Pietro Gentile

Background: Autologous fat grafting (AFG) has become a technique in aesthetic and reconstructive breast surgery. However, graft retention remains variable and requires repeated procedures. Stromal vascular fraction (SVF) enrichment has been proposed to improve graft survival through angiogenesis and tissue integration, although comparative evidence remains limited. Objectives: The endpoint was MRI-based graft retention at 12 months. Secondary outcomes included 24-month retention, complications, BREAST-Q outcomes, radiologic findings, and revision procedures. MRI volumetric assessment was performed using 3-dimensional segmentation protocols and analyzed by breast radiologists. Methods: A multicenter, randomized controlled study was conducted across 6 centers between January 2021 and March 2025. Patients affected by bilateral breast hypoplasia, breast asymmetry associated with unilateral breast hypoplasia, breast ptosis/pseudoptosis, and postlumpectomy defects were randomized to standard AFG or SVF-enriched AFG. Results: Three hundred and twelve patients were randomized (156 per group). Follow-up was 28.6 ± 6.4 months. At 12 months, MRI graft retention was greater in the SVF-enriched group compared with standard fat grafting (71.8% ± 11.2% vs 56.4% ± 13.7%; P < .001). Retention persisted at 24 months (66.2% ± 12.0% vs 49.8% ± 14.1%; P < .001). BREAST-Q scores were higher in the SVF group at both follow-up intervals. Fat necrosis and oil cyst formation rates were similar between groups. No suspicious MRI findings attributable to fat grafting were identified during follow-up. Conclusions: SVF-enriched AFG demonstrated improved volumetric persistence and higher patient-reported satisfaction compared with standard AFG, without increased radiologic or clinical complications. MRI-based evaluation may improve reproducibility in future breast fat grafting studies. Level of Evidence: 1 (Therapeutic): For image description, please refer to the figure legend and surrounding text.

Background: Liposuction is among the most frequently performed aesthetic surgical procedures worldwide. Although short-term safety has improved with modern technologies and protocols, robust long-term prospective data regarding contour durability, weight stability, satisfaction, and complications remain limited. Objectives: This study evaluated long-term aesthetic outcomes, body contour stability, patient satisfaction, weight changes, and complications after modern liposuction using standardized clinical, photographic, and patient-reported assessments. Methods: A prospective multicenter cohort study was conducted across 8 tertiary plastic surgery centers. Patients undergoing abdominal, flank, thigh, back, or circumferential liposuction were enrolled between January 2016 and December 2019 and followed through December 2024. Primary endpoints included contour improvement, maintenance, and complication rates. Secondary outcomes included BODY-Q scores, revision surgery, weight variation, skin quality changes, and predictors of complications. Standardized photography and anthropometric measurements were obtained at baseline, 6 months, 1 year, 3 years, and 5 years. Statistical analyses included Kaplan–Meier analysis, multivariate logistic regression, and repeated-measures mixed models. Results: A total of 1248 patients were included, with a mean follow-up of 52.4 ± 11.6 months. Mean aspirated fat volume was 3180 ± 920 mL. Stable contour improvement was maintained in 78.6% at 5 years. BODY-Q scores improved significantly from baseline (P < .001). Overall complication rate was 14.8%, with major complications in 1.9%. The most frequent complications were contour irregularities (5.8%), edema (4.9%), seroma (2.6%), and fibrosis (2.3%). Revision surgery was required in 8.7%. High BMI, smoking, aspirate volume >5 L, and combined procedures predicted complications. Conclusions: Modern liposuction provides durable improvement and high satisfaction with low major complication rates. Level of Evidence: 2 (Therapeutic):

Autologous fat grafting (AFG) is increasingly used for aesthetic breast augmentation and remodeling because it provides natural tissue augmentation without permanent implants. This systematic review and meta-analysis evaluated complications, radiologic outcomes, graft retention, and patient satisfaction following AFG. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 compliant search identified 40 primary clinical studies including 5684 patients. The risk of bias was assessed using the RoB2, ROBINS-I, and Newcastle–Ottawa scale. Random-effects meta-analysis used restricted maximum likelihood estimation as the primary model, with Hartung–Knapp adjustment and DerSimonian–Laird and Paule–Mandel estimators in sensitivity analyses. Mean follow-up exceeded 6 months. The pooled complication rate was 25.9% (95% CI, 22.4-29.6), mainly consisting of minor radiologic or palpable findings; fat necrosis was the most common adverse event. Benign radiologic findings included fat necrosis (8.8%) and calcifications (1.1%), without evidence of impaired cancer detection. Mean injected fat volume was 310 mL per breast. Twelve-month volume retention was 61.3% (95% CI, 57.1-65.4), with higher retention in stromal vascular fraction/platelet-rich plasma–enriched grafts (68.9% vs 56.1%; P < .01), although evidence remained heterogeneous. Patient satisfaction was 93.1% (95% CI, 90.4-95.8), despite heterogeneous PROMs. Heterogeneity was substantial for complications (I2 = 78%; τ2 = 0.021; Q = 177.6; P < .001) and volume retention (I2 = 82%; τ2 = 0.067; Q = 216.4; P < .001), and moderate for radiologic outcomes (I2 = 52%; τ2 = 0.008; Q = 81.3; P < .001), reflecting variability in techniques, imaging, processing, enrichment, assessment methods, and follow-up. Current observational evidence supports favorable safety profiles; however, oncologic outcomes were not quantitatively pooled, and prospective comparative studies with standardized reporting are required. Level of Evidence: 3 (Therapeutic) For image description, please refer to the figure legend and surrounding text.

