Effects of latissimus dorsi (LD) flap harvest on shoulder function in delayed breast reconstruction. A long-term analysis considering the acromiohumeral interval (AHI), the WOSI, and BREAST-Q questionnaires

BACKGROUND

The latissimus dorsi (LD) flap is reliable and versatile with many indications and low donor site morbidity. The aim of this study is to evaluate the long-term effects of LD flap on the shoulder function in patients undergoing delayed breast reconstruction.

METHODS

This case-control study enrolled women who underwent implant-based (IB) breast reconstruction, radical lymphadenectomy, and radiotherapy between 2006 and 2016. The study group included 72 women, with a history of severe capsular contracture, who received a secondary LD flap reconstruction. The control group consisted of a matched cohort of 80 patients with IB breast reconstruction. Shoulder function was assessed using the acromiohumeral interval (AHI) measurement in standard X-rays. The validated Western Ontario Shoulder Instability (WOSI) and BREAST-Q questionnaires were used to assess outcomes one year postoperatively and data were analyzed using Fisher's exact test and the Mann-Whitney test.

RESULTS

Out of 72 patients from the study group, 40 had valuable pre- and postoperative X-rays to measure the AHI. An AHI reduction was recorded only in 7/40 patients. From the WOSI analysis, no significant differences in shoulder function and back pain between the two groups were registered. BREAST-Q scores in the LD group were higher in most domains, including satisfaction with breasts and psychosocial well-being. However, the Mann-Whitney test showed no significant difference between the two groups (p > 0.05).

CONCLUSION

LD flap, with detachment of its insertions from the humerus, does not seem to have a negative impact on back and shoulder function and is correlated with high patient satisfaction in breast reconstruction following radiotherapy.

Feasibility study on equine acellular pericardium matrix (APM): A new tool for breast reconstruction

The advent of acellular dermal matrix (ADM) for lower pole coverage allows immediate reconstructions with improved aesthetic outcomes and faster recovery. This study describes for the first time, the use of a new acellular pericardium matrix (APM) in implant-based breast reconstruction and characterises its safety profile. Equity is a membrane with a natural cross-linked structure with many of the properties of ADMs, but improved resistance and reduced thickness. A retrospective data collection of all Equity APM reconstructions was conducted at two Italian hospital centres with substantial experience using biomaterials. Between May 2013 and October 2018, a total of 63 APM-assisted breast reconstructions were performed in 55 women. The reconstructed breasts were small to medium and the mean implant weight was 285 g, ranging from 145 g to 685 g. Two patients were previously irradiated while seven received post-operative radiation; five were active smokers and six were hypertensive. Complications included visibility in the upper pole (9.5%), seroma (1.6%), dehiscence, infection and necrosis (3.2% for each). Implant loss occurred in 3.2% of the cases. The patients were highly satisfied, reporting scores above 50 for each section of the Breast-Q questionnaire. With an acceptable complication rate, the use of the equine APM can be considered safe with satisfactory aesthetic results. Although the retrospective nature of this study limits its clinical impact, the use of Equity can be considered a viable alternative to thicker and expensive ADMs.

Role of Spreader Flaps in Rhinoplasty: Analysis of Patients Undergoing Correction for Severe Septal Deviation with Long-Term Follow-Up

INTRODUCTION

The aim of this randomized controlled study was to analyze the long-term results of patients undergoing rhinoplasty because of severe septal deviation and to evaluate the stability of results.

MATERIALS AND METHODS

The study was performed with a randomized design. Patients were randomly divided into four groups: group 1, spreader flaps were used in combination with spreader grafts; group 2, spreader flaps were used alone; group 3, spreader grafts were used alone; and group 4, neither spreader flaps nor grafts flaps were used. Patients answered the Italian version of the FACE-Q rhinoplasty module. Anthropometric measurements were performed by AutoCAD for MAC. We determined the angle of deviation, and we compared the pre- and postoperative angles and compared patient satisfaction in the four groups using the Chi-squared test for unpaired data. Two plastic surgeons reviewed all the postoperative photographs of the study patients and rated the photographs on a scale of 1 to 5.

