at Department of Plastic Surgery, Aarhus University Hospital, Denmark. 21 patients underwent BR with a one-stage direct-to-implant technique using ADM and 23 patients underwent BR with a two-stage expander-to-implant technique. Follow-up time was 2 years. Results! The risk of implant loss was equal between groups; one-stage group 16% and two-stage group 17% whereas the risk of implant exchange (but not loss of BR) was 13% in the one-stage group compared to 7% in the two-stage group. The risk of at least one major complication were equal between groups; 28% and 24% but the risk of at least one minor complication was significantly higher in the two-stage group (41%) compared to the one-stage group (3%). Number of aesthetic corrections were equally frequent in the two treatment groups (one-stage group 1.8, two-stage group 1.5). Patient and investigator assessed aesthetic outcome was very high in both groups as well as the degree of symmetry between breasts. No capsular contracture Baker grade 3 or 4 was observed. Conclusions! The present study design sets limitations for drawing wide conclusions. This study did not reveal any significant differences between the two breast reconstructive techniques besides a higher risk of minor complications in the two-stage group, that did, however, not lead to a higher risk of implant loss. With equally high satisfaction with the aesthetic result and no significant difference in number of aesthetic corrections between the two groups we suggest, that the one-stage approach using ADM may be feasible and allows the patient to achieve an implant-based BR with a minimum of surgeries and outpatient visits. The study was registered in ClinicalTrials.gov (NCT04209010).

Background The aesthetic outcome after burr hole trepanation for the evacuation of chronic subdural hematomas (cSDH) is often unsatisfactory, as the bony skull defects may cause visible skin depressions. The purpose of this study was to evaluate the efficacy of burr hole cover placement to improve the aesthetic outcome. Methods We reviewed consecutive patients treated by burr hole trepanation for cSDH with or without placement of burr hole covers by a single surgeon between October 2016 and May 2018. The clinical data, including complications, were derived from the institution’s prospective patient registry. The primary endpoint was the aesthetic outcome, as perceived by patients on the aesthetic numeric analog (ANA) scale, assessed by means of a standardized telephone interview. Secondary endpoints were skin depression rates and wound pain, as well as complications. Results From n = 33, outcome evaluation was possible in n = 28 patients (n = 24 male; mean age of 70.4 ± 16.1 years) with uni- (n = 20) or bilateral cSDH (n = 8). A total of 14 burr hole covers were placed in 11 patients and compared to 50 burr holes that were not covered. Patient satisfaction with the aesthetic outcome was significantly better for covered burr holes (mean ANA 9.3 ± 0.74 vs. 7.9 ± 1.0; p

Background: The suturing technique and its associated complications could affect cosmetic outcome after facial surgery. Literature on this topic is limited.Objective: To compare the cosmetic results 12 months after treatment and complications associated with simple interrupted sutures (SIS) versus running subcuticular sutures (RSS) in facial surgery.Methods: A randomized, controlled multicenter trial was performed. Adults receiving dermatologic surgery on the face were randomized to receive SIS or RSS for wound closure. The primary outcome was the overall opinion score on the Patient and Observer Scar Assessment Scale (POSAS) 12 months after surgery. Secondary outcomes were the complication rates and scores according to alternative methods for assessment of cosmetic outcome. The observer of cosmetic outcome was blinded to treatment assignment.Results: 142 patients were randomized to receive SIS (n = 73) or RSS (n = 69). Twelve months after surgery, the median score of the overall opinion on the POSAS was 2.0 (range 1-8) according to the patients and 3.0 (range 1-8) according to the observer in both groups. In the RSS group, hyper-or hypoesthesia was reported more often.Limitations: The cosmetic result was assessed by 1 observer.Conclusion: SIS and RSS in facial surgery resulted in comparable cosmetic outcomes. RSS was more often associated with hyper-or hypoesthesia.