Background: Androgenetic alopecia (AGA) is the most common cause of progressive hair loss in men and women and is associated with significant psychosocial distress. Platelet-rich plasma (PRP) is a regenerative therapy that stimulates follicular activity, angiogenesis, and dermal papilla activation through growth factor release. Objectives: This prospective randomized evaluator-blinded clinical trial evaluated the long-term efficacy and safety of autologous nonactivated PRP (A-PRP) delivered through a standardized mechanical and controlled infiltration protocol. Methods: Between January 2015 and January 2025, 234 patients with AGA were enrolled, including 135 men (Norwood–Hamilton I-IV) and 99 women (Ludwig I-II); 25 patients had previous confirmed coronavirus disease 2019 (COVID-19) infection. Patients received 3 A-PRP sessions at 30-day intervals with intradermal administration of 0.2 mL/cm2. Hair density (HD), hair thickness (HT), and total hair count (HC) were assessed by computerized trichoscopy and phototrichogram analysis at baseline, 12, 36, 60, and 120 months. Results: At 12 months, HD increased by 31.4%, HT by 26.8%, and HC by 29.7% compared with baseline (P < .001). HD remained above baseline at 36 months (+24.1%) and 60 months (+17.3%). At 120 months, patients receiving maintenance treatment showed an 11.2% improvement. Female patients demonstrated greater preservation of hair shaft diameter. No significant differences were observed according to previous COVID-19 infection, and no severe adverse events occurred. Conclusions: Standardized A-PRP infiltration provides a safe and effective regenerative approach for AGA, with maintained clinical improvement during long-term follow-up. These findings support the role of standardized delivery protocols in improving reproducibility and therapeutic consistency in regenerative hair restoration. Level of Evidence: 2 (Therapeutic): For image description, please refer to the figure legend and surrounding text.

Background: The author presents his own experience using breast implants (BIs) or fat grafting, commonly called lipofilling (LPF), to correct breast hypoplasia. Objectives: Compare the aesthetic results obtained in a study group (SG) using BIs in breast hypoplasia correction with those of a control group (CG) treated with LPF, analyzing the influence of breast and chest deformities (tuberous breast, breast volume differences/asymmetries, nipple–areola complex asymmetry, pectus excavatum, and carinatum) in the outcomes. Methods: A randomized, open-label controlled study was performed. A total of 95 patients affected by breast hypoplasia (SG) were treated with BI, comparing results with the CG (n = 90) treated with LPF. The pre-operative analysis was conducted through anamnesis (considering also the patient’s expectations), clinical and photographic assessment, and an instrumental evaluation based on magnetic resonance imaging, mammography, and ultrasound. Post-operative follow-up occurred at 1, 2, 4 weeks, 3, 6, 12 months, and then annually until the fourth year. Results: 87,5% (n = 83) of SG patients treated with BI showed excellent aesthetic outcomes after 12 months compared with the CG patients treated with LPF, who showed the same results in 70% (n = 63) of cases. Breast augmentation maintenance in the SG was significantly higher than in the CG ( p  < .0001). However, more natural results were reported in the CG than in the SG ( p  < .0001). Conclusions: BI and LPF were safe and effective in this controlled trial. CG's patients displayed more natural results, obtaining a better pectus excavatum correction, while SG’s patients showed more evident and lasting results. Level of Evidence I: 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: Periareolar mastopexy (PM) is a widely used technique for breast lift surgery, often combined with implants to improve breast volume. In recent years, autologous fat grafting (FG) has emerged as an adjunct to PM, enhancing contour and soft tissue volume. Objectives: This article aimed to assess the complication rate, patient satisfaction, aesthetic outcomes, and long-term PM results combined with breast implants (BI) and FG. Methods: A systematic review was performed using PubMed, MEDLINE, Web of Science, Embase, PreMEDLINE, EBase, CINAHL, Clinicaltrials.gov, Scopus, and Cochrane databases. The protocol was developed following the Preferred Reporting for Items for Systematic Reviews-Protocols (PRISMA-P) guidelines. The included studies had to match predetermined criteria according to the PICOS approach. Results: A total of 13 studies with 1165 patients were included. The results showed a significant improvement in patient satisfaction, with 85% of patients reporting high satisfaction levels. The complication rate was relatively low, with capsular contracture (7.3%), fat absorption (9.7%), and wound healing issues (4.9%) being the most common. Aesthetic outcomes, measured by breast symmetry and shape, showed favorable results in 78.2% of patients. The combination of PM with BI and FG improved the breast’s volume and contour, providing a more natural outcome than BI alone. Conclusions: PM with BI and FG appears to be a safe and effective procedure for enhancing breast aesthetics. The combination of these techniques offers significant improvements in patient satisfaction and aesthetic outcomes with acceptable complication rates. Further large-scale randomized controlled trials are needed to confirm these findings and establish long-term safety profiles. Level of Evidence I: Evidence from a systematic review of all relevant controlled trials. 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 .

