Barbara Cagli

Wedge Excision of the Nail Fold in the Treatment of Ingrown Toenail

Abstract:Many treatment modalities of ingrown toenail are reported in the literature, often associated with unacceptably high recurrence rate. The authors present their technique, which aims at reducing the convexity of the nail fold. After complete removal of the nail plate and accurate debridement of the granulomatous tissue, a wedge-shaped ellipsis of skin and subcutaneous tissue, lateral to the affected nail fold, is removed. Approximation of the margins of the resulting defect determines eversion of the nail fold. One hundred twenty ingrown toenails were treated with the wedge excision of the nail fold at the outpatient clinic of the department of plastic surgery, Campus Bio-Medico University, Rome, Italy, between January 1998 and January 2002. Six recurrences were observed. In addition to the high cure rate, short postoperative pain duration, and morbidity as well as low risk of postoperative infection, the remarkable esthetic results achievable with this method are indicated.

Implant Breast Reconstruction After Salvage Mastectomy in Previously Irradiated Patients

The most common surgical approach in case of local tumor recurrence after quadrantectomy and radiotherapy is salvage mastectomy. Breast reconstruction is the subsequent phase of the treatment and the plastic surgeon has to operate on previously irradiated and manipulated tissues. The medical literature highlights that breast reconstruction with tissue expanders is not a pursuable option, considering previous radiotherapy a contraindication. The purpose of this retrospective study is to evaluate the influence of previous radiotherapy on 2-stage breast reconstruction (tissue expander/implant). Only patients with analogous timing of radiation therapy and the same demolitive and reconstructive procedures were recruited. The results of this study prove that, after salvage mastectomy in previously irradiated patients, implant reconstruction is still possible. Further comparative studies are, of course, advisable to draw any conclusion on the possibility to perform implant reconstruction in previously irradiated patients.

Predictive and protective factors for partial necrosis in DIEP flap breast reconstruction: does nulliparity bias flap viability?

AbstractAlthough success rate of deep inferior epigastric perforator (DIEP) flap breast reconstruction has greatly improved, complications still occasionally occur. Perfusion-related complications (PRCs) (ie, fat necrosis and partial flap necrosis) are the most frequent concern, affecting aesthetic final result of the reconstructed breast.The aim of our study was to retrospectively investigate 287 consecutive DIEP flap breast reconstructions to investigate predictive and protective factors for PRCs.From May 2004 to February 2012, 287 DIEP flap breast reconstructions were performed on 270 patients; 247 unilateral flaps, including Holm vascular zones I to III, were retrospectively selected and analyzed. Tobacco use, mean blood pressure over the first postoperative 48 hours, superficial epigastric vein drainage, medial/lateral row perforator, nulliparity, crystalloid versus combined crystalloid/colloid intravenous fluid infusion therapy, and learning curve were evaluated by univariate and multivariate logistic regression analyses.Perfusion-related complications occurred 32 (12.9%) times, 79 (31.9%) patients were smokers, 48 (19.4%) showed postoperative mean blood pressure less than 75 mm Hg, 29 (11.7%) were nulliparous, and 173 (70%) had superficial epigastric vein drainage. Selected perforators were 110 (44.5%) from lateral row, 137 (55.5%) from medial row; 91 (36.8%) received crystalloid fluid infusion, whereas 156 (63.2%) combined crystalloid/colloid fluid infusion. From univariate analysis emerged significance of nulliparity, perforator row and intravenous fluid infusion for PRC. Nevertheless, multivariate model confirmed only nulliparity as a significant risk factor (P = 0.029), although variable correlations to other predictors were found: both medial row perforator and combined crystalloid/colloid fluid infusion potentially decrease the PRC risk of 11.6% and 27.6%, respectively. Learning curve did not show significant decrease of PRC risk over time.Our study first proved nulliparity as a statistically significant predictor for PRCs in DIEP flap breast reconstruction, possibly due to different superficial abdominal perfusion between pluriparous and nulliparous women, with potential weaker pattern of perforators and smaller angiosomes in the latter. The choice of medial row perforators and combined crystalloid/colloid fluid infusion might reduce PRC risk.

Decision making in the treatment of tuberous and tubular breasts: volume adjustment as a crucial stage in the surgical strategy.

Tuberous and tubular breasts, two distinct deformities based on the same anatomic anomaly, are characterized by several morphologic alterations with a wide spectrum of expression. The classifications reported in the literature are based primarily on deformity of shape, but other parameters such as breast volume and symmetry often are underrated. This study aimed to define tuberous and tubular breasts and their management accurately on the basis of multiple anatomic alterations involving breast volume and symmetry as well as shape.The records of 30 patients affected by tubular and tuberous breast were reviewed. Surgical strategy included correction of breast shape through areola and gland alterations, correction of volume asymmetry through parenchyma resection, and volume augmentation through permanent expandable breast implant insertion. All the patients were treated bilaterally.Evaluation using a visual analogic scale confirmed high patient satisfaction with a mean value of 92.6% in the assessment of shape, volume, and symmetry. Correct diagnosis, careful preoperative evaluation, and a comprehensive surgical strategy can achieve, in one surgical procedure, good and long-lasting outcomes in terms of breast shape and volume symmetry.

