The Superficial Musculoaponeurotic System: Does It Really Exist as an Anatomical Entity?

BACKGROUND

The exact anatomical entity behind the term superficial musculoaponeurotic system (SMAS) remains poorly understood. The different interpretations of the term SMAS by anatomists, surgeons, and histologists have caused confusion. This article aims to provide clarity regarding this term and the relevant anatomy.

METHODS

A literature review was conducted to uncover the variety of descriptions of the term SMAS. A feasibility study, followed by a conclusive series of standardized layered dissections complemented by histologic analysis and sheet plastination, was performed on 50 cadaver heads (16 embalmed and 34 fresh; mean age, 75 years).

RESULTS

Most literature considers the SMAS as layer 3, that is, a musculoaponeurotic layer that separates the subcutaneous fat of the superficial fascia from the deep fat of the deep fascia. The authors' dissections, histologic analysis, and sheet plastination demonstrated that layer 3 is present only where there are flat mimetic muscles and platysma-auricular fascia over the posterior part of the parotid gland as the evolutionary remnant of the platysma, but not between the flat mimetic muscles. Here, the subcutaneous fat is in direct contact with the deep fat without the interposition of a musculoaponeurotic layer 3.

CONCLUSIONS

Because of the absence of a distinct and complete layer 3 connecting the flat mimetic muscles, the authors conclude that the SMAS as originally described does not exist as a specific anatomical entity. In retrospect, the surgically created compound layered flap composed of a variable thickness of subcutaneous fat, mimetic muscles (eg, platysma, orbicularis oculi), and a thin layer of deep fascia is what is known as the "SMAS."

Anatomy of the Facial Glideplanes, Deep Plane Spaces and Ligaments: Implications for Surgical and Non-Surgical Lifting Procedures

BACKGROUND

The soft tissue glideplanes of the face are functionally important and have a role in facial rejuvenation surgery. The aim of this study was to improve our understanding of soft tissue mobility of the face and its impact on the redraping of tissues involved in facelifting. The consequences of "no-release" and "extensive-release" lifting were analyzed to explain the difference in efficacy and potential longevity between these two contrasting philosophies.

MATERIALS METHODS

Preliminary dissections and macro sectioning were followed by a definitive series of standardized layered dissections on fifty cadaver heads, along with histology, sheet plastination, and mechanical testing.

RESULTS

The previously described spaces are potential surgical dissection planes deep to the superficial fascia layer. The classically described retaining ligaments are local reinforcements of a system of small retaining fibers (retinacula cutis and deep retinacula fibers) which provide support of the soft tissues of the face and neck against gravitational sagging while allowing certain mobility. This mobility is utilized when mobile tissues are lifted without surgical release. However, the process of dragging up these fibers results in a loss of their previous, anti-gravitational, supportive orientation.

CONCLUSION

No-release lifting techniques, such as thread lifts and minimal-invasive facelifts, tighten "tissue laxity" with a change of the gravity-opposing tissue architecture, placing the weight of the flap solely on the fixation, which limits longevity of the lift. The alternative, to perform a full release with redraping, enables reattachment of the flap to a higher position, with preservation of the original deep fascial architecture with its antigravity orientation and natural mobility, conceivably improving the longevity of the lift.

The Functional Anatomy and Innervation of the Platysma is Segmental: Implications for Lower Lip Dysfunction, Recurrent Platysmal Bands, and Surgical Rejuvenation

BACKGROUND

Despite the central role of the platysma in face and neck rejuvenation, much confusion exists regarding its surgical anatomy.

OBJECTIVES

This study was undertaken to clarify the regional anatomy of the platysma and its innervation pattern and to explain clinical phenomena, such as the origin of platysmal bands and their recurrence, and the etiology of lower lip dysfunction after neck lift procedures.

METHODS

Fifty-five cadaver heads were studied (16 embalmed, 39 fresh, mean age 75 years). Following preliminary dissections and macro-sectioning, a series of standardized layered dissections were performed, complemented by histology and sheet plastination.

RESULTS

In addition to its origin and insertion, the platysma is attached to the skin and deep fascia across its entire superficial and deep surfaces. This composite system explains the age-related formation of static platysmal bands, recurrent platysmal bands after complete platysma transection, and recurrent anterior neck laxity after no-release lifting. The facial part of the platysma is primarily innervated by the marginal mandibular branch of the facial nerve, whereas the submandibular platysma is innervated by the "first" cervical branches, which terminate at the mandibular origin of the depressor labii inferioris. This pattern has implications for postoperative dysfunction of the lower lip, including pseudoparalysis, and potential targeted surgical denervation.

CONCLUSIONS

This anatomical study, comprised of layered dissections, large histology, and sheet plastination, fully describes the anatomy of the platysma including its bony, fascial, and dermal attachments, as well as its segmental innervation including its nerve danger zones. It provides a sound anatomical basis for the further development of surgical techniques to rejuvenate the neck with prevention of recurrent platysmal banding.

Lifting the Anterior Midcheek and Nasolabial Fold: Introduction to the Melo Fat Pad Anatomy and Its Role in Longevity and Recurrence

BACKGROUND

A limitation of current facelift techniques is the early postoperative reappearance of anterior midcheek laxity associated with recurrence of the nasolabial fold (NLF).

OBJECTIVES

This study was undertaken to examine the regional anatomy of the anterior midcheek and NLF with a focus on explaining the early recurrence phenomenon and to explore the possibility of alternative surgical methods that prolong NLF correction.

METHODS

Fifty cadaver heads were studied (16 embalmed, 34 fresh; mean age, 75 years). Following preliminary dissections and macrosectioning, a series of standardized layered dissections were performed, complemented by histology, sheet plastination, and microcomputed tomography. Mechanical testing of the melo fat pad (MFP) and skin was performed to gain insight on which structure is responsible for transmission of the lifting tension in a composite facelift procedure.

RESULTS

Anatomic dissections, sheet plastination, and microcomputed tomography demonstrated the 3-dimensional architecture and borders of the MFP. Histology of a lifted midcheek demonstrated that a composite MFP lift causes a change in connective tissue organization from a hanging-down pattern into a pulled-upward pattern, suggesting traction on the skin. Mechanical testing confirmed that, in a composite lift, despite the sutures being placed directly into the deep aspect of the MFP, the lifting tension distal to the suture is transmitted through the skin and not through the MFP.