RESULTS

A total of 264 patients who underwent primary rhinoplasty between January 2010 and September 2016 satisfied the inclusion criteria and were finally enrolled in this study. Anthropometric measurements revealed statistically significant differences (P < 0.01) between the preoperative and postoperative values for the angle of septal deviation in group 1 versus the other groups. Over the long-term follow-up, group 1 maintained an angle close to 180 degrees (P < 0.01). Group 1 and group 3 were more satisfied compared with groups 2 and 4 (P < 0.01). According to evaluations by the 2 reviewers, group 1 and group 3 were the most satisfactory outcomes (P < 0.01).

CONCLUSIONS

This was the first randomized study to show that the combined use of the spreader flap and spreader graft is the best choice for a good long-term outcome and durable correction of septal deviation.

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 .

Definition of "Gender Angle" in Caucasian Population

INTRODUCTION

The goal of this study report is to define the "gender angle," a new angle which represents the masculine or feminine nasal shape, for performing a gender-oriented rhinoplasty. The use of the "gender angle" in Caucasian patients will help the plastic surgeon in the search for a suitable nose for the patient's face and above all for the search for maximum patient satisfaction.

MATERIALS AND METHODS

The study population was obtained from Caucasian patients who had undergone rhinoplasty between January 1986 and September 2016 at our department. Patients answered the Italian version of the FACE-Q outcome instrument on post-rhinoplasty satisfaction with their nose. Anthropometric measurements were taken retrospectively by AutoCAD for MAC on a photograph of the profile view taken postoperatively at the last follow-up.

RESULTS

A total of 1774 (706 male and 1068 female) patients satisfied the inclusion criteria and were finally enrolled in this study. We identified a gender-specific angle ranging from 168° to 182° for the male nose and from 160° to 178° for the female nose. We subdivided all study patients into 3 ranges of angles as follows: male nose, range 1 = 168°-172°, range 2 = 173°-177°, range 3 = 178°-182°; female nose, range 1 = 160°-166°, range 2 = 167°-171°, range 3 = 172°-178°. All study patients completed the FACE-Q rhinoplasty postoperative module. Analysis was performed of the FACE-Q results and the angle obtained for each nose. The most satisfactory angle range for male patients was range 3 (P = 0.01) and for the female patients was range 2 (P = 0.01).

CONCLUSIONS

The "gender angle" might be a parameter that effectively provides the optimal cosmetic result for male and female patients who undergo rhinoplasty.

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 .

Treatment of Severe Gynecomastia After Massive Weight Loss: Analysis of Long-Term Outcomes Measured with the Italian Version of the BODY-Q

INTRODUCTION

The objectives of this study are: (1) comparison of long-term outcomes after correction of severe gynecomastia using different techniques; (2) apply the Italian version of the BODY-Q; (3) present the role of intercostal perforator flap (ICAP) after massive weight loss for correction of severe gynecomastia.

MATERIALS AND METHODS

Between January 2008 and March 2016, we performed surgical correction of bilateral severe gynecomastia in 80 men (160 breasts) following massive weight loss. Patients answered the Italian version of BODY-Q postoperative module. All patients had experienced substantial weight loss (> 30 kg), presented with bilateral severe tissue ptosis of the breast, follow-up of almost 2 years and had a good understanding of the Italian language, and signed consents were included in the study. The sample was studied about age, BMI, comorbidity, bariatric surgical procedure, follow-up, type of post-bariatric surgical procedure, complications and secondary procedures.

RESULTS

We performed 487 severe gynecomastia corrections from 2008 to 2016; 80 patients adhered to the inclusion criteria and formed our study group. This cross-sectional study compared three cohorts: 52 access using a circumareolar scar, 18 with an inframammary fold scar, 10 with an inframammary fold scar using intercostal perforator flaps. There were 16 secondary procedures in group one, 2 in group two and 1 in group three. We compared the secondary procedures of group 1 with the other groups, and we obtained a significant difference with a P = 0.04. The mean patient age was 36.5 years, and the average body mass index was 27.5 kg/m² at the time of surgical correction of gynecomastia. From the BODY-Q analysis, the group of patients undergoing adenomammectomy with inframammary fold scar using intercostal perforator flaps has achieved significantly better results regarding the satisfaction with chest, psychosocial function, satisfaction with outcome and better body image.

