Carmine Alfano

Surgical Correction of Blepharoptosis Using the Levator Aponeurosis-Müller's Muscle Complex Readaptation Technique : A 15-Year Experience

Background: Palpebral ptosis is defined as abnormal drooping of the upper lid, caused by partial or total reduction in levator muscle function. It may be caused by various abnormalities, both congenital and acquired. The aim of this article is to report the long-term follow-up of results obtained with the levator aponeurosis–Müller’s muscle complex readaptation technique. Methods: In a clinical study, 144 eyelids (102 patients) affected by congenital or acquired blepharoptosis were treated using the levator aponeurosis–Müller’s muscle complex readaptation technique. Degree of ptosis and levator function were measured preoperatively and postoperatively. All patients were followed up for 1 year, 54 of them for 3 years, 22 for 5 years, and 12 for 10 years. Results: Complete correction or mild residual ptosis was achieved in over 83 percent. All ptosis with preoperative levator function greater than 8 mm was completely corrected, whereas eyelids with poor or absent levator function showed a variable degree of postoperative correction and a statistically significant difference. Ptosis correction between eyelids with levator function greater than 8 mm or less than 8 mm was analyzed statistically using the McNemar test for paired data. Conclusions: This surgical technique is effective in both acquired and congenital ptosis. In particular, the authors obtained better results in those with fair to good (>8 mm) levator function than in those with poor or absent (≤8 mm) levator function.

Transplantation of autologous cultivated conjunctival epithelium for the restoration of defects in the ocular surface.

Ocular surface disorders are often characterised by partial or complete loss of corneo-conjunctival epithelium, which causes dramatic functional and cosmetic problems. Depletion of stem cells and the scarcity of donor tissue available make large or bilateral defects challenging to reconstruct, and usually require the transplantation of heterotopic or allogeneic grafts. We investigated the feasibility of restoring severely damaged ocular surfaces with autologous cultivated conjunctival epithelium. Conjunctival cells were harvested from the healthy eyelid bed of four patients with oculopalpebral diseases. An epithelial sheet reproducing the original conjunctival epithelium was generated by serial cell culture. This was transplanted for the first time ever to our knowledge on to the ocular surface of the same patients. Take was excellent and the cultivated epithelium was stable, resulting in great improvement of patients symptoms and cosmesis. Transplantation of cultivated conjunctival cells opens new perspectives in the treatment of severe ocular surface disorders.

Breastfeeding After Reduction Mammaplasty Using Different Techniques

BackgroundThis study reviewed mammary glandular function and breastfeeding after reduction mammaplasty performed via four different surgical techniques. Patients who underwent this procedure were asked to answer questions concerning the birth of a child, natural breastfeeding, and the reasons why natural breastfeeding was not performed or was interrupted.MethodsBetween 1992 and 2001, 368 reduction mammaplasties were performed in the Department of Plastic Surgery at the “La Sapienza” University of Rome. After reduction mammaplasty, 105 patients had a child and were enrolled in the study. Breastfeeding data were compared with data from hospital records at the time of surgery in terms of patient age, reduction mammaplasty technique, sensitivity of the nipple–areola complex after the operation, and proportion of the gland removed.ResultsMaternal breastfeeding was considered to have occurred if it lasted more than 3 weeks and was not accompanied by any nutritional supplements. Babies were breastfed by 60.7% of the patients who underwent a superior pedicle reduction mammaplasty, by 43.5% of those who underwent an inferior pedicle reduction mammaplasty, by 48% of those who underwent a medial pedicle reduction mammaplasty, and by 55.1% of those who underwent a lateral pedicle reduction mammaplasty.ConclusionsThe findings demonstrate that conservative reduction mammaplasty techniques supported by medical and paramedical staff permit subsequent breastfeeding. In particular, the best outcomes resulted from superior pedicle reduction mammaplasty. Skilled execution of the surgical technique is mandatory to guarantee adequate vascularization and sensitivity of the nipple–areola complex and to spare as many of the glandular ducts and lobules as possible.