CONCLUSIONS

The usual method of performing a composite midcheek lift results in the skin, and not the MFP itself, bearing the load of the nondissected tissues distal to the lifting suture. For this reason, early recurrence of the NLF occurs following skin relaxation in the postoperative period. Accordingly, specific surgical procedures for remodeling the MFP should be explored, possibly in combination with volume restoration of the fat and bone, for more lasting improvement of the NLF.

The Influence of BIA-ALCL on the Use of Textured Breast Implant and its Placement: A Survey of Dutch Plastic Surgeons

BACKGROUND

Breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) and its association with macrotextured breast implants may have induced plastic surgeons to change their breast augmentation and breast reconstruction practice.

OBJECTIVES

The aim of this study was to survey Dutch plastic surgeons about the effects of BIA-ALCL on their choice of breast implant texture and placement technique.

METHODS

An online questionnaire was distributed to all members of the Dutch Association of Plastic Surgeons. Descriptive data were presented as frequencies and percentages. Technique alterations were analyzed by the marginal homogeneity test for paired nominal data.

RESULTS

A total of 63 plastic surgeons completed the questionnaire. The majority of respondents altered their use of textured implants due to BIA-ALCL concerns for both breast augmentation and reconstruction (75.4% and 69.8%, respectively; both being statistically significant, P < .001). Microtextured and smooth/nanotextured breast implants are now most frequently used. BIA-ALCL did not influence the placement technique in breast augmentation and reconstruction (87.7% and 94.3%, respectively). Dual-plane breast implant placement is still the most favored technique for breast augmentation, and submuscular placement is still most favored for breast reconstruction.

CONCLUSIONS

BIA-ALCL has had a significant impact on the use of macrotextured breast implants by Dutch plastic surgeons in both aesthetic and reconstructive breast surgery. Breast implant placement technique has not been affected.

LEVEL OF EVIDENCE: 4

"The Deep Fascia of the Head and Neck Revisited: Relationship with the Facial Nerve and Implications for Rhytidectomy"

INTRODUCTION

The deep fascia is important in facelift surgery as it is relied on for protection of the facial nerve during surgical dissection. Lack of consistency with the term may be due to the term deep fascia having two different meanings. It is a specific type of connective tissue, classically, thin, fibrous and flat. Whereas, in the description of the layers of the face and neck, the deep fascia layer includes all the connective tissue deep to the superficial fascia layer. This cadaver study was undertaken to clarify the layered anatomy of the face and neck and its relationship with the facial nerve branches.

MATERIALS METHODS

Preliminary dissections and macro sectioning, followed by a conclusive series of standardized layered dissections, histology and sheet plastination, was performed on fifty cadaver heads.

RESULTS

The deep fascia is thin in convex areas of the face and neck, while thicker in concave areas, it being interspersed with deep fat. The facial nerve branches, after emerging from the parotid gland, are embedded within the deep fascia, not deep to it. They transition from deep within the deep fascia at specific locations to course in the most superficial part of the deep fascia where they underlie their target superficial fascia muscles and are at risk from deep plane facelift dissection.

CONCLUSION

The deep fascia layer is a multilamellar fibrofatty layer of variable thickness, which includes the deep fat in which the facial nerve branches are embedded. In deep plane facelift surgery, dissection must be performed in the most superficial level of this deep fascia layer.

LEVEL OF EVIDENCE

No level of evidence is needed for Cadaver Study Articles.

Adipose Tissue-Derived Components: From Cells to Tissue Glue to Treat Dermal Damage

In recent decades, adipose tissue transplantation has become an essential treatment modality for tissue (volume) restoration and regeneration. The regenerative application of adipose tissue has only recently proven its usefulness; for example, the method is useful in reducing dermal scarring and accelerating skin-wound healing. The therapeutic effect is ascribed to the tissue stromal vascular fraction (tSVF) in adipose tissue. This consists of stromal cells, the trophic factors they secrete and the extracellular matrix (ECM), which have immune-modulating, pro-angiogenic and anti-fibrotic properties. This concise review focused on dermal regeneration using the following adipose-tissue components: adipose-tissue-derived stromal cells (ASCs), their secreted trophic factors (ASCs secretome), and the ECM. The opportunities of using a therapeutically functional scaffold, composed of a decellularized ECM hydrogel loaded with trophic factors of ASCs, to enhance wound healing are explored as well. An ECM-based hydrogel loaded with trophic factors combines all regenerative components of adipose tissue, while averting the possible disadvantages of the therapeutic use of adipose tissue, e.g., the necessity of liposuction procedures with a (small) risk of complications, the impossibility of interpatient use, and the limited storage options.

Does Scarpa's Fascia Preservation in Abdominoplasty Reduce Seroma? A Systematic Review

BACKGROUND

Abdominoplasty is a widely utilized cosmetic surgery procedure. Despite its popularity, seroma formation remains a prevalent complication. This can lead to extended recovery time, increased medical appointments and the potention for infection or the need for additional surgical revision. Preserving Scarpa's fascia may mitigate the risk of seroma in patients following abdominoplasty.

OBJECTIVES

The goal of this systematic review is to determine the impact of preserving Scarpa's fascia on the occurrence of seroma and total drain output following an abdominoplasty procedure.

METHODS

This systematic review searched academic literature in MEDLINE (via PubMed, National Institutes of Health, Bethesda, MD), EMBASE (OvidSP) (Elsevier, Amsterdam, the Netherlands), and The Cochrane Central Register of Controlled Trials (Wiley, Hoboken, NJ). for clinical and observational studies published in peer-reviewed journals from inception to November 2022, which evaluated the impact of preserving Scarpa's fascia on postoperative seroma and total drain output during abdominoplasty. The primary outcomes of interests were seroma and total drain output, with secondary outcomes of interests including hematoma, time to drain removal, length of hospital stay, wound dehiscence and infection rate.

RESULTS

This systematic review of 8 studies, involving 846 patients, found that the preservation of Scarpa's fascia during an abdominoplasty procedure was associated with decreased seroma occurrence, reduced drain output, faster drain removal, and less infections. However, it did not affect the incidence of hematoma, hospital stay duration, or wound dehiscence.

