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The transverse rectus abdominis muscle (TRAM) flap technique is the most versatile and artistic procedure currently used for breast reconstruction. Several variations have been described in the past with regard to the aesthetic objectives of reconstruction and the technical steps to achieve these goals. This study aimed to analyze changes introduced by the authors to improve the aesthetic outcome of breast reconstruction using the pedicle TRAM flap in terms of three specific aesthetic goals: (1) better definition of the submammary fold, (2) improved reconstruction of the tail of the breast and anterior axillary wall after axillary clearance, and (3) improved projection of the lower pole of the reconstructed breast. The design of the pedicle flap has been modified to accommodate four surgical scenarios: vertical orientations of the flap with either an ipsi or contralateral pedicle and horizontal orientation of the flap with either an ipsi or contralateral pedicle. In each of these variations, specific surgical steps were undertaken to produce extension of the flap into the axilla, better definition of the submammary fold, and folding of the flap in its lower part to increase lower pole projection. Postoperatively, standardized five-view images of the patients were taken and presented to blinded observers, who were requested to award a numeric score to the aesthetic outcome. The numeric scores then were analyzed statistically. An experimental group of 11 patients who underwent reconstruction using the modified/improved technique were compared with a control group of 17 patients who underwent reconstruction using the classic technique. The incidences of complications for the two groups were compared and analyzed as well. The two groups of patients were comparable in terms of their age distribution and incidences of donor site and recipient site complications. A statistically significant difference was noted between the aesthetic scores awarded to patients who underwent surgery using the improved technique and those awarded to those who underwent surgery using the classic technique (p = 0.0006). A model is presented for statistical analysis of the aesthetic outcome for breast reconstruction using an improved TRAM flap design as compared with using a classic TRAM flap design. This model offers an evidence-based decision-making process and uses the principle of aesthetic breast surgery adapted to breast reconstruction. On the basis of this model, the authors conclude that the aesthetic outcome of breast reconstruction can be improved by attention to details such as better projection of the breast’s lower pole, improved sculpting of the submammary fold, and attention to filling contour deficits of the axilla after axillary clearance.

Augmentation mammoplasty is a commonly performed procedure with a very high satisfaction rate. Various techniques have been described since the report of the first augmentation mammoplasty in 1963. Muscle-splitting augmentation mammoplasty, a technique first published in 2007, has been used by the author for primary and secondary augmentation mammoplasties and for mastopexy with augmentation. A retrospective analysis of data prospectively collected using the Excel spreadsheet was performed. The patients were divided into three groups. The mammoplasty for group A used the subglandular pocket. In group B, the partial submuscular pocket was used for mammoplasties. Both of these groups had their mammoplasties performed between 1999 and 2005. Group C, the third group, included patients who had muscle-splitting mammoplasties between 2005 and 2011. Group A involved 793 patients who had their augmentation mammoplasties in the subglandular pocket. Of these 793 patients, 751 had the same size implants and were included in the analysis. The mean age of the patients in group A was 30.9 ± 7.98 years (range 18–59 years), and their mean implant size was 317.5 cc ± 2.05 (range 200–555). In group A, 45.1 % (n = 339) of the patients were smokers, and 62.2 % (n = 467) had drains. The majority of the patients (78 %) had an overnight stay in the clinic. Hematoma was seen in 2.7 % (n = 20) of the group A patients. Revision was performed for 6 % (n = 45). Periprosthetic infection was seen in 0.4 % (n = 3) and minor wound healing problems in 1.3 % (n = 10). Group B comprised 110 patients who had mammoplasties performed in partial submuscular pockets. All the patients had the same size implants. The mean age of the group B patients was 33 ± 8.26 years (range 20–58 years), and their mean implant size was 300.6 cc ± 35.92 (range 205–395). Of these 110 patients, 51.8 % (n = 57) were smokers, and 94.5 % (n = 104) had drains. Hematoma was seen in 1.8 % (n = 2), and revision was performed for 7.3 % (n = 8) in the submuscular subgroup. Infection was seen in 3.6 % (n = 4) and minor wound healing problems in 4.5 % (n = 5). Group C consisted of 1,123 patients who had breast augmentation in the muscle-splitting biplane. Of these 1,123 patients, 914 had the same size implants. The mean age of the patients was 30.0 ± 8.78 years (range 18–67 years), and their mean implant size was 338.2 cc ± 58.01 (range 170–655). In group C, 33.6 % of the patients were smokers, and 8 % had drains. The majority of the patients (93.4 %) were treated as day cases. Hematoma was seen in 0.7 %, and 1.2 % of the patients had revision surgery. Infection was seen in 1.6 % (n = 15) and minor wound healing in 4 % (n = 45). Muscle-splitting mammoplasty is a technique that can be performed as a day case without drains. The overall complications in the group were significantly lower than with the other two techniques performed by the author. This journal requires that authors assign a 41 level of evidence to each article. For a full description of 42 these Evidence-Based Medicine ratings, please refer to the 43 Table of Contents or the online Instructions to Authors 44 http://www.springer.com/00266 .

Nevus sebaceous has been considered a relatively infrequent and unimportant congenital hamartoma for plastic surgeons unless the lesions are so big that they require a demanding defect closure. As the dignity of such tumors is primarily benign and the malformed sebaceous glands are localized abnormally high in the dermis, the temptation is appealing not to excise these tumors any more but to eradicate them by laser beam therapy. Yet a nevus sebaceous not only affects sebaceous glands but includes various other malformations of the affected skin and its appendages. In addition, different malignant tumors may occur in nevus sebaceous, even in children and young adults. We encountered 4 such malignant tumors of 18 nevi sebaceous operated on from 1989 to 1997. All nevi had been unsuspicious macroscopically. In three patients, one of them only 15 years old, an associated basal cell carcinoma was found. In the fourth patient there was a mixture of three additional tumors, a cystadenoma, a keratoacanthoma, and a basal cell carcinoma, besides the sebaceous malformations. These findings have two consequences: first, to continue surgical treatment of nevus sebaceous instead of dermabrasion or dermablation and to have the specimen examined histologically and, second, to excise such tumors as early in childhood as possible.

There are no studies about the treatment of nasal bone fractures in patients with dorsal augmentations using silicone implants. We aimed to describe the characteristics of nasal bone fracture in patients who underwent rhinoplasty and compare the difference between closed reduction and conservative treatment of nasal bone fractures in patients with a history of rhinoplasty. Between January 2013 and June 2018, a total of 463 patients were admitted to our center for nasal bone fracture; 17 patients with nasal bone fractures who underwent rhinoplasty were included, of which, five underwent closed reduction in the nasal bone and 12 underwent conservative treatment. Three of 12 patients who were initially treated conservatively underwent a secondary rhinoplasty for esthetic improvements. All patients were classified according to fracture site and the presence of a nasal septal fracture—in accordance with the modified Murray classification—and were analyzed for the correlation between fracture type and disease course. The nasal bone fracture types per computed tomography findings were unilateral (n = 13), bilateral (n = 4), septal (n = 1), and M-type (n = 1). No significant differences in fracture site (P > 0.05) and the presence of a nasal septal fracture (P > 0.05) were found between the groups. Fracture type did not significantly differ among patients who underwent closed reduction, conservative treatment without secondary rhinoplasty, and secondary rhinoplasty (P > 0.05). Despite risking traumatic capsular rupture, implant removal is seldom required and closed reduction is recommended if visible deviations are present; otherwise, only conservative treatment is recommended. 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.