CONCLUSIONS

This is the first study that used the BODY-Q to analyze the correction of severe gynecomastia following massive weight loss with long-term results. The use of this patient-reported outcome measure underlined that the intercostal artery perforator flap, used in the correction of severe gynecomastia following massive weight loss, is a safe and effective technique with good outcomes and high patient satisfaction.

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 .

Analysis of Symmetry Stability Following Implant-Based Breast Reconstruction and Contralateral Management in 582 Patients with Long-Term Outcomes

INTRODUCTION

This study aimed to analyse the long-term outcomes following breast reconstruction and contralateral management to evaluate the stability of breast symmetry and patient satisfaction.

MATERIALS AND METHODS

The study population consisted of women who had undergone implant-based monolateral breast reconstruction and contralateral management. Patients answered the BREAST-Q reconstruction module. Two reviewers analysed the post-operative outcomes of the patients included and compiled the Kroll Scale. Patients were divided into three groups: implant-based contralateral management, breast reduction and mastopexy. The Fisher's exact test was applied to the results.

RESULTS

From the BREAST-Q analysis, the group of patients undergoing contralateral breast augmentation achieved significantly better results regarding the ability to wear clothing (p ≪ 0.001), symmetry (p ≪ 0.001), psychosocial well-being (p ≪ 0.001) and physical well-being (p ≪ 0.001). From the analysis of the Kroll Scale, the group of implant-based contralateral management received the highest score for symmetry (p ≪ 0.001), shape (p ≪ 0.001) and aesthetic result overall (p ≪ 0.001).

CONCLUSIONS

This study was the first to use BREAST-Q to analyse the stability of breast symmetry following breast reconstruction with long-term results. The implant-based contralateral management was the most effective procedure for achieving a stable and lasting result to obtain the high satisfaction of patients.

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 .

Mastopexy on Reconstructed Breast Following Massive Weight Loss: An Innovative Technique Using Dermo-Capsular Flaps

BACKGROUND

We have developed a dermo-capsular flap mastopexy technique for patients who have experienced massive weight loss after breast reconstruction. The aim of this technique is to lift the inframammary fold, adequately cover the implant, and remove excess skin, elevating the breast and obtaining symmetry with the contralateral breast.

METHODS

Between January 2014 and February 2017, we performed this technique on 20 women who were candidates for second-stage breast reconstruction following nipple-sparing mastectomy. All patients had experienced substantial weight loss (> 15 kg) and presented with ptosis after first-stage reconstruction.

RESULTS

There were 8 patients with bilateral reconstruction following bilateral mastectomy (4 with bilateral nipple-sparing mastectomy). There were 12 patients with unilateral mastectomy, all with contralateral breast ptosis treated by augmentation via inverted-T mastopexy (n = 7) or crescent mastopexy (n = 5). The average lift of the nipple-areola complex was 5 cm (range 2-8 cm). The average follow-up was 12 months (range 4-36 months). Two patients had complications, including partial wound dehiscence (in a heavy smoker) and recurrence of breast asymmetry.

CONCLUSIONS

Implant breast reconstruction after massive weight loss is still possible even in the setting of thin, ptotic, and anelastic breast tissue. Our inverted-T dermo-capsular flap mastopexy technique for reconstructed breast is safe and effective with good outcomes and high patient satisfaction.

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 .

The Role of Lipofilling After Breast Reconstruction: Evaluation of Outcomes and Patient Satisfaction with BREAST-Q

INTRODUCTION

The aim of this study was to measure patient satisfaction using the BREAST-Q reconstruction module in patients selected for lipofilling procedures after implant breast reconstructions.

MATERIALS AND METHODS

Seventy patients who underwent breast reconstruction with or without delayed lipofilling were enrolled between 2011 and 2015, and they completed BREAST-Q surveys. We administered the questionnaire electronically 6 months and 1 year after surgery. We divided patients into two groups. In group A, we included patients (46) who underwent secondary lipofilling almost 1 year after implant-based breast reconstruction; in group B (24), patients who underwent implant-based breast reconstruction without any lipofilling procedure. Statistical analysis was performed using descriptive and summary statistics to identify a central tendency between the two groups.