CONCLUSIONS

The preservation of Scarpa's fascia during an abdominoplasty procedure should be considered as a routine practice, as it has been shown to result in reduced seroma incidence rates and faster drain removal.

The Surgical Anatomy of the Jowl and the Mandibular Ligament Reassessed

INTRODUCTION

A visible jowl is a reason patients consider lower facial rejuvenation surgery. The anatomical changes that lead to formation of the jowl remain unclear. The aim of this study was to elucidate the anatomy of the jowl, the mandibular ligament and the labiomandibular crease, and their relationship with the marginal mandibular branch of the facial nerve.

MATERIALS AND METHODS

Forty-nine cadaver heads were studied (16 embalmed, 33 fresh, mean age 75 years). Following preliminary dissections and macro-sectioning, a series of standardized layered dissections were performed, complemented by histology, sheet plastination and micro-CT.

RESULTS

The jowl forms in the subcutaneous layer where it overlies the posterior part of the mandibular ligament. The mandibular ligament proper exists only in the deep, sub-platysma plane, formed by the combined muscular attachment to the mandible of the specific lower lip depressor muscles and the platysma. The mandibular ligament does not have a definitive subcutaneous component. The labiomandibular crease inferior to the oral commissure marks the posterior extent of the fixed dermal attachment of depressor anguli oris.

CONCLUSION

Jowls develop as a consequence of aging changes on the functional adaptions of the mouth in humans. To accommodate wide jaw opening with a narrowed commissure requires hypermobility of the tissues overlying the mandible immediately lateral to the level of the oral commissure. This hypermobility over the mandibular attachment of the lower lip depressor muscles occurs entirely in the subcutaneous layer to allow the mandible to move largely independent from the skin. The short, elastic subcutaneous connective tissue, which allows this exceptional mobility without laxity in youth, lengthens with aging, resulting in laxity. The development of subcutaneous and dermal redundancy constitutes the jowl in this location.

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 ."

Enhanced study of facial soft tissues using a novel large scale histology technique

The safety and effectiveness of facial cosmetic surgery procedures are dependent on detailed 3D understanding of the complex surgical anatomy of the face. Traditional, small sample size anatomical dissection studies have limitations in providing definitive clarification of the fascial layers of the face, and especially in their relationship with the facial nerve, and their reaction to surgical manipulation. The objective study of large tissue areas is required to effectively demonstrate the broader architecture. Conventional histology techniques were modified to handle extraordinarily large tissue samples to fulfill this requirement. Full-thickness soft tissue samples (skin to bone) of maximum length 18 cm, width 4 cm, and tissue thickness 1 cm, were harvested from 20 hemifaces of 15 fresh human cadavers (mean age at death = 81 years). After fixation, the samples were processed with an automated processor using paraffin wax for 156 h, sectioned at 30 μm, collected on gelatin-chromium-coated glass slides, stained with a Masson's Trichrome technique and photographed. Using this technique, excellent visualization was obtained of the fascial connective tissue and its relationship with the facial mimetic muscles, muscles of mastication and salivary glands in 73 large histological slides. The resulting slides improved the study of the platysma and superficial musculo-aponeurotic system (SMAS), the spaces and ligaments, the malar fat pad, and the facial nerve in relations to the deep fascia. Additionally, surgically induced changes in the soft-tissue organization were successfully visualized. This technique enables improved insight into the broad structural architecture and histomorphology of large-scale facial tissues.

Supplementation of Facial Fat Grafting to Increase Volume Retention: A Systematic Review

BACKGROUND

For decades, facial fat grafting has been used in clinical practice for volume restoration. The main challenge of this technique is variable volume retention. The addition of supplements to augment fat grafts and increase volume retention has been reported in recent years.

OBJECTIVES

The aim of this systematic review was to investigate which supplements increase volume retention in facial fat grafting as assessed by volumetric outcomes and patient satisfaction.

METHODS

Embase, Medline, Ovid, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, and Google Scholar were searched up to November 30, 2020. Only studies assessing volume after facial fat grafting with supplementation in human subjects were included. Outcomes of interest were volume or patient satisfaction. The quality of the studies was assessed with the Effective Public Health Practice Project tool.

RESULTS

After duplicates were removed 3724 studies were screened by title and abstract. After reading 95 full-text articles, 27 studies were eligible and included for comparison. Supplementation comprised of platelet-rich plasma, platelet-rich fibrin, adipose tissue-derived stromal cells or bone marrow-derived stromal cells, cellular or tissue stromal vascular fraction, or nanofat. In 13 out of 22 studies the supplemented group showed improved volumetric retention and 5 out of 16 studies showed greater satisfaction. The scientific quality of the studies was rated as weak for 20 of 27 studies, moderate for 6 of 27 studies, and strong for 1 study.

CONCLUSIONS

It remains unclear if additives contribute to facial fat graft retention and there is a need to standardize methodology.

LEVEL OF EVIDENCE: 4

Lifting the Mouth Corner: A Systematic Review of Techniques, Clinical Outcomes, and Patient Satisfaction

BACKGROUND

Mouth corners are an essential part of the centrofacial area for perception of attractiveness and emotions. Downturned mouth corners are a result of aging or have a congenital origin. Different mouth corner lifting techniques are described in the literature.

OBJECTIVES

This review was performed to systematically assess and compare invasive and noninvasive mouth corner lifting techniques and their effectiveness, patient satisfaction, and adverse effects.

METHODS

MEDLINE (via PubMed), EMBASE (OvidSP), and the Cochrane Central Register of controlled trials databases were searched for clinical and observational studies published in peer-reviewed academic journals with abstracts available (searched from May 18, 2019, to December 18, 2021). Outcomes of interest were aesthetic mouth corner lifting techniques, the degree of lift as well as the longevity of the lifting effect, patient satisfaction, and adverse effects. Techniques were subdivided in invasive techniques and noninvasive techniques.