An approach to managing non-melanoma skin cancer of the nose with mucosal invasion: our experience

Conclusions. The absence of recurrences after final nasal reconstruction demonstrates the reliability of our three-stage strategy and the necessity to delay nasal reconstruction, focusing attention on oncological safety for nasal non-melanoma skin cancer (NMSC) with mucosal invasion. Objectives. To validate a therapeutic strategy aimed at oncological safety and minimization of possible recurrences after full-thickness excision of nasal NMSC with mucosal invasion. The strategy was divided into three stages: surgical excision with clinically safe perilesional skin margins and extemporary frozen section histological control; 8–15 months follow-up leaving the nasal defect unreconstructed with a ‘wait and see’ strategy; new extemporary histological control of defect margins and, if negative, definitive reconstruction. Patients and methods. Twenty patients affected by nasal NMSC with mucosal invasion were treated and followed up. Results. Basal cell carcinoma was the most common lesion (75%), followed by squamous cell carcinoma (25%). Ultrasonography excluded lymphatic involvement for SCC. Before final reconstruction, extemporary histological examination revealed the presence of tumour cells in three patients. After tumour extirpation, these patients were resubmitted to a new follow-up period before reconstruction. No recurrences were observed after definitive nasal reconstruction in all patients during the 5-year follow-up.

Reconstruction of the lower lip with a full thickness nasolabial island flap.

We have used a full thickness nasolabial island flap to reconstruct the lower lip after excision of its median or paramedian part for carcinoma in 12 patients. The flap is transposed through a subcutaneous tunnel over the modiolus without interrupting the muscle fibres of the commissura. All the patients were men who smoked, with a mean age of 64 years, and they have been followed up for a mean of 18 months (range 6-36). Functional and aesthetic results were good in all cases; there have been no recurrences or lymph node metastases, and the only postoperative complications were two cases of superficial necrosis of the distal part of the flap which healed spontaneously without scarring. We think that the full thickness nasolabial island flap is a satisfactory technique for reconstruction of the lower lip.

Evidence-Based Evaluation Technique to Assess Augmentation Mammaplasty Results: A Simple Method to Objectively Analyze Mammary Symmetry and Position

BACKGROUND Despite the great variety of mammaplasty techniques, outcome assessment remains a challenging issue. OBJECTIVES The authors devised an objective method to evaluate mammary symmetry based on statistical analysis of objective manual breast measurements and validated the method by applying it to results of a randomized controlled trial on the correction of breast asymmetry. METHODS Sixty consecutive patients with hypoplastic breasts and small-volume asymmetry were enrolled in the study and randomly assigned to 1 of 2 groups. One group received a fixed-volume implant in 1 breast and an adjustable-volume implant in the other. The other group received 2 fixed-volume implants of different sizes. The differences in specific breast and chest measurements, obtained before surgery and during follow-up, were analyzed statistically with the Wilcoxon signed rank test. RESULTS Correction of the asymmetry resulted in the reduction of the differences between left and right values for each specific breast measurement. Placement of an adjustable implant on 1 side yielded better symmetry than placement of 2 fixed-volume prostheses of different sizes. Patient and physician satisfaction was high for both groups. CONCLUSIONS This objective analysis of clinical parameters enables comparing results for different patients in large clinical trials and for the same patient at different follow-up periods. LEVEL OF EVIDENCE 3.

Lateral Canthoplasty by the Micro-Mitek Anchor System: 10-Year Review of 96 Patients

PURPOSE Lateral canthoplasty is useful to correct lower eyelid malposition, restore eyelid function, and protect the ocular surface. An effective method for fixation of soft tissue in the face, such as the lateral canthus, using the Micro-Mitek Anchor System is presented. PATIENTS AND METHODS We report our experience in 96 patients who underwent lateral canthoplasty by Micro-Mitek Anchor. One hundred twenty-four lateral canthoplasties were performed, including, senile ectropion, tumors, trauma, cicatricial retraction, and lower eyelid malposition after blepharoplasty. RESULTS The insertion of a bone anchor requires a limited dissection, and the insertion area can be determined accurately. Using the bone anchor to fixate the lateral canthus to the facial skeleton is an effective way to prevent drooping of the canthus due to gravitational forces. CONCLUSIONS Lateral canthoplasty using the Mitek Anchor System has the advantage of being an easy technique with accurate placement of the anchor, reducing operating time.