RESULTS

All patients answered the postoperative BREAST-Q reconstruction module. The mean age of the patients was 41 years. Eleven of the 70 patients underwent a bilateral mastectomy. The mean follow-up was 2.5 years. The average amount of fat graft injected was 110 cc. In group A, there were two patients who had a complication: 1 infection and 1 intraoperative implant rupture. The average number of lipofilling procedures was 2.2. After further analysis of the questionnaire, we observed that patients in group A obtained significantly better postoperative results than patients from group B (control) regarding the following items: the ability to wear more fitted clothing; the reconstructed breast softness; symmetry (breasts of equal size relative to the other); reconstructed breast look and touch; amount of implant rippling perceived by the patients; and psychosocial well-being and physical well-being: chest and upper body.

CONCLUSIONS

Our results are encouraging regarding the use of autologous fat grafting to improve cosmetic outcomes and to reduce postoperative pain after breast reconstruction. This is the first study that applied BREAST-Q to breast lipofilling to demonstrate better outcomes achieved by patients who underwent secondary lipostructures.

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 .

Management of contralateral breast following mastectomy and breast reconstruction using a mirror adjustment with crescent mastopexy technique

INTRODUCTION

Heterologous breast reconstruction after mastectomy sometimes requires the management of the contralateral breast to achieve symmetric long lasting aesthetic results. Some techniques could be used for the symmetrization of contralateral breast with or without implants as breast augmentation, reduction mammoplasty, mastopexy, with T inverted, J, vertical, periareolar, semi-circular, or axillary scars. The aim of this study is to present the use of crescent mastopexy technique with implants in contralateral adjustment following monolateral breast reconstruction compared with a control group in which patients underwent other contralateral procedures. We used BREAST-Q to evaluate breast perception and patient's satisfaction and surgeon-rated aesthetic outcomes were measured using the Kroll evaluation (a global and itemized aesthetic tool).

MATERIALS AND METHODS

A retrospective study was designed. We enrolled in the study 55 patients who had undergone breast reconstruction with implants and contralateral breast symmetrization procedure at our hospital between 2010 and 2016, and they answered to BREAST-Q postoperative module after almost 1 year from breast reconstruction. The study population consisted of 2 groups of women: patient underwent contralateral adjustment with crescent mastopexy and augmentation and patients underwent other contralateral procedures. Statistical analysis was performed using descriptive and summary statistics to identify a central tendency between the two groups, we applied Fisher's exact test to the results to obtain answers 1 year after the last procedure for the two groups.

RESULTS

This cross-sectional study compared two cohorts in which 55 women underwent monolateral mastectomy and breast reconstruction with contralateral adjustment, 15 of these underwent contralateral crescent mastopexy with augmentation, and 40 (control group) underwent contralateral breast adjustment with other mastopexy and augmentation technique (27 patients underwent T inverted mastopexy, 2 J mastopexy, 6 vertical scar mastopexy, 5 periareolar mastopexy). Nineteen patients suffered of co-morbidities (smoking, autoimmune disease, cardiological, neurological, and dismetabolic). All patients answered the postoperative BREAST-Q reconstruction module almost 1 year from last surgical procedure.

CONCLUSIONS

In patients with a pseudoptosis or mild ptosis of the contralateral breast, crescent mastopexy could be a valid procedure with minimal scars, better symmetry, and global cosmetic results than other procedures. This is the first study which compares crescent mastopexy with augmentation with other mastopexy procedures. Level III: evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.

LEVEL (III)

Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.

Comparative Study Using Autologous Fat Grafts Plus Platelet-Rich Plasma With or Without Fractional CO2 Laser Resurfacing in Treatment of Acne Scars: Analysis of Outcomes and Satisfaction With FACE-Q

BACKGROUND

A multitude of options are traditionally used for the treatment of acne scars; however, newer treatment modalities are emerging to decrease the propensity for post-inflammatory hyperpigmentation and upregulate new collagen production. The aim of this study was to evaluate the efficacy of nanofat and platelet-rich plasma (PRP) infiltration alone and combined with fractional CO₂ laser resurfacing to improve atrophic scars of the face.