RESULTS

Out of 968 studies found from the search, 11 were included in the qualitative analysis. In general, surgical techniques seem to have a better mouth corner lifting effect than nonsurgical techniques; however, objective evidence is weak, and surgery inevitably results in a scar. Reported patient satisfaction was good for both surgical and nonsurgical techniques and no severe complications have been described.

CONCLUSIONS

Surgical techniques seem to have a better lifting effect on mouth corners than nonsurgical techniques. Nevertheless, objective evidence is weak, and a scar is inevitable.

LEVEL OF EVIDENCE: 4

Stromal vascular fraction-enriched fat grafting as treatment of adherent scars: study design of a non-randomized early phase trial

Background

In the last decades, autologous fat grafting has been used to treat adherent dermal scars. The observed regenerative and scar-reducing properties have been mainly ascribed to the tissue-derived stromal vascular fraction (tSVF) in adipose tissue. Adipose tissue’s components augment local angiogenesis and mitosis in resident tissue cells. Moreover, it promotes collagen remodeling. We hypothesize that tSVF potentiates fat grafting-based treatment of adherent scars. Therefore, this study aims to investigate the effect of tSVF-enriched fat grafting on scar pliability over a 12-month period.

Methods and design

A clinical multicenter non-randomized early phase trial will be conducted in two dedicated Dutch Burn Centers (Red Cross Hospital, Beverwijk, and Martini Hospital, Groningen). After informed consent, 46 patients (≥18 years) with adherent scars caused by burns, necrotic fasciitis, or degloving injury who have an indication for fat grafting will receive a sub-cicatricic tSVF-enriched fat graft. The primary outcome is the change in scar pliability measured by the Cutometer between pre- and 12 months post-grafting. Secondary outcomes are scar pliability (after 3 months), scar erythema, and melanin measured by the DSM II Colormeter; scar quality assessed by the patient and observer scales of the Patient and Observer Scar Assessment Scale (POSAS) 2.0; and histological analysis of scar biopsies (voluntary) and tSVF quality and composition. This study has been approved by the Dutch Central Committee for Clinical Research (CCMO), NL72094.000.20.

Conclusion

This study will test the clinical efficacy of tSVF-enriched fat grafting to treat dermal scars while the underlying working mechanism will be probed into too.

Trial registration

Dutch Trial Register NL 8461. Registered on 16 March 2020

Tissue Stromal Vascular Fraction Improves Early Scar Healing: A Prospective Randomized Multicenter Clinical Trial

BACKGROUND

Wound healing and scar formation depends on a plethora of factors. Given the impact of abnormal scar formation, interventions aimed to improve scar formation would be most advantageous. The tissue stromal vascular fraction (tSVF) of adipose tissue is composed of a heterogenous mixture of cells embedded in extracellular matrix. It contains growth factors and cytokines involved in wound-healing processes, eg, parenchymal proliferation, inflammation, angiogenesis, and matrix remodeling.

OBJECTIVES

The aim of this study was to investigate the hypothesis that tSVF reduces postsurgical scar formation.

METHODS

This prospective, double-blind, placebo-controlled, randomized trial was conducted between 2016 and 2020. Forty mammoplasty patients were enrolled and followed for 1 year. At the end of the mammoplasty procedure, all patients received tSVF in the lateral 5 cm of the horizontal scar of 1 breast and a placebo injection in the contralateral breast to serve as an intrapatient control. Primary outcome was scar quality measure by the Patient and Observer Scar Assessment Scale (POSAS). Secondary outcomes were obtained from photographic evaluation and histologic analysis of scar tissue samples.

RESULTS

Thirty-four of 40 patients completed follow-up. At 6 months postoperation, injection of tSVF had significantly improved postoperative scar appearance as assessed by the POSAS questionnaire. No difference was observed at 12 months postoperation. No improvement was seen based on the evaluation of photographs and histologic analysis of postoperative scars between both groups.

CONCLUSIONS

Injection of tSVF resulted in improved wound healing and reduced scar formation at 6 months postoperation, without any noticeable advantageous effects seen at 12 months.

LEVEL OF EVIDENCE: 2

Limited efficacy of adipose stromal cell secretome-loaded skin-derived hydrogels to augment skin flap regeneration in rats

Insufficient vascularization is a recurring cause of impaired pedicled skin flap healing. The administration of adipose tissue-derived stromal cells' (ASC) secretome is a novel approach to augment vascularization. Yet, the secretome comprised soluble factors that require a sustained release vehicle to increase residence time. We hypothesized that administration of a hydrogel derived from decellularized extracellular matrix (ECM) of porcine skin with bound trophic factors from ASCs, enhances skin flap viability and wound repair in a rat model. Porcine skin was decellularized and pepsin-digested to form a hydrogel at 37°C. Conditioned medium (CMe) of human ASC was collected, concentrated twentyfold and mixed with the hydrogel. Sixty Wistar rats were included. A dorsal skin flap (caudal based) of 3 x 10 cm was elevated for topical application of: DMEM medium (group I), a pre-hydrogel with or without ASC CMe (group II and III) or ASC CMe (group IV). After 7, 14 and 28 days, perfusion was measured and skin flaps were harvested for wound healing assessment and immunohistochemical analysis. Decellularized skin ECM hydrogel contained negligible amounts of DNA (11.6 ± 0.6 ng/mg), was noncytotoxic and well-tolerated by rats. Irrespective of ASC secretome, ECM hydrogel application resulted macroscopically and microscopically in similar dermal wound healing in terms of proliferation, immune response and matrix remodeling as the control group. However, ASC CMe alone increased vessel density after seven days. Concluding, porcine skin derived ECM hydrogels loaded with ASC secretome are non-cytotoxic but demand optimization to significantly augment wound healing of skin flaps.

Single Center and Surgeon's Long-Term (15-19 Years) Patient Satisfaction and Revision Rate of Round Textured Eurosilicone Breast Implants

BACKGROUND

Breast augmentation is one of the most commonly performed aesthetic plastic surgical procedures, with over 250,000 procedures in the United States in 2020 alone. However, the safety of breast implants should be closely researched and monitored, especially in the long term.

OBJECTIVES

This study was undertaken to evaluate the long-term results of round micro-textured Eurosilicone (Eurosilicone S.A.S, Apt Cedex, France) Cristalline Paragel breast implants from a single-center, single-surgeon experience regarding both patient-reported outcome measures and revisions.