Purpose To establish whether objective measurements of symmetry of volume and shape using three-dimensional surface imaging (3D-SI) can be used as surrogate markers of aesthetic outcome in patients who have undergone breast conserving therapy (BCT). Methods Women who had undergone unilateral BCT in the preceding 1–6 years were invited to participate. Participants completed a satisfaction questionnaire (BREAST-Q) and underwent 3D-SI. Volume and surface symmetry were measured on the images. Assessment of aesthetic outcome was undertaken by a panel of clinicians. The Kruskal–Wallis test was used to assess the relationship between volume and shape symmetry measurements with the panel score. Spearman’s rho correlations were used to assess the relationship between the measurements and patient satisfaction. Results 200 women participated. Median volume symmetry was 87% (IQR 78–93) and shape symmetry was 5.9 mm (IQR 4.2–8.0). The participants were grouped according to panel assessment of aesthetic outcome (poor, fair, good, excellent) and the median volume and shape symmetry was calculated for each group. Volume symmetry significantly differed between the groups. Post hoc pairwise comparisons demonstrated that these differences existed between panel scores of fair versus good and good versus excellent. Median shape symmetry also differed according to patient panel groups with four significant pairwise comparisons between poor versus good, poor versus excellent, fair versus good and fair versus excellent. There was a significant but weak correlation of both volume symmetry and surface asymmetry with BREAST-Q scores (correlation coefficients 0.187 and −0.229, respectively). Conclusion Breast volume and shape symmetry are both associated with panel assessment scores and patient satisfaction. The objective volume and shape symmetry measures were strongly associated with panel assessment scores, such that a 3D-SI tool could replace panel assessment as a faster and more objective method of evaluating aesthetic outcomes.

OBJECTIVESkin depressions may appear as undesired effects after burr-hole trepanation for the evacuation of chronic subdural hematomas (cSDH). Placement of burr-hole covers to reconstruct skull defects can prevent skin depressions, with the potential to improve the aesthetic result and patient satisfaction. The perception of the relevance of this practice, however, appears to vary substantially among neurosurgeons. The authors aimed to identify current practice variations with regard to the application of burr-hole covers after trepanation for cSDH.METHODSAn electronic survey containing 12 questions was sent to resident and faculty neurosurgeons practicing in different parts of the world, as identified by an Internet search. All responses completed between September 2018 and December 2018 were considered. Descriptive statistics and logistic regression were used to analyze the data.RESULTSA total of 604 responses were obtained, of which 576 (95.4%) provided complete data. The respondents’ mean age was 42.4 years (SD 10.5), and 86.5% were male. The sample consisted of residents, fellows, junior/senior consultants, and department chairs from 79 countries (77.4% Europe, 11.8% Asia, 5.4% America, 3.5% Africa, and 1.9% Australasia). Skin depressions were considered a relevant issue by 31.6%, and 76.0% indicated that patients complain about skin depressions more or less frequently. Burr-hole covers are placed by 28.1% in the context of cSDH evacuation more or less frequently. The most frequent reasons for not placing a burr-hole cover were the lack of proven benefit (34.8%), followed by additional costs (21.9%), technical difficulty (19.9%), and fear of increased complications (4.9%). Most respondents (77.5%) stated that they would consider placing burr-hole covers in the future if there was evidence for superiority of the practice. The use of burr-hole covers varied substantially across countries, but a country’s gross domestic product per capita was not associated with their placement.CONCLUSIONSOnly a minority of neurosurgeons place burr-hole covers after trepanation for cSDH on a regular basis, even though the majority of participants reported complaints from patients regarding postoperative skin depressions. There are significant differences in the patterns of care among countries. Class I evidence with regard to patient satisfaction and safety of burr-hole cover placement is likely to have an impact on future cSDH management.

Objective To evaluate the clinical, functional and aesthetic outcomes for radial forearm free flap (RFFF) donor sites covered with amniotic membrane (AM). Material and methods The healing process of patients with RFFF donor sites covered with AM was prospectively followed for 1 year. Additionally at the 12-month evaluation, objective scoring systems were used to assess the aesthetic (Vancouver scar scale, VSS: range 1–13) and functional outcome (skin sensibility, hand/wrist functionality [goniometer], grip strength [score 1 = excellent, 5 = poor]). By using a subjective rating system (score 1 = excellent, 5 = poor), the patient-reported aesthetic and functionality outcome was correlated with objective data analysis. Results Twenty-one out of 23 patients were followed for 12 months (dropout: 2 patients at 3 months). In 17/23 (73.9%) patients RFFF defect covered with AM showed an uneventful healing period ( 3 months p p = 0.012) and the use of antihypertensive medications provided positive effects (p = 0.041) on the aesthetic outcome. Conclusion RFFF donor site defects covered using AM show excellent clinical, aesthetic and functional outcome representing patient comorbidities (BMI, antihypertensive drugs) might affect the aesthetic outcome. Clinical relevance In relation to the excellent outcomes found, the use of AM offers an alternative treatment procedure for RFFF defect covering.