Objective: To report in vitro , preclinical, and clinical effectiveness of nanofat in adults undergoing reconstructive or functional surgery and to produce a series of consensus statements about nanofat definition by experts. Methods: We conducted a systematic review using PubMed and Web of Science database, retaining studies about nanofat alone. To produce consensus recommendations about nanofat, we invited experts to answer a survey about manufacturing, biological characteristics, and nomenclature of nanofat. Results: A review of 39 articles showed that nanofat seems to have strong regenerative potential. There were 16 studies about the clinical effectiveness of the nanofat in wound healing, aesthetic surgery, and functional disabilities. However, majority of applications lack robust clinical evidence, mainly due to the design of the clinical studies. The experts suggested that nanofat refers to lipoaspirate that benefits from a washing step, followed by emulsification (20–30 passes) with a connector size between 1.2 and 1.6 mm, and a final filtration step (pore size around 300–500 µm). Conclusion: Nanofat seems to have strong regenerative potentials but with a lack of robust clinical evidences. Our experts have suggested the first consensus about a definition of the nanofat that can be used by the academic societies in the coming years.

Background The combined use of micro-needling (MND), growth factors (GFs), and low-level light/laser therapy (LLLT), here identified as photobiostimulation therapy (PBST) and pulsed electromagnetic field therapy (PEMF), is a hair loss (HL) treatment that needs to be standardized as it seems to have promising effects on hair regrowth (HR-G). Objectives The study compared the clinical and instrumental results obtained in patients affected by androgenic alopecia (AGA) and HL related to COVID-19 treated using PEMF combined with PBST with those obtained by only PBST. Methods A multicentric, retrospective, observational, case–control study was conducted. Fifty-three patients were initially enrolled (30 males classified as stages I–III vertex by the Norwood–Hamilton scale, while 23 females classified in stages I–II by the Ludwig scale). Forty patients (20 females and 20 males) were analyzed after exclusion and inclusion criteria assessment. Twenty patients were treated with the combined use of PEMF and PBST (study group - SG) while 20 patients were treated with PBST (control group -CG). The HR-G was evaluated through photography, physician’s, and patient’s global assessment scales, in addition to standardized phototrichograms, during a short follow-up at T0-baseline, T1-16 weeks. Results The promising results in SG patients, represented by a hair count (HC) increase of 14 hairs/0.65 cm² at T1 after 16 weeks in the targeted area, compared with the baseline results (41 ± 2 hairs/0.65 cm2 at T1 versus 27 ± 2 hairs/0.65 cm² at baseline), were observed using computerized trichograms. There was a statistically significant difference in HR-G (p = 0.0325) compared with an HC increase of 11 ± 2 hairs/0.65 cm² in the CG. Conclusions The comparison between SG and CG indicated that PEMF combined with PBST was a more efficient strategy in HR-G in terms of HC improvement than PBST alone. Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Background The use of micrografts (MCGs) containing human follicle mesenchymal stem cells (HF-MSCs) is a hair loss (HL) treatment that needs to be standardized as seems to have promising effects on hair regrowth (HR-G) also thanks to the presence of extracellular vesicles (EVs). Objectives The study aims to report both the in vivo results, obtained in patients affected by androgenic alopecia (AGA) treated using MCGs, and in vitro analysis characterizing the EVs. Methods A multicentric, retrospective, observational, evaluator-blinded study was conducted. Eighty-three AGA patients were initially enrolled [52 suffering from male pattern hair loss (MPHL) at stages I–III vertex by the Norwood–Hamilton scale and 31 suffering from female PHL (FPHL) at stages I–II by the Ludwig scale]. Sixty patients (20 females and 40 males) were treated and analyzed after exclusion and inclusion criteria assessment. The in vivo HR-G was evaluated through photography, physician’s, and patient’s global assessment scales, in addition to standardized photo-trichograms, during a follow-up for 1 year, while the in vitro analysis was performed through a quantitative, morphological, and dimensional characterization of the EVs population using transmission electron microscopy (TEM) and fluorescent microscopy. Results A hair density (HD) increase of 28 ± 4 hairs/cm² at T4 after 12 months in the targeted area (TA) of FPHL, compared with the baseline, was observed using computerized trichograms with a statistically significant difference (SSD) in hair regrowth (HR-G) (p = 0.0429). Regarding MPHL, an HD increase of 30 ± 5 hairs/cm² at T4 after 12 months in the TA was observed with an SSD in HR-G (p = 0.0012). The presence of EVs and their interaction with the surrounding cellular population were demonstrated. Conclusions MCGs containing HF-MSCs and exosomes may fill in as a safe and viable alternative treatment against HL in mild and moderate degrees of AGA both in MPHL and in FPHL. 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.