Treatment of Early-Stage Pressure Ulcers by Using Autologous Adipose Tissue Grafts

Assessing pressure ulcers (PUs) in early stages allows patients to receive safer treatment. Up to now, in addition to clinical evaluation, ultrasonography seems to be the most suitable technique to achieve this goal. Several treatments are applied to prevent ulcer progression but none of them is totally effective. Furthermore, the in-depth knowledge of fat regenerative properties has led to a wide use of it. With this study the authors aim at introducing a new approach to cure and prevent the worsening of early-stage PUs by using fat grafts. The authors selected 42 patients who showed clinical and ultrasonographic evidence of early-stage PUs. Values of skin thickness, fascial integrity, and subcutaneous vascularity were recorded both on the PU area and the healthy trochanteric one, used as control region. Fat grafting was performed on all patients. At three months, abnormal ultrasonographic findings, such as reduction of cutaneous and subcutaneous thickness, discontinuous fascia, and decrease in subcutaneous vascularity, all were modified with respect to almost all the corresponding parameters of the control region. Results highlight that the use of fat grafts proved to be an effective treatment for early-stage PUs, especially in the care of neurological and chronic bedridden patients.

Patient Satisfaction and Clinical Outcomes Following 414 Breast Reductions: Application of BREAST-Q

AbstractBackgroundThe aim of this study was to measure breast satisfaction and quality of life using the BREAST-Q Reduction Module in a large sample of postoperative patients having breast reduction using the inverted T technique.MethodsWith due approval from the ethics committee of our university, 414 patients who were seen in consultation for breast reduction surgery between 2005 and 2015 performed by the same team were asked to fill out BREAST-Q surveys. The patient factors collected for all those undergoing breast reduction included age, body mass index, incision pattern, areola complex pedicle used, amount of tissue resected, concurrent procedures, and complications.ResultsAt our Department of plastic, reconstructive, and aesthetic surgery, 414 women underwent reduction mammoplasty with the inverted T technique from 2005 to 2015. All patients answered the BREAST-Q reduction mammoplasty postoperative module. Postoperative patients who presented with severe hypertrophy and asymmetry Grade C were more satisfied than others.ConclusionsOur study represents the largest number of patients who answered the BREAST-Q reduction mammoplasty module. The goal of breast surgery should be the attainment of patient satisfaction with good breast volume, shape, and symmetry.Level of evidence IVThis journal requires that authors assign a level of evidence to each submission to which Evidence Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors. http://www.springer.com/00266

Aesthetic subpectoral placement of implantable cardioverter defibrillators.

AbstractThe implantable cardioverter defibrillator (ICD) is the treatment of choice for life-threatening arrhythmias. Usually, the device is placed, by a subclavian access, on the upper portion of the pectoralis major muscle. As a result, the visibility of the device and the wide subclavian scar create an important aesthetic deformity, especially in young women, evolving in a relevant psychosocial distress. The authors report their experience with subpectoral ICD implantation. Between January 2001 and December 2011, approximately 30 consecutive female patients underwent submuscular ICD implantation or substitution, performed in collaboration with the cardiology team. No significant complications, except 1 case of wound dehiscence and 2 cases of caudal dislocation of the device, were observed. At 6 and 12 months’ follow-up, no significant difference between preoperative and postoperative breast symmetry and volume was noticed. The combined approach aims at reducing the visible signs of the procedure and improving the psychological outcomes.

How to redefine the inframammary fold: the "slingshot" capsular flap.

BackgroundCaudal dislocation of the inframammary fold (IMF) affects cosmetic appearance of the breast. Up until now, few methods have been proposed. The authors introduced a new capsular flap to improve long-lasting results. Materials and MethodsThirty consecutive patients affected by lower dislocation of the IMF have been retrospectively evaluated. Patients have been classified for age, degree of capsular contracture, and IMF dislocation (measured in centimeters). All dislocations have been corrected using a capsular flap cranially advanced on the chest wall in a “slingshot” fashion and anchored to the periosteum of the IV to V rib. ResultsNo major complications have been registered. In 2 cases, recurrence of IMF dislocation occurred within 15 months. In 3 cases, hypodefinition of the fold in the long-term was recorded. ConclusionsThe slingshot capsular flap seems a valid option to redefine the IMF, improving aesthetic appearance and stability of the result.

Recurrent Scrotal Hemangiomas During Treatment With Sunitinib

Cutaneous hemangioma is a benign, self-involuting tumor of endothelial cells. In most cases, it is already present at birth or develops as a rapid capillary growth during the first years of life, and in 75% to 100% of cases, it progressively disappears during the first 7 years, thus defining a proliferative phase followed by an involutive phase; among the different histologic types, capillary is the most common. Sunitinib (SUTENT, Pfizer, New York, New York) is an orally administered tyrosine kinase inhibitor approved for the treatment of gastrointestinal stromal tumor and advanced or metastatic renal cell carcinoma. It

Extended cutaneous 'thoracoabdominal' flap for large chest wall reconstruction.

Major chest wall reconstructions are usually required after radical excision of advanced cancer stages and large radionecrosis in patients with poor general conditions. Fasciocutaneous, muscular, and musculocutaneous flaps have all been described, with the last ones being commonly considered a first choice. The authors introduce an extended pure cutaneous flap from the omolateral thoracoabdominal area that is able to cover extensive defects. The vascular supply is provided by the lateral cutaneous branches from intercostal, subcostal, and lumbar arteries. Between February 2002 and 2005, 18 female patients underwent major chest wall reconstruction with this technique. Flap dimensions ranged between 15 × 15 and 25 × 30 cm. No major complications were registered. Four flaps sustained a partial loss at the distal margin but 1 case only required further surgical debridement. The extended cutaneous “thoracoabdominal” flap proved to be a quick, single-stage procedure with a low morbidity rate, specifically indicated in patients with a poor prognosis.