METHODS

From March 2014 to June 2015, 30 patients with atrophic acne scars on the cheeks were selected for this study. Patients were evaluated pre- and postoperatively by physical examination, photographs and ultrasound with a 22-MHz probe to measure subcutaneous tissue thickness. All patients were treated with infiltration of nanofat plus PRP. The production of PRP was achieved using the RegenLab THT tube^® method. In 15 randomly chosen patients, a fractional CO₂ laser resurfacing at 15 W was also performed right after the infiltration. An Italian version of the FACE-Q postoperative module was administered to analyze each patient's satisfaction and aesthetic perception of the result.

RESULTS

The average preoperative thickness of subcutaneous tissue of patients from group A was 0.532 cm, while the average preoperative thickness of subcutaneous tissue of patients from group B was 0.737 cm. The average postoperative thickness of subcutaneous tissue was 1.201 cm in group A and 1.367 cm in group B. The improvement of thickness of subcutaneous tissue was 0.668 cm in group A and 0.63 cm in group B. We applied a t test on unpaired data, comparing the difference in thickness obtained with the treatment in both group A and in group B, with a p value =0.7289 (not significant). All patients in both groups had a treatment benefit, confirmed with FACE-Q postoperative module, but without a significant difference between the two groups.

CONCLUSIONS

Subcutaneous infiltration with nanofat and PRP seems to be effective to improve atrophic scars, either alone or combined with fractional CO₂ laser resurfacing. The FACE-Q module confirmed the impact of treatment of facial acne scars in social life and relationships.

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 .

A Systematic Review of Patient-Reported Outcome Measures Following Transsexual Surgery

BACKGROUND

The aims of our study were to identify studies that evaluated patient satisfaction after transsexual surgery, analyze existing questionnaires, and summarize their development, psychometric properties, and content.

METHODS

A systematic review of the English-language literature was performed. Patient-reported outcome measures designed to assess patient satisfaction and quality of life following transsexual surgery were identified. Qualifying instruments were assessed for content and adherence to international guidelines for development and validation.

RESULTS

From 796 articles, 19 studies had sufficient data and met the inclusion criteria. Included were a total of 2299 patients and 17 patient-reported outcome measures: 10 generic instruments that assessed quality of life, 4 specific for female genital or sexual satisfaction, 2 specific for transsexual body image or gender dysphoria, and 1 specific for plastic surgery. The questionnaires were analyzed by reviewers to assess the adherence to the rules of the US FDA and the Scientific Advisory Committee of the Medical Outcomes Trust. We identified 17 individual questionnaires that were included. All measures were limited by either their development, their validation, or their content.

CONCLUSIONS

There is a need for a new self-assessment tool, which should include functional, psychorelational, and cosmetic components, to measure satisfaction and quality of life of patients who have undergone transsexual surgery.

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 .

Ten years experience with breast reconstruction after salvage mastectomy in previously irradiated patients: analysis of outcomes, satisfaction and well-being

OBJECTIVE

Reconstruction following mastectomy offers women an opportunity to mollify some of the emotional and aesthetic effects of this devastating disease.

PATIENTS AND METHODS

The authors reviewed the files of 83 patients who underwent immediate postmastectomy reconstruction with tissue expander between January of 2003 and June of 2012 at our hospital. The patients were divided into two groups: Group A (study group) included 30 patients with previous quadrantectomy and radiotherapy who underwent salvage mastectomy after local recurrence; Group B (control group) included 53 patients submitted to primary radical mastectomy. We submitted Breast-Q reconstruction post-operative module to all of our patients.

