Cristiano Monarca

Minimally Invasive Combined Treatment for Parry-Romberg Syndrome

BackgroundFacial hemiatrophy, a typical manifestation of Parry-Romberg syndrome, produces massive face asymmetry, causing marked aesthetic damage and severe psychological discomfort, with repercussions to the psychophysical status of the patient. This article presents a successful combined treatment that results in resolution of symptoms and patient satisfaction.MethodsThe authors proposed a clinic-therapeutic management comprising a customized program of bio-lipo-intense pulsed light (IPL) remodeling.ResultsIn 2007, at a 1-year follow-up visit, the patient presented a stable result. She is satisfied with the augmentation treatment, the new volume and contours of the face, and the resolution of the sclerosis and ochrodermia.ConclusionThe authors have succeeded with a minimally invasive reconstructive technique for Romberg disease using a customized therapeutic program of poly-L-lactic acid, lipofilling, and IPL therapy. They report a case of good healing without recurrences and complications, with a good cosmetic result, and with satisfaction of the patient.

Optimal care for eyelid contraction after radiotherapy: case report and literature review.

Radiotherapy represents a major problem in facial surgery. Orbital and periorbital radiation therapy causes a contraction of the soft tissues. Scarring with ectropion is the most severe complication, with shrinking of the anterior lamella, skin dystrophy, muscle atrophy, and alteration of the remaining soft tissues. Goals for reconstruction include correction of distorted orbitofacial tissues and the restoration of orbital structures. The management of these patients is not standardized. We suggest systematically using a combined approach of surgery and lipofilling to restore the orbital deformity and dystrophy, respectively. For this purpose, we present the case of a 65-year-old woman with asymmetry of the orbital regions and severe lower eyelid cicatricial ectropion due to multiple radiation treatments in childhood for an extensive cavernous hemangioma of the right side of the face. We performed a reconstructive procedure using a tarsal strip technique in association with contralateral upper eyelid graft to correct the extensive retraction of the right lower eyelid and lid asymmetry. Subsequently, the patient underwent lipofilling to correct the post-radiotherapy dystrophy. Skin texture, softness, and elasticity greatly improved with further symmetrization. The combined treatment with surgery and lipofilling can significantly improve the functional and cosmetic outcome of shortened and dystrophic eyelids with a successful result with regard to post-radiotherapy retraction.

Upper-Lip Augmentation by Graft of Preseptal Orbicularis Oculi Muscle Through Blepharoplasty

BackgroundUpper-lip augmentation is used to enhance a thin upper lip or correct lip deficiencies or senile hypotrophy. We describe an easy, effective, and reproducible technique.MethodsWe use two preseptal orbicularis oculi muscle grafts that provide a reliable option for soft-tissue upper-lip augmentation, with improved vertical lip height and lateral lip projection and reappearance of the Cupid’s bow. Muscle grafts are harvested from a blepharoplasty done at the same time.ResultsThe advantages of this procedure include the creation of an anatomically natural upper lip through preserving the continuity and function of the labial structure, good augmentation, no donor-site morbidity, no visible scars on the vermilion, and successful rejuvenation with the associated blepharoplasty.ConclusionBoth patients and surgeons were satisfied with the results because the muscle grafts produce a youthful appearance by adding natural, soft roundness and fullness to the upper lip without an artificial look or the use of synthetic material, providing long-term augmentation.

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.

Eyebrow Reconstruction: Technical Strategies

The eyebrows have a combined linguistic and affective function and play a key role in facial expressions. Eyebrows loss (madarosis) has various etiologies [1, 2] and may cause disfigurement and discomfort. Eyebrow transplantation is the best aesthetically acceptable procedure that is performed to improve the patient’s appearance and self-esteem. Reconstruction techniques using micrografts of various sizes usually yield good results. Transplantation methods vary from physician to physician; some use a 18-21-G needle with stick-and-place, some use implanters, and others use premade incisions with a tiny microblade, such as a 15 Sharpoint, and place the grafts afterward. The success of reconstruction depends on the surgeon’s knowledge of eyebrow anatomy and his or her ability to reproduce the angle and direction of single-hair grafts to achieve natural results [3]. Here we report our successful, easy approach, with more than 90 cases of eyebrow reconstruction by follicular unit transplant (FUT). Eyebrow design is critical [4] and has three key points: symmetry, direction, and angle. We obtained perfect symmetry by drawing the eyebrow on transparent paper, which is then used as a template for the design of a perfectly symmetrical contralateral eyebrow (Fig. 1). The donor hair is the scalp, in the occipital area, where a strip with an appropriate number of bulbs is harvested. Strip harvesting is about 45 to preserve the adjacent bulbs. Extensive dissection of at least a 1-2-cm margin to suture the donor area without tension ensures a good scar. Micrografts are prepared by means of magnification, and each hair graft is transplanted microsurgically into an incision prepared for it by using of a needle bayonet of 18/19 G (Fig. 2a). This needle is extremely handy; it simplifies and speeds up the creation of the microincision. It overcomes the main difficulty of the eyebrow transplant, reproducing the very acute angle between the hair-stem and the skin. Indeed, this needle is inserted with ease at an acute angle, virtually flat to the skin (Fig. 2b), reproducing the correct original anatomy and shortening the operative time. On average, 100-300 follicular unit grafts are transplanted microsurgically (Fig. 3). Patients who have this eyebrow transplantation for both reconstructive and aesthetic reasons (Fig. 3) are generally very satisfied. The presented technique simplifies the precise, oriented placement of single-hair grafts and has been time-tested by the senior author for the last 20 years. The bayonet needle is a novel and simple approach to FUT, with satisfactory results and a very low complication rate. It is safe, effective, minimally invasive, and very handy in allowing rapid movement. Furthermore, it has no additional costs because it is packed on the operating table by a 18/19-G needle. The results of our technique are natural, beautifully shaped, and contoured. The one problem is that the hair will continue to grow, which necessitates trimming the hair monthly. After a few years, hair transplants adapt to the recipient site by a mechanism that we call ‘‘field effect,’’ as in pubic restoration [5] and other ectopic transplants. However, this is a minor problem for most patients because the defect is caused by a disfigurement due to oncological surgery (Fig. 4), radiotherapy (Fig. 5), burns or severe Electronic supplementary material The online version of this article (doi:10.1007/s00266-011-9712-1) contains supplementary material, which is available to authorized users.

