Gabriel de Almeida Arruda Felix

Background: Breast symmetry and harmony remain challenging goals in aesthetic breast surgery. Preoperative marking is fundamental for planning; however, most techniques rely on nipple–areola complex (NAC) distances and subjective visual assessment, often neglecting thoracic width, height, and the true breast footprint. A geometric framework based on harmonic proportions can help standardize preoperative planning and may improve the reproducibility of breast markings. Methods: A two-dimensional geometric template was developed by integrating constant anatomical references (sternum, clavicles, axillary and acromial lines, and umbilicus) with proportional relationships derived from aesthetic and anthropometric studies. The template was calibrated for each patient’s using thoracic width and height and was designed to be superimposed on standardized frontal photographs. It guides the NAC position, breast width, upper pole contour, and inframammary fold level. The model was applied in mastopexy and reduction mammaplasty as a preoperative planning and postoperative photographic overlay comparison, as well as a visual aid in resident teaching sessions. Results: The template was easily incorporated into daily practice using standard clinical photographs and simple digital overlays. Geometric gridlines and proportional curves allowed visualization of the NAC position, breast symmetry, and contour in relation to thoracic dimensions. Repeated overlays facilitated the longitudinal comparison of breast position and shape. During teaching sessions, the template was used as a visual aid to facilitate resident understanding of the geometric relationships between thoracic anatomy, the breast footprint, and marking decisions. Conclusions: This innovative geometric template offers a simple, visually intuitive tool for standardizing preoperative marking and supporting postoperative photographic overlay comparisons in breast surgeries. It is inexpensive, compatible with existing photographic workflows, and may support training and future digital or artificial intelligence integration. Prospective studies are needed to quantify the impact of these factors on aesthetic outcomes and learning curves. 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: Objective breast volume measurement is critical for breast asymmetry surgery. BREAST-V is a practical anthropometric formula, but its interchangeability with MRI, particularly after surgery, is unclear. Objectives: The aim of this study was to evaluate agreement between BREAST-V and MRI before and after breast asymmetry surgery. Methods: Forty patients underwent preoperative and postoperative MRI and BREAST-V assessments. Agreement was evaluated using intraclass correlation coefficient (ICC), Bland–Altman analysis, and error metrics. Intraoperative field changes were recorded, an MRI-based minimal clinically important difference (MCID) was derived using distribution-based methods, and satisfaction was assessed with BREAST-Q. Results: Preoperatively, BREAST-V showed good association and moderate agreement with MRI (ICC = 0.788; r = 0.840; P < .001). Postoperatively, agreement was poor (ICC = 0.210; r = 0.339; P = .032). Bland–Altman bias increased from +69.5 mL preoperatively to +279.2 mL postoperatively, with wide limits of agreement (−366.4 to +505.5 and −67.2 to +625.7 mL, respectively). Error metrics showed clinically relevant divergence, particularly postoperatively (mean absolute error, 177.6 vs 280.5 mL; mean absolute percentage error, 35.5% vs 41.0%). The MRI-derived MCID for asymmetry was 92.5 mL. Among 30 patients with paired BREAST-Q data, Satisfaction with Breasts improved from 25.0 ± 24.1 to 81.0 ± 12.7 points (mean improvement, 56.0; 95% CI, 46.4-65.6; P < .001). Conclusions: BREAST-V may be useful for preoperative planning but should not be considered interchangeable with MRI after surgical remodeling. Level of Evidence: 4 (Diagnostic):