Background and aim The reproducible measurement of aesthetic outcomes after cleft lip and palate (CLP) surgery remains elusive, and there is no internationally recognised system. The aim of this pilot study was to better understand how humans rate post-operative aesthetic outcome after unilateral cleft lip and palate (UCLP) repair using a novel web-based rating platform with an extended panel of surgeon raters. Methods Cropped images of 5-year-old UCLP patients were arranged in a randomly generated sequence within a web-based aesthetic scoring tool as part of an agreement/reliability study. Assessors rated the appearances of patients using a five-point Likert-type scale on two occasions. A mixed-effect statistical model was adopted to analyse the effects of rater, image and timing. Results Images of 76 patients were scored by 29 UK-based cleft surgeons. Intra-rater variability was found, and the linear weighted kappa was 0.56. This allowed identification of the most and least consistent raters. The random image effect (p

BACKGROUND: This study focused on the possible effect of platelet-rich plasma (PRP) on recovery time and aesthetic outcome after facial rejuvenation. We conducted a retrospective analysis with regard to recovery time and the aesthetic improvement after treatment among four groups of patients: those treated with fat grafting only (Group I), those treated with fat grafting and PRP (Group II), those treated with a minimal access cranial suspension (MACS)-lift and fat grafting (Group III), and those treated with a MACS-lift, fat grafting, and PRP (Group IV).METHODS: For the first part of this study, i.e., evaluation of recovery time after surgery, the following selection criteria were used: nonsmoking females, aged 35-65 years, with a complete documented follow-up. In total, 82 patients were included in the evaluation of patient-reported recovery time. For the second part of the study, i.e., evaluation of potential differences in aesthetic outcome, the records of these 82 patients were screened for the presence of pre- and postoperative standardized photographs in three views (AP, lateral, and oblique), leaving 37 patients to evaluate. A questionnaire was developed to evaluate the aesthetic outcome in all four groups of patients. This questionnaire was given to an expert panel that consisted of ten plastic surgeons.RESULTS: The addition of PRP to a lipofilling procedure resulted in a significant drop in the number of days needed to recover before returning to work or to restart social activities [Group I (no PRP) took 18.9 days vs Group II (PRP) took 13.2 days, p = 0.019]. There seemed to be no effect when PRP was added to a MACS-lift + lipofilling procedure. Also, the aesthetic outcome of the lipofilling and MACS-lift + lipofilling groups that received PRP (Groups II and IV) was significantly better than the groups without PRP (Groups I and III).CONCLUSIONS: Adding PRP to facial lipofilling reduces recovery time and improves the overall aesthetic outcome of a MACS-lift.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: This study focused on the possible effect of platelet-rich plasma (PRP) on recovery time and aesthetic outcome after facial rejuvenation. We conducted a retrospective analysis with regard to recovery time and the aesthetic improvement after treatment among four groups of patients: those treated with fat grafting only (Group I), those treated with fat grafting and PRP (Group II), those treated with a minimal access cranial suspension (MACS)-lift and fat grafting (Group III), and those treated with a MACS-lift, fat grafting, and PRP (Group IV). METHODS: For the first part of this study, i.e., evaluation of recovery time after surgery, the following selection criteria were used: nonsmoking females, aged 35-65 years, with a complete documented follow-up. In total, 82 patients were included in the evaluation of patient-reported recovery time. For the second part of the study, i.e., evaluation of potential differences in aesthetic outcome, the records of these 82 patients were screened for the presence of pre- and postoperative standardized photographs in three views (AP, lateral, and oblique), leaving 37 patients to evaluate. A questionnaire was developed to evaluate the aesthetic outcome in all four groups of patients. This questionnaire was given to an expert panel that consisted of ten plastic surgeons. RESULTS: The addition of PRP to a lipofilling procedure resulted in a significant drop in the number of days needed to recover before returning to work or to restart social activities [Group I (no PRP) took 18.9 days vs Group II (PRP) took 13.2 days, p = 0.019]. There seemed to be no effect when PRP was added to a MACS-lift + lipofilling procedure. Also, the aesthetic outcome of the lipofilling and MACS-lift + lipofilling groups that received PRP (Groups II and IV) was significantly better than the groups without PRP (Groups I and III). CONCLUSIONS: Adding PRP to facial lipofilling reduces recovery time and improves the overall aesthetic outcome of a MACS-lift. 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 When the inframammary fold (IMF) is excised in mastectomy procedures for oncologic reasons, it must be recreated to restore a natural breast shape. Despite refinements in surgical techniques, postoperative loss of a well-defined IMF can occur. This study aimed to assess the outcomes of IMF recreation after two-stage, implant-based breast reconstruction. Methods We retrospectively reviewed 75 consecutive patients who underwent unilateral, two-stage, implant-based breast reconstruction between 2013 and 2015 at the authors’ institution. Among them, IMF recreation was performed in 37 patients through a modified Nava’s internal method. Aesthetic outcomes of the recreated IMFs were evaluated by observer assessment of two criteria, and critical factors affecting IMF outcomes were also analyzed. Results We found that contralateral breast ptosis (p