The Use of Mechanical Acoustic Vibrations to Improve Abdominal Contour

Adaptive effects caused by mechanical acoustic vibrations on the neuromuscular system are widely described. These vibrations applied to the muscle belly cause the “vibration tonic reflex” characterized by an improvement in power contraction of the stimulated muscle. Mechanical acoustic vibrations of moderate strength placed on limited body areas produce a positive muscle activity without damage. A prospective study from January to September 2006 investigated 60 sedentary patients presenting with muscular hypotrophy associated or not associated with lipodystrophy of the abdominal region who desired a substantial contour improvement of such area without invasive procedures. Of these patients, 40 were subjected to a treatment protocol with mechanical acoustic vibrations applied to the abdomen, associated or not associated with physical aerobic exercise of moderate intensity. The remaining 20 patients engaged only in the physical training. The study aimed to evaluate whether the application of mechanical acoustic vibrations could improve body contour.

Keystone flap: freestyle technique to enhance the mobility of the flap (Re: ANZ J. Surg. 2011; 81: 650–2)

teratoma. Cystic teratomas are the most common benign ovarian tumours occurring in the childbearing years. While the risk of cyst rupture during surgical removal is common (~15%), the incidence of subsequent acute chemical peritonitis is uncommon (~0.6%), and that of chronic granulomatous peritonitis is even rarer (~0.2%). Granulomatous peritonitis results from widespread peritoneal and omental implantation of neuroglial elements spilt from the ruptured teratoma, triggering chronic inflammation. This inflammatory process produces significant scarring which predisposes to recurrent adhesive small bowel obstructions, and together with chronic abdominal pain are the main causes of patient morbidity. Despite this, long-term survival is not diminished. As granulomatous peritonitis can mimic peritoneal carcinomatosis, miliary tuberculosis and metastatic mesothelioma, microscopic examination of nodular disease is necessary prior to any definitive management. Once granulomatous peritonitis is diagnosed, extensive resections of the nodular disease should be avoided to minimize unnecessary patient morbidity.

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.

A horizontal V-Y advancement lower eyelid flap: our experience performing a bilateral suspension to the periosteum.

tific basis; thus, the evidence level is none. The authors also mention the complications of polyacrylamide gel in women who were treated with polyacrylamide gel injections for breast augmentation in Ukraine.3 Again, the citation does not apply to our study because the injected polyacrylamide gel was not the same as that used in our population (Aquamid; Contura International A/S, Soeborg, Denmark), the anatomical region is not comparable (breast tissue versus face), the indications are different (breast augmentation versus human immunodeficiency virus–related lipodystrophy), and the volumes injected were much larger (mean, 230 ml versus 7 ml). The second case reported by Wang et al. describes a patient who was continuously treated with polyacrylamide gel for 8 years and who developed facial ulcers and infection. The skin ulcers and scars shown in Figure 1 could have been caused by an inadequate injective technique (too superficial an injection), excessive volume of injected material per cubic millimeter (repeated injections for 8 years are certainly suspicious), inadequate filler (not all polyacrylamide gels are the same), inadequate patient behavior and, in some cases, injection in areas different from those used in patients with human immunodeficiency virus–related lipodystrophy. More information should be provided to correctly interpret this case report. Finally, Dr. Wang presents a case of the deleterious effects of golden threads. Golden threads are not used for human immunodeficiency virus lipodystrophy; therefore, the example has no relevance to our case. Regarding the necessity of a follow-up longer than 5 years, it should be noted that in our series, 5 years was the minimal duration of follow-up, with some patients being followed for up to 6.85 years, the longest follow-up reported in the literature to date. The previously described complications of polyacrylamide gel (localized accumulation, material migration, and infection) had a low incidence in our study where a correct injective technique and careful avoidance of contamination were meticulously followed. Side effects of fillers should certainly be monitored carefully, with well-designed (if possible, blind and randomized) studies. Conversely, unsubstantiated hypotheses based on case reports will only create untoward panic in a community of already fragile patients. DOI: 10.1097/PRS.0b013e318254b639

Keystone flap: freestyle technique to enhance the mobility of the flap [corrected].

teratoma. Cystic teratomas are the most common benign ovarian tumours occurring in the childbearing years. While the risk of cyst rupture during surgical removal is common (~15%), the incidence of subsequent acute chemical peritonitis is uncommon (~0.6%), and that of chronic granulomatous peritonitis is even rarer (~0.2%). Granulomatous peritonitis results from widespread peritoneal and omental implantation of neuroglial elements spilt from the ruptured teratoma, triggering chronic inflammation. This inflammatory process produces significant scarring which predisposes to recurrent adhesive small bowel obstructions, and together with chronic abdominal pain are the main causes of patient morbidity. Despite this, long-term survival is not diminished. As granulomatous peritonitis can mimic peritoneal carcinomatosis, miliary tuberculosis and metastatic mesothelioma, microscopic examination of nodular disease is necessary prior to any definitive management. Once granulomatous peritonitis is diagnosed, extensive resections of the nodular disease should be avoided to minimize unnecessary patient morbidity.