Background: Keloids are fibroproliferative scars that extend beyond the original wound margins and may cause pain, pruritus, and substantial psychosocial distress. Earlobe keloids are common, clinically distinctive lesions with high recurrence rates; however, the molecular mechanisms underlying their development remain incompletely characterized. Existing transcriptomic studies have largely focused on extracellular matrix genes, with limited integration of metabolism-related pathways. Aims: To characterize the integrated transcriptomic profile of earlobe keloids compared with site-matched normotrophic scars, allowing the characterization of a site-specific molecular profile, focusing on collagen and extracellular matrix, metalloproteinases, and metabolism-related genes, and to validate selected targets at the mRNA and protein levels. Methods: In this primary analytical case–control study, tissue samples were obtained from 11 earlobe keloids and 10 normotrophic earlobe scars in adults aged 18–50 years. After histopathological confirmation, total RNA was extracted and analyzed using next-generation RNA sequencing on the Ion S5 platform. Differentially expressed genes were identified using an absolute fold change ≥ 2 and a false discovery rate (FDR)-adjusted p value < 0.05, as calculated in Ion Reporter. Panels of collagen and extracellular matrix genes, metalloproteinase-related genes, and metabolism-related genes were selected for validation by quantitative real-time polymerase chain reaction, with ACTB and GAPDH as housekeeping genes. Relative expression was calculated using the 2 ^−ΔΔCt method. ADAM12 protein levels were quantified in tissue lysates using enzyme-linked immunosorbent assay. Statistical significance was set at p < 0.05. Results: RNA sequencing identified 20,809 genes across all samples, of which 664 were differentially expressed between keloid and normotrophic scar tissue. Earlobe keloids showed marked upregulation of collagen and extracellular matrix genes, including FN1, COL1A1, COL1A2, COL3A1, COL5A1, COL5A2, SPARC, LOX, and LOXL2, indicating reinforced matrix deposition and crosslinking. Metalloproteinase genes, such as ADAM12, MMP2, MMP11, MMP13, ADAMTS2, and ADAMTS12, together with TIMP1, were also overexpressed. Quantitative real-time PCR showed high concordance with transcriptomic fold changes, and ADAM12 protein was significantly increased in keloid tissue compared with normotrophic scars ( p < 0.001). Metabolism-related genes, CPXM1, GALNT5, CHST6, and NOX4, were overexpressed, whereas ACADM, LEPR, APOC1, THRSP, and AWAT2 were downregulated, suggesting altered glycosylation, oxidative stress, and disturbed lipid metabolism in earlobe keloids. Conclusion: Earlobe keloids display a site-specific molecular profile characterized by coordinated dysregulation of collagen, metalloproteinases, and metabolism-related genes. The convergence of extracellular matrix accumulation, protease–antiprotease imbalance, and metabolic reprogramming supports the concept of keloids as metabolically active fibrotic tumors and identifies targets, such as ADAM12 and NOX4, for future translational studies. These findings reinforce the concept of anatomical site-dependent keloid biology and support targeted therapeutic approaches. 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 .

Congenital upper eyelid entropion is rare but can rapidly cause severe corneal morbidity in neonates if left untreated. In extremely low-birth-weight infants with multisystem anomalies, surgical intervention carries substantial risks, creating a balance between life-preserving caution and vision-preserving urgency. We report a case of early surgical correction in a late preterm neonate weighing 900g who presented with bilateral congenital upper eyelid entropion and right corneal ulceration. Surgical correction involved transposing the pretarsal orbicularis and levator aponeurosis complex, fixing it to the superior tarsal border to restore lamellar balance. Immediate postoperative bilateral eyelid eversion was achieved, resolving ocular irritation. At 4 months postoperatively, the eyelid position was stable without recurrence. Early surgical correction can safely restore lamellar balance and prevent irreversible corneal sequelae in fragile neonates.