RESULTS

The median follow-up time for the whole group was 36 months (range = 12-144 months). Between group A and group B, there were no significant differences. In the group A, the median time from RT to reconstruction was 24 months (range = 9-192 months). The overall rate of complications was not similar between the two groups (66.6% vs. 58.5%; p = NS). However, the  major complications occurred mostly in the irradiated group, showing a trend of statistical significance (53.3% vs. 32.0%; p = 0.07). In this group, the occurrence of major complications was not different according to time from RT to reconstruction (p = 0.313). In particularly, patients from the irradiated group (group A) had a significantly higher risk of grade III-IV capsular contracture (relative risk 3.75, p = 0.02) and autologous salvage reconstruction (relative risk 10.4, p = 0.02).

CONCLUSIONS

The results of this study prove that heterologous reconstruction is still possible following salvage mastectomy in previously irradiated patients.

How to assess appearance distress and motivation in plastic surgery candidates: Italian validation of Derriford Appearance Scale 59 (DAS 59)

OBJECTIVE

The Derriford Appearance Scale (DAS) 59 was specifically designed to measure psychosocial adjustment in patients with appearance problems. Previous studies using the DAS59 have proven it to be a reliable method of assessing the appearance-related quality of life after plastic surgery procedures. The aim of this study was to develop a valid and reliable Italian version of the DAS59.

PATIENTS AND METHODS

The first Italian translation of this questionnaire was conducted according to the DAS59 protocol that was designed by the original authors of the questionnaire. Eight hundred patients participated in this study and filled out three questionnaires (DAS59, General Health Questionnaire (GHQ)12 and Beck's Depression Inventory (BDI)-II). There were 400 adult patients with a history of previous plastic surgeries and 400 adult patients without any personal history of previous plastic surgery procedures. A total of 50 patients were selected randomly for test-retest analysis.

RESULTS

The overall internal consistency was excellent (α = 0.95) and equal to that of the original article that first described the scale. There was a good correlation between all the items. Domains demonstrated good internal consistency (Cronbach's alpha) and correlation within themselves. The construct validity of the Italian DAS59 was assessed under convergent validity that confirmed the correlation with scales related to other psychological conditions. GHQ12 showed relevant correlation with DAS59, while BDI-II did not.

CONCLUSIONS

A valid and reliable Italian DAS59 version was developed that can be used for research and clinical assessment of patients with appearance problems and concerns, especially before and after plastic surgery procedures.

Expander/Implant breast reconstruction after reconstruction using an extended cutaneous thoracoabdominal flap: a case report

Many flaps have been described and are being used in the reconstruction of extensive tissue defects in the thoracic wall. The extended cutaneous thoracoabdominal flap, described in 2006, is an excellent option for chest wall reconstruction in patients with advanced breast cancer, being associated with a low morbidity rate and good functional results. The main disadvantage of this technique is the poor cosmetic outcome and the complete absence of a breast crease. We present the first case of a two-stage heterologous breast reconstruction after reconstruction using an extended cutaneous thoracoabdominal flap.

Appearance distress and dysfunction in the elderly: international contrasts across Italy and the UK using DAS59

BACKGROUND

As the global population grows, the percentage of those over 60 will escalate disproportionately. Their needs will become an ever more dominant feature of public policy and healthcare provision. Older adults' appearance is often removed from cultural ideals and stereotypes of beauty, often seen as synonymous with "youth." This has seen older adults' concerns about appearance and body image somewhat sidelined in practice and in research. This study investigates the extent to which self-consciousness of appearance is associated with distress and dysfunction in those over 60 years old. Furthermore, we contrast the extent of this phenomenon in two European nations, UK and Italy, and consider the direct impact and interaction of cultural context and participant gender.

METHOD

To make an objective measurement of distress and dysfunction, we translated a widely used psychometric measure, the Derriford Appearance Scale 59 following an established and reliable translation protocol. Data were collected from community samples.

RESULTS

The Italian translation was sound, with acceptability in the Italian-speaking sample and acceptable internal consistency scores for full-scale and subscales. ANOVA analysis demonstrated that for overall adjustment, and all subscale scores, the Italians were more distressed about their appearance than UK comparators. Moreover, there were significant differences between Italian women and men, with Italian women more distressed than Italian men overall, and also general self-consciousness, sexual self-consciousness, and social self-consciousness subscales.

CONCLUSION

These results are considered in the context of aging and cultural and gender issues in appearance, including the Italian concept of bella figura.

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 .