METHODS

A retrospective cohort study was undertaken of 84 patients who underwent primary breast augmentation with round micro-textured Eurosilicone Cristalline Paragel breast implants, either submuscular (dual-plane) or subglandular placed, between 2001 and 2004. All patients were contacted for informed consent, and after approval, the validated BREAST-Q questionnaire was sent and utilized to analyze patient satisfaction. In addition, objective data regarding revisions, including capsular contracture, rupture rate, pain, and/or aesthetic causes needing revision surgery, were analyzed.

RESULTS

High BREAST-Q scores (67%-100% for 0-100 scale variables and 66.0%-77.3% of the patients scored "very satisfied" on categorical variables) were found without clinically significant differences between patients with dual-plane-placed implants and subglandular-placed implants. The overall revision rate was 29.8%, also with no significant differences between groups (P = 0.317).

CONCLUSIONS

This study showed high patient satisfaction and relatively low revision rates after 15 to 19 years of follow-up of round micro-textured Eurosilicone Cristalline Paragel breast implants. No clinically relevant significant differences were found between dual-plane and subglandular placement of the implants.

LEVEL OF EVIDENCE: 4

Autologous Lipofilling Improves Clinical Outcome in Patients With Symptomatic Dermal Scars Through Induction of a Pro-Regenerative Immune Response

BACKGROUND

Autologous lipofilling is an emerging procedure to treat and possibly reverse dermal scars and to reduce scar-related pain, but its efficacy and mechanisms are poorly understood.

OBJECTIVES

The aim of this study was to test the hypothesis that repeated lipografts reverse dermal scars by reinitiation of wound healing.

METHODS

In a prospective, non-placebo-controlled clinical study, 27 adult patients with symptomatic scars were given 2 lipofilling treatments at 3-month intervals. As primary outcome, clinical effects were measured with the Patient and Observer Scar Assessment Scale (POSAS). Scar biopsies were taken before and after treatments to assess scar remodeling at a cellular level.

RESULTS

Twenty patients completed the study. Patients' scars improved after lipofilling. The total POSAS scores (combined patient and observer scores) decreased from 73.2  [14.7] points (mean [standard deviation]) pretreatment to 46.1 [14.0] and 32.3 [13.2] points after the first and second lipofilling treatment, respectively. Patient POSAS scores decreased from 37.3 [8.8] points to 27.2 [11.3] and 21.1 [11.4] points, whereas observer POSAS scores decreased from 35.9 [9.5] points to 18.9 [6.0] and 11.3 [4.5] points after the first and second treatment, respectively. After each lipofilling treatment, T lymphocytes, mast cells, and M2 macrophages had invaded scar tissue and were associated with increased vascularization. In addition, the scar-associated epidermis showed an increase in epidermal cell proliferation to levels similar to that normal in skin. Moreover, lipofilling treatment caused normalization of the extracellular matrix organization towards that of normal skin.

CONCLUSIONS

Autologous lipofilling improves the clinical outcome of dermal scars through the induction of a pro-regenerative immune response, increased vascularization, and epidermal proliferation and remodeling of scar tissue extracellular matrix.

LEVEL OF EVIDENCE: 4

Autologous lipoaspirate as a new treatment of vulvar lichen sclerosus: a review on literature

Lichen sclerosus (LS) is a chronic inflammatory dermatosis that mostly affects the genital and anal skin areas. Symptoms may vary from pruritis and pain to sexual dysfunction; however, LS can also be asymptomatic. LS occurs at all ages and in both sexes. Approximately 5% of all women affected by vulvar LS will develop vulvar squamous cell carcinoma. Topical treatment is safe but less effective resulting in chronic course in most patients, who suffer from persistent itching and pain. In severe cases of therapy‐resistant LS, there is no adequate treatment. Fat grafting is a novel regenerative therapy to reduce dermal fibrosis. The therapeutic effect of adipose tissue grafts for LS is already investigated in various pioneering studies. This review provides an overview of these studies and the putative mechanisms‐of‐action of fat grafting to treat LS.

The minimal access cranial suspension (MACS) lift: A systematic review of literature 18 years after its introduction

BACKGROUND

One of the most popular short-scar rhytidectomy techniques used nowadays is the minimal access cranial suspension (MACS) lift developed by Tonnard and Vaerpele. The technique uses purse-string sutures in combination with limited skin undermining to obtain a clear vertical tissue repositioning. Since its introduction, the technique has extensively been described and used around the world by facial plastic surgeons. Now, 18 years after its introduction, a systematic review concerning the results and complications of the MACS lift is presented to establish its current position in facial rejuvenation.

METHODS

The MEDLINE, Embase, Cochrane Central, and Google Scholar databases were searched for studies evaluating the MACS lift (June 10, 2020). Outcomes of interest were long-term effect, satisfaction, and complications of the MACS lifting as determined by the patient and/or surgeon.

RESULTS

Six studies were included, with 739 patients treated with the MACS lift in total. No major complications were reported, four studies did report on the occurrence of minor complications. All of the six studies reported relatively high levels of satisfaction. Three studies reported a shorter procedural duration for the MACS lift compared with the conventional facelift. In three of the six included studies, the level of evidence was low. The effect on neck rejuvenation is limited.

CONCLUSION

The MACS lift can be considered a minimally invasive facelift procedure with a relatively low complication rate. The procedure, often combined with additional procedures, results in evident patient and/or surgeon satisfaction. To obtain a better desired result on an aged neck area, additional procedures are warranted.

Skin measurement devices to assess skin quality: A systematic review on reliability and validity

Background

Many treatments aim to slow down or reverse the visible signs of skin aging and thereby improve skin quality. Measurement devices are frequently employed to measure the effects of these treatments to improve skin quality, for example, skin elasticity, color, and texture. However, it remains unknown which of these devices is most reliable and valid.

Materials and methods

MEDLINE, Embase, Cochrane Central, Web of Science, and Google Scholar databases were searched. Instruments were scored on reporting construct validity by means of convergent validity, interobserver, intraobserver, and interinstrument reliability.