Background Liposuction is the most frequently performed plastic surgery procedure. Skin laxity remains a persistent challenge after the procedure. To address this issue, various devices aimed at promoting skin retraction have been explored, although comparative data are inconsistent. Objectives The primary aim of this study was to systematically review the literature on skin retraction rates associated with different liposuction devices and critically evaluate the quality of the evidence. The secondary aim was to present a comparative summary of reported retraction percentages to highlight inconsistencies and to guide future research. Methods A systematic review was conducted across four major databases following the PRISMA guidelines. Studies were selected by two independent authors, and included articles underwent qualitative synthesis and risk of bias assessment. Results Nineteen studies were included. The analysis revealed significant heterogeneity among studies (I² = 96.8%) and a serious risk of bias in approximately 50% of the studies. The calculated weighted average skin retraction percentages for each technology were as follows: Radiofrequency-Assisted Liposuction (RFAL), 31.38%; Laser-Assisted Liposuction (LAL), 29.87%; Ultrasound-Assisted Liposuction (UAL), 17.0%; and Suction-Assisted Liposuction (SAL), 12.35%. Conclusion Evidence on skin retraction from adjuvant liposuction technologies is limited by significant study heterogeneity and a high risk of bias, precluding firm conclusions regarding the superiority of any single device. This review underscores the urgent need for larger, high-quality randomized controlled trials with standardized methodologies to validate the clinical utility of these technologies. 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: Transgender men often experience body image dissatisfaction because of incongruence between their gender identity and physical appearance. Masculinizing mammoplasty (MM) aligns physical appearance with gender identity; however, its impact on body image satisfaction in Brazil has not been comprehensively assessed using validated tools. Objectives: To evaluate satisfaction with chest appearance, nipple aesthetics, and body investment among transgender men in Brazil, comparing those who have undergone MM with those who have not, using validated tools, such as the BODY-Q Chest, BODY-Q Nipple, and Body Investment Scale. Methods: This cross-sectional study included 90 transgender men aged ≥18 years recruited between June and September 2024. Participants were allocated to 2 groups: those who had undergone MM (n = 45) and those eligible but had not yet undergone surgery (n = 45). Inverse probability of treatment weighting and regression models adjusted for age, BMI, and education level were used. Results: Participants had a mean age of 32.2 years (standard deviation [SD] ±8.1, range, 19-62) and BMI of 27.9 kg/m2 (SD ±4.8). The MM group had a mean time since surgery of 40 months (SD ±29.2). After adjustment, MM was associated with significantly greater satisfaction with chest appearance (average treatment effect [ATE], 60.98; 95% CI, 53.02-68.93), nipple aesthetics (ATE, 50.61; 95% CI, 38.99-62.23), and body investment (ATE, 11.02; 95% CI, 5.66-16.38). Chest binding was significantly reduced in the MM group (P < .001). Conclusions: Transgender men in Brazil who underwent MM reported higher body image satisfaction and quality of life, supporting the role of this procedure in enhancing mental health. Level of Evidence: 3 (Therapeutic):

Introduction Rib resection and remodeling have gained attention as cosmetic procedures to enhance body contours, particularly waist-to-hip ratio. Historically, rib resection has been used for medical reasons; however, plastic surgeons have recently adopted it for aesthetic purposes. However, concerns remain regarding the safety and effectiveness of the procedure, particularly due to the potential for complications, such as pneumothorax, chronic pain, and impaired respiratory function. This systematic review aimed to assess the existing evidence on rib resection or remodeling for body contouring. Methods A systematic review was conducted following PRISMA guidelines. Databases including PubMed, EMBASE, Cochrane, and others were searched for studies involving rib resection or remodeling for aesthetic purposes. Studies were selected based on predefined inclusion criteria, including adult patients and outcomes related to waist circumference reduction, adverse events, and patient satisfaction. Risk of bias was assessed using the ROBINS-I tool. Results This review included 12 studies that revealed variability in techniques, patient selection, and outcomes. Rib resection was associated with significant risks such as pneumothorax and chronic pain; however, newer rib remodeling techniques, such as green-stick fractures and rib shaving, showed fewer complications. Despite promising results in some cases, the lack of long-term studies and randomized clinical trials limits the ability to draw definitive conclusions regarding the efficacy and safety of these procedures. Conclusion Rib remodeling appears to offer a less invasive alternative to full-rib resection, with a reduced risk of complications. However, the current literature is insufficient to provide conclusive evidence regarding the long-term safety and efficacy of these procedures. Further high-quality studies, including randomized trials, are needed to inform surgical practices and patient decision-making regarding rib-based body contouring. 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.