Acquisition and elaboration of superficial three-dimensional images in plastic and reconstructive surgery: Applications

Since 1970, as computed axial tomography machines became easily available and became more sophisticated, image acquisition techniques and analysis improved, developed rapidly and became very useful in medical diagnosis. Today it is possible to examine either the anatomic and functional aspects of deep body organs and tissues including all the minute details as well as their morphological relations with superficial structures. Through precise graphic elaboration programs we can obtain information about spatial relations which was not possible using simply classical clinical examination. It is possible, for example, to point out an area of interest from its anatomic context, to carry out virtual cleavage of planes and to measure volumes and distances. New developments in image acquisition systems permit transfer of three-dimensional data directly from existing objects. The three -dimensional computerized axial tomography for deep structures, and the laser scanners for superficial structure, quickly furnish (1-3 seconds for the laser scanners) useful information to plan the surgical operation. When analysing 3D-imaging techniques it is important to appreciate their utility for the planning and the follow up of surgery, particularly for the head and thorax, where the three dimensional evaluation is better than the classic double dimensional system that is incomplete and difficult to interpret. In the future, these systems will be important for the best aesthetic and functional results and above all for reducing the surgical time.

Varioscope M5: a new type of magnification system in anterolateral thigh perforator free-flap surgery.

Free microvascular tissue transfer has become a key procedure for the surgical treatment of large tissue defects that requires specialized practitioners and magnification instruments. The operating microscope traditionally has filled this requirement. A study was performed focusing on the evaluation of a new magnification system, the Varioscope M5 (Life Optics, Vienna, Austria), in reconstructive procedures with a perforator free flap. The device was employed by the same operator during dissection and microvascular anastomosis of 12 anterolateral thigh perforator flaps in head and neck reconstruction. The need to operate in a different way, not provided by an operating microscope, gave us the idea of exploring an alternative to the classical visualization systems. Specific advantages such as reduced cost, freedom of movement, auto focus, minimal upkeep, and a variable range of magnification are some of the reasons that convinced us to try this new type of magnification system. Increasing interest in microsurgery magnification highlights the need for further technical developments in this field. We consider the Varioscope M5 an alternative option for surgical magnification in most free tissue transfers, especially when an operating microscope is not supplied.

Postoperative Nipple-Areola Complex Monitoring: The “Trapdoor” Dressing

Postoperative monitoring of the nipple-areola complex is a common procedure in breast surgery [1]. Following reconstructive and aesthetic surgery a compressive and stable dressing may be used in supporting the new shape of the breast [2]. During the postoperative period the dressing should be easily removable to check the nipple-areola complex viability. Many custom-made dressings, with more than one sterile drape or gauze, are used in many centers but very few are discussed in the literature. We introduce a simple, fast, practical, and easily reproducible dressing for postoperative monitoring of the nipple-areola complex. A double layer of sterile gauze is opened and folded in two specular layers, defining an anterior and a posterior layer (Fig. 1a, b). The posterior layer is folded in two other specular layers (Fig. 1c). A hole is made by an ovalar or triangular cut in the posterior layer (Fig. 1d–f). The posterior layer is applied over the nipple-areola complex and fixed to the skin using sterile tape (Fig. 2a, b). Leaving the dressing intact, the anterior layer can be used as a ‘‘trapdoor’’ to visualize the nipple-areola complex (Fig. 2c, d). The ‘‘trapdoor’’ dressing is very comfortable for the patients and very practical for the health care providers because it avoids dressing change and allows nipple-areola monitoring without affecting the sterile field. The dressing saves time and money and is also very easy to remove in case of bleeding or nonsterile contamination.