Results

For the evaluation of skin color, 11 studies were included describing 16 measurement devices, analyzing 3172 subjects. The most reliable device for skin color assessment is the Minolta Chromameter CR‐300 due to good interobserver, intraobserver, and interinstrument reliability. For skin elasticity, seven studies assessed nine types of devices analyzing 290 subjects in total. No intra and interobserver reliability was reported. Skin texture was assessed in two studies evaluating 72 subjects using three different types of measurement devices. The PRIMOS device reported excellent intra and interobserver reliability. None of the included reviewed devices could be determined to be valid based on construct validity.

Conclusion

The most reliable devices to evaluate skin color and texture in ordinary skin were, respectively, the Minolta Chromameter and PRIMOS. No reliable device is available to measure skin elasticity in ordinary skin and none of the included devices could be determined to be designated as valid.

Extracellular matrix-derived hydrogels to augment dermal wound healing: a systematic review

BACKGROUND

Chronic, non-healing, dermal wounds form a worldwide medical problem with limited and inadequate treatment options and high societal burden and costs. With the advent of regenerative therapies exploiting extracellular matrix (ECM) components, its efficacy to augment wound healing is to be explored. This systematic review was performed to assess and compare the current therapeutic efficacy of ECM hydrogels on dermal wound healing.

METHODS

The electronic databases of (Embase, Medline Ovid, Cochrane Central) were searched for in vivo and clinical studies on the therapeutic effect of ECM-composed hydrogels on dermal wound healing (13th of April 2021). Two reviewers selected studies independently. Studies were assessed based on ECM content, ECM hydrogel composition, additives and wound healing outcomes such as wound size, angiogenesis and complications.

RESULTS

Of the 2102 publications, nine rodent-based studies were included while clinical studies were not published at the time of the search. Procedures to decellularize tissue or cultured cells and subsequently generate hydrogels were highly variable and in demand of standardization. ECM hydrogels with or without additives reduced wound size and also seem to enhance angiogenesis. Serious complications were not reported.

CONCLUSION

To date, preclinical studies preclude to draw firm conclusions on the efficacy and working mechanism of ECM-derived hydrogels on dermal wound healing. The use of ECM hydrogels can be considered safe. Standardization of decellularization protocols and implementation of quality and cytotoxicity controls will enable obtaining a generic and comparable ECM product.

The Addition of Tissue Stromal Vascular Fraction to Platelet-Rich Plasma Supplemented Lipofilling Does Not Improve Facial Skin Quality: A Prospective Randomized Clinical Trial

BACKGROUND

Lipofilling has become popular as a treatment to improve aging-related skin characteristics (eg, wrinkles, pigmentation spots, pores, or rosacea). Different additives such as platelet-rich plasma (PRP) or stromal vascular fraction (SVF) have been combined with lipofilling to increase the therapeutic effect of adipose-derived stromal cells (ASCs).

OBJECTIVES

The aim of this study was to examine the hypothesis that mechanically isolated SVF augments the therapeutic effect of PRP-supplemented lipofilling to improve facial skin quality.

METHODS

This prospective, double-blind, placebo-controlled, randomized trial was conducted between 2016 and 2019. In total, 28 female subjects were enrolled; 25 completed the follow-up. All patients received PRP-supplemented lipofilling with either mechanically isolated SVF or saline. SVF was isolated by fractionation of adipose tissue (tSVF). Results were evaluated by changes in skin elasticity and transepidermal water loss, changes in skin-aging-related features, ie, superficial spots, wrinkles, skin texture, pores, vascularity, and pigmentation, as well as patient satisfaction (FACE-Q), recovery, and number of complications up to 1 year postoperative.

RESULTS

The addition of tSVF to PRP-supplemented lipofilling did not improve skin elasticity, transepidermal water loss, or skin-aging-related features. No improvement in patient satisfaction with overall facial appearance or facial skin quality was seen when tSVF was added to PRP-supplemented lipofilling.

CONCLUSIONS

In comparison to PRP-supplemented lipofilling, PRP-supplemented lipofilling combined with tSVF does not improve facial skin quality or patient satisfaction in a healthy population. PRP-supplemented lipofilling combined with tSVF can be considered a safe procedure.

LEVEL OF EVIDENCE: 2

Adipose tissue-derived extracellular matrix hydrogels as a release platform for secreted paracrine factors

Fat grafting is an established clinical intervention to promote tissue repair. The role of the fat's extracellular matrix (ECM) in regeneration is largely neglected. We investigated in vitro the use of human adipose tissue‐derived ECM hydrogels as release platform for factors secreted by adipose‐derived stromal cells (ASCs). Lipoaspirates from nondiabetic and diabetic donors were decellularized. Finely powdered acellular ECM was evaluated for cell remainders and DNA content. Acellular ECM was digested, and hydrogels were formed at 37°C and their viscoelastic relaxation properties investigated. Release of ASC‐released factors from hydrogels was immune assessed, and bio‐activity was determined by fibroblast proliferation and migration and endothelial angiogenesis. Acellular ECM contained no detectable cell remainders and negligible DNA contents. Viscoelastic relaxation measurements yielded no data for diabetic‐derived hydrogels due to gel instability. Hydrogels released several ASC‐released factors concurrently in a sustained fashion. Functionally, released factors stimulated fibroblast proliferation and migration as well as angiogenesis. No difference between nondiabetic and diabetic hydrogels in release of factors was measured. Adipose ECM hydrogels incubated with released factors by ASC are a promising new therapeutic modality to promote several important wound healing‐related processes by releasing factors in a controlled way.

Effectiveness, Longevity, and Complications of Facelift by Barbed Suture Insertion

BACKGROUND

Minimally invasive facelift techniques involving barbed suture insertion have become popular among patients who wish to correct facial tissue ptosis.

OBJECTIVES

The authors sought to determine the effectiveness, longevity, complications, and postoperative sequelae associated with facelift by means of barbed polydioxanone (PDO) threads.

METHODS

A total of 160 consecutive patients who underwent facelift with barbed threads were evaluated retrospectively. For malar augmentation and correction of nasolabial grooves, 2 or 3 PDO threads (23 gauge) were placed per side; for treatment of mandibular lines, 2 to 4 PDO threads (21 gauge) were inserted per side.

RESULTS

Immediately after suture placement and for 1 month postoperatively, patients experienced improvement in facial tissue ptosis. This aesthetic result declined noticeably by 6 months and was absent by 1 year. The overall complication rate in the early postoperative period was 34% (55 of 160 patients). Eighteen patients (11.2%) had superficial displacement of the barbed sutures, 15 (9.4%) experienced transient erythema, 10 (6.2%) had infection, 10 (6.2%) experienced skin dimpling, and 2 (1.2%) had temporary facial stiffness.

CONCLUSIONS

Placement of barbed threads yields instantaneous improvement in facial ptosis that is no longer apparent by 1 year. Given this transient benefit and the complication rate of 34%, we recommend limiting this procedure to patients with contraindications for more invasive facial surgery.

LEVEL OF EVIDENCE: 4

Evaluation of anatomical and round breast implant aesthetics and preferences in Dutch young lay and plastic surgeon cohort

BACKGROUND

Literature remains inconclusive on the attractiveness and natural aspect of anatomical breast implants, and thus far, studies have failed to demonstrate the visible difference in implants that are in practice compared to those that are round. This study was undertaken to evaluate (1) whether lay and professional participants can distinguish between breasts augmented with either round or anatomical breast implants and (2) their opinion with regard to naturalness and attractiveness of these augmented breasts.

METHODS

Twenty breast augmentations (10 anatomical and 10 round implants), each depicted by two postoperative pictures, were scored by 100 lay participants and 15 plastic surgeons. Implant volume ranged from 275 to 400 g. Ptotic or malformed breasts were excluded. Finally, they had to score the most natural, unnatural, attractive, and unattractive breast shapes on a schematic depiction of breast types with varying upper poles.

RESULTS

The rate of correct implant identifications was 74.0% (1480/2000 observations, p < 0.001) in the lay and 67.3% (202/300 observations, p < 0.001) in the surgeon cohort. Breasts with anatomical implants were rated as significantly more natural (3.3 ± 1.0 vs. 2.6 ± 1.0, p < 0.001 and 3.3 ± 1.0 vs. 2.2 ± 0.9, p < 0.001, respectively) and more attractive (3.1 ± 1.0 vs. 2.6 ± 1.0, p < 0.001 and 3.6 ± 0.9 vs. 2.7 ± 0.9, p < 0.001, respectively) versus round implants by both lay participants and surgeons. Participants preferred breasts with a neutral or slightly negative upper pole contour.

CONCLUSION

Participants were able to distinguish between the results achieved with either anatomical or round textured Allergan breast implants and found augmented breasts with the anatomical implants more natural and attractive.

Comparison of intraoperative procedures for isolation of clinical grade stromal vascular fraction for regenerative purposes: a systematic review

Intraoperative application of the stromal vascular fraction (SVF) of adipose tissue requires a fast and efficient isolation procedure of adipose tissue. This review was performed to systematically assess and compare procedures currently used for the intraoperative isolation of cellular SVF (cSVF) and tissue SVF (tSVF) that still contain the extracellular matrix. Pubmed, EMBASE and the Cochrane central register of controlled trials databases were searched for studies that compare procedures for intraoperative isolation of SVF (searched 28 September 2016). Outcomes of interest were cell yield, viability of cells, composition of SVF, duration, cost and procedure characteristics. Procedures were subdivided into procedures resulting in a cSVF or tSVF. Thirteen out of 3038 studies, evaluating 18 intraoperative isolation procedures, were considered eligible. In general, cSVF and tSVF intraoperative isolation procedures had similar cell yield, cell viability and SVF composition compared to a nonintraoperative (i.e. culture laboratory-based collagenase protocol) control group within the same studies. The majority of intraoperative isolation procedures are less time consuming than nonintraoperative control groups, however. Intraoperative isolation procedures are less time-consuming than nonintraoperative control groups with similar cell yield, viability of cells and composition of SVF, and therefore more suitable for use in the clinic. Nevertheless, none of the intraoperative isolation procedures could be designated as the preferred procedure to isolate SVF. Copyright © 2017 John Wiley & Sons, Ltd.

The power of fat and its adipose-derived stromal cells: emerging concepts for fibrotic scar treatment

Lipofilling or lipografting is a novel and promising treatment method for reduction or prevention of dermal scars after injury. Ample anecdotal evidence from case reports supports the scar‐reducing properties of adipose tissue grafts. However, only a few properly controlled and designed clinical trials have been conducted thus far on this topic. Also, the underlying mechanism by which lipofilling improves scar aspect and reduces neuropathic scar pain remains largely undiscovered. Adipose‐derived stromal or stem cells (ADSC) are often described to be responsible for this therapeutic effect of lipofilling. We review the recent literature and discuss anticipated mechanisms that govern anti‐scarring capacity of adipose tissue and its ADSC. Both clinical and animal studies clearly demonstrated that lipofilling and ADSC influence processes associated with wound healing, including extracellular matrix remodelling, angiogenesis and modulation of inflammation in dermal scars. However, randomized clinical trials, providing sufficient level of evidence for lipofilling and/or ADSC as an anti‐scarring treatment, are lacking yet warranted in the near future. © 2017 The Authors Journal of Tissue Engineering and Regenerative Medicine Published by John Wiley & Sons Ltd

The fractionation of adipose tissue procedure to obtain stromal vascular fractions for regenerative purposes

Autologous adipose tissue transplantation is clinically used to reduce dermal scarring and to restore volume loss. The therapeutic benefit on tissue damage more likely depends on the stromal vascular fraction of adipose tissue than on the adipocyte fraction. This stromal vascular fraction can be obtained by dissociation of adipose tissue, either enzymatically or mechanical. Enzymatic dissociation procedures are time-consuming and expensive. Therefore, we developed a new inexpensive mechanical dissociation procedure to obtain the stromal vascular fraction from adipose tissue in a time sparing way, which is directly available for therapeutic injection. This mechanical dissociation procedure is denoted as the fractionation of adipose tissue (FAT) procedure. The FAT procedure was performed in eleven patients. The composition of the FAT-stromal vascular fraction was characterized by immunohistochemistry. Adipose derived stromal cells isolated from the FAT-stromal vascular fraction were compared with adipose derived stromal cells isolated from nondissociated adipose tissue (control) for their CD-surface marker expression, differentiation and colony forming unit capacity. Case reports demonstrated the therapeutic effect of the FAT-stromal vascular fraction. The FAT-stromal vascular fraction is an enrichment of extracellular matrix containing a microvasculature and culturable adipose derived stromal cells. Adipose derived stromal cells isolated from FAT-stromal vascular fraction did not differ from adipose derived stromal cells isolated from the control group in CD-surface marker expression, differentiation and colony forming unit capacity. The FAT procedure is a rapid effective mechanical dissociation procedure to generate FAT-stromal vascular fraction ready for injection with all its therapeutic components of adipose tissue: it contains culturable adipose derived stromal cells embedded in their natural supportive extracellular matrix together with the microvasculature.

The Role of Topical Vitamin E in Scar Management: A Systematic Review

BACKGROUND

The practice of prescribing vitamin E after surgery for scar prevention and treatment is widespread and increasingly popular among both the public and clinicians. However, very little evidence exists for this "ritual."

OBJECTIVES

This review was undertaken to critically analyze the current literature about the effect of vitamin E on treating scars.

METHODS

The Cochrane, Medline, and PubMed databases were searched based on the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P). The studies and levels of recommendation were graded according to the American Society of Plastic Surgeons (ASPS) criteria. Only prospective studies were included.

RESULTS

Only six studies met the inclusion criteria. Of these six included studies, three reported a significant improvement in the cosmetic appearance of scars when using vitamin E: one study used topical vitamin E in white children as monotherapy, and two studies used vitamin E in an adult population as combination therapy. The other three selected studies showed no significant improvement in scar appearance when using topical vitamin E as monotherapy. Two of the six included studies reported adverse events of vitamin E application: contact dermatitis and increased incidence of itching and rash.

CONCLUSIONS

We conclude that there is not yet sufficient evidence that monotherapy with topical vitamin E has a significant beneficial effect on scar appearance to justify its widespread use. Further prospective studies with vitamin E monotherapy and/or combination therapy are warranted to draw better conclusions regarding the value of vitamin E in the management of scar healing.

LEVEL OF EVIDENCE

2 Therapeutic.

Adipose tissue-derived stromal cells inhibit TGF-β1-induced differentiation of human dermal fibroblasts and keloid scar-derived fibroblasts in a paracrine fashion

BACKGROUND

Adipose tissue-derived stromal cells augment wound healing and skin regeneration. It is unknown whether and how they can also influence dermal scarring. The authors hypothesized that adipose tissue-derived stromal cells inhibit adverse differentiation of dermal fibroblasts induced by the pivotal factor in scarring, namely, transforming growth factor (TGF)-β.

METHODS

TGF-β1-treated adult human dermal fibroblasts and keloid scar-derived fibroblasts were incubated with adipose tissue-derived stromal cell-conditioned medium and assessed for proliferation and differentiation, particularly the production of collagen, expression of SM22α, and development of hypertrophy and contractility.

RESULTS

TGF-β1-induced proliferation of adult human dermal fibroblasts was abolished by adipose tissue-derived stromal cell-conditioned medium. Simultaneously, the medium reduced SM22α gene and protein expression of TGF-β1-treated adult human dermal fibroblasts, and their contractility was reduced also. Furthermore, the medium strongly reduced transcription of collagen I and III genes and their corresponding proteins. In contrast, it tipped the balance of matrix turnover to degradation through stimulating gene expression of matrix metalloproteinase (MMP)-1, MMP-2, and MMP-14, whereas MMP-2 activity was up-regulated also. Even in end-stage myofibroblasts (i.e., keloid scar-derived fibroblasts), adipose tissue-derived stromal cell-conditioned medium suppressed TGF-β1-induced myofibroblast contraction and collagen III gene expression.

CONCLUSION

The authors show that adipose tissue-derived stromal cells inhibit TGF-β1-induced adverse differentiation and function of adult human dermal fibroblasts and TGF-β1-induced contraction in keloid scar-derived fibroblasts, in a paracrine fashion.

The effects of platelet-rich plasma on recovery time and aesthetic outcome in facial rejuvenation: preliminary retrospective observations

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 .

No (wo)man is an island--the influence of physicians' personal predisposition to labia minora appearance on their clinical decision making: a cross-sectional survey

INTRODUCTION

Physicians are increasingly presented with women requesting a labia minora reduction procedure.

AIM

To assess the influencing factor of personal predisposition in general practitioners, gynecologists, and plastic surgeons to labia minora appearance in relation to their willingness to refer for, or perform, a surgical labia minora reduction.

METHODS

Cross-sectional self-administered questionnaire survey. Between May 2009 and August 2009, 210 physicians were surveyed. Primary care: general practitioners working in the north of the Netherlands. Secondary care: gynecologists and plastic surgeons working in five hospitals in the north of the Netherlands.

MAIN OUTCOME MEASURES

A five-point Likert scale appraisal of four pictures showing a vulva, each displaying different sizes of labia minora, indicating a physician's personal predisposition, manifesting as willingness to refer for, or perform, a labia minora reduction.

RESULTS

A total of 164/210 (78.1%) physicians completed the questionnaire, consisting of 80 general practitioners, 41 gynecologists, and 43 plastic surgeons (96 males, 68 females). Ninety percent of all physicians believe, to a certain extent, that a vulva with very small labia minora represents society's ideal (2-5 on the Likert scale). More plastic surgeons regarded the picture with the largest labia minora as distasteful and unnatural, compared with general practitioners and gynecologists (P < 0.01), and regarded such a woman as a candidate for a labia minora reduction procedure (P < 0.001). Irrespective of the woman's labia minora size and the absence of physical complaints, plastic surgeons were significantly more open to performing a labia minora reduction procedure than gynecologists (P < 0.001). Male physicians were more inclined to opt for a surgical reduction procedure than their female colleagues (P < 0.01).

CONCLUSIONS

The personal predisposition of physicians (taking account of their specific gender and specialty) concerning labia minora size and appearance influences their clinical decision making regarding a labia minora reduction procedure. Heightened awareness of one's personal predisposition vis-à-vis referral and willingness to operate is needed.