Damiano Tambasco

DIEP flap donor site versus elective abdominoplasty short-term complication rates: a meta-analysis.

BackgroundAlthough over the past decade the DIEP flap has emerged as one of the preferred choices for autologous breast reconstruction and the donor-site closure has much in common with the standard abdominoplasty technique, reports on comparisons of the complication rates between DIEP and elective abdominoplasty patients are not currently available. The purpose of this study was to compare DIEP donor-site and elective abdominoplasty short-term complications rates, in support of surgical choices.MethodsSearches of MEDLINE and CENTRAL for English language articles on DIEP and elective abdominoplasty (EA) published from January 1999 through December 2009 identified 33 studies that met the inclusion criteria and included 3,937 patients. A random-effects model was used to calculate the average complication rate in the literature.ResultsThe rate of seroma/hematoma in EA (16.1%, 95% confidence interval [CI]xa0=xa012.2–20.9%) was approximately four times the rate in DIEP flap patients (3.7%, 95% CIxa0=xa01.5–8.8%) was found from analyzing the data under a random-effects model. No substantial differences in the rates of infection, abdominal/umbilical necrosis, or wound dehiscence/delayed healing between the two series of patients were detected.ConclusionsThis meta-analysis reveals that DIEP donor-site complication rates were comparable to those in elective abdominoplasty, and, the rate of seroma in DIEP is an even lower than that of one of the most performed procedures in plastic surgery. We argue that patients presenting for a DIEP flap should be informed about this interesting comparison.

Micro- and Macroscopic Structural Modification of Subcutaneous Adipose Tissue After Bariatric Surgery

We found the article by Levy et al. [1] entitled Macroscopic Anatomic Changes of Subcutaneous Fat Tissue in Massive-Weight Loss Patients, recently published in your online journal, very interesting. It is a relevant article from a scientific point of view and extremely useful in terms of surgical repeatability. As clearly mentioned in the article, obesity currently is a worldwide disease, with several physical and psychological consequences [2–4] affecting both developed and developing countries. Because of scarce compliance to physical exercise and diet prescriptions, obese, and particularly severely obese individuals, are unable to achieve a proper and durable weight loss. By contrast, bariatric surgery has shown long-term effectiveness in treating morbid obesity, allowing great and stable weight loss. However, one of its side effects is represented by hanging and redundant skin, which is responsible for functional and psychological disturbance for the patients. Such unaesthetic deformities are correctable only with plastic surgery in the form of reconstructive body contouring. Despite this, modifications in the tissue composition of surgical massive weight loss patients can be noticed. These patients typically experience a higher rate of surgical complications than the standard population, which can be partly explained by these alterations [5]. Based on the anatomic data from the study performed by Levy et al. [1], after gastric banding, a restrictive bariatric procedure, significant macroscopic alterations of the adipose tissue were found in all four areas they examined (epigastric, umbilical, hypogastric and lumbar regions). These alterations were loss of the superficial fascial system (with infiltration by white, atrophic, and hyperplastic adipose cells) and discontinuation of the areolar and lamellar layers. Our experience with body contouring for massive weight loss after bariatric surgery is linked primarily to biliopancreatic diversion, a mainly malabsorptive bariatric procedure. Nevertheless, our macroscopic observations are similar to those obtained by Levy et al. [1]: penetration of the superficial fascial system by white atrophic adipose cells combined with gelatinous consistency and absence of compactness of the subcutaneous tissue (Fig. 1). We underscore how the aforementioned anatomic changes, in our case, were associated with microscopic modifications, as shown in our previous study [5] evaluating the problematic wound-healing process in postbariatric patients. In fact, using evidence by Weigert–Van Gieson stain for elastic fibers and connectivum applied on the cutaneous and subcutaneous tissue taken from the horizontal scar during abdominoplasty, we documented anomalies of the dermal elastic (overgrowth, disarray, greater dimensions, serpiginous and polyfragmented aspect, occasional increment in number) and collagen (thickened, hyperosinophilic, and sclerodermoid) fibers. Moreover, we noted modifications involving the subcutaneous tissue: diffuse sclerosis, collapsed adipocytes, fibrous septum thickening, and pseudocysts. Finally, in the extracellular matrix, there was evidence of persistent inflammation (Fig. 2). M. D’Ettorre (&) R. Bracaglia D. Tambasco S. Gentileschi Department of Plastic and Reconstructive Surgery, Catholic University, Largo A. Gemelli, 8, 00168 Rome, RM, Italy e-mail: marco.dettorre@hotmail.it

Adipocyte damage in relation to different pressures generated during manual lipoaspiration with a syringe.

Adipocyte Damage in Relation to Different Pressures Generated during Manual Lipoaspiration with a Syringe Sir: W found the recently published work of Rodriguez and Condé-Green entitled “Quantification of Negative Pressures Generated by Syringes of Different Calibers Used for Liposuction” extremely interesting.1 Fat grafting has recently been experiencing an exponential growth of its surgical indications.2 However, it is commonly thought that, in contrast to liposuction with a cannula by a continuous vacuum system, harvesting through small syringes (e.g., 10-cc syringes) allows injury to be avoided and the viability of adipocytes to be preserved. These uninjured adipocytes can then be injected, after processing, into the recipient site, maximizing long-term surgical results. Rodriguez and Condé-Green demonstrated that negative pressure generated by a syringe is determined by the volume or number of cubic centimeters introduced in the syringe by pulling back the plunger. Another surprising observation is that syringe caliber should be considered a secondary factor. The pressure increase inside the syringe as the plunger is pulled back is not linear but parabolic, with rapid increases in negative pressure generated initially at low volumes and leveling off only after approximately 13 cc of plunger pull-back. Thus, the greatest increase in pressure is registered during one of the most commonly used harvesting methods, namely, harvesting with a 10-cc syringe. Rodriguez and Condé-Green use a graphic to help surgeons apply the desired negative pressure regardless of the syringe used, without quantifying the viability decrease in relation to the different pressures. Aiming to fill this gap, we compared the level of damage between samples of fat harvested with 5 (sample A) or 10 cc (sample B) of plunger pull-back in a 10-cc syringe and with 15 (sample C) and 30 cc (sample D) in a 30-cc syringe. The samples were collected manually, through a twohole Coleman blunt microcannula attached to LuerLok syringes (Becton Dickinson, Franklin Lakes, N.J.), from the same donor site (thigh) performing a wet technique of harvesting. Adipose tissue samples were fixed in 4% formaldehyde in isotonic phosphate-buffered saline for 24 hours. Tissue sections of 5 mm were dehydrated in graded ethanol, cleared in xylene, pelleted by centrifugation at 100 g for 5 minutes, and embedded in paraffin. On a microphotograph (20 ), with a corresponding field of 125,000 m2, counting of adipocytes with cy-

Recurrent inverted nipple: a reliable technique for the most difficult cases.

AbstractThe inverted nipple is a frequent pathologic condition, involving up to 10% of women. This deformity results in a negative self-image for the affected patient. Recurrence after corrective surgery is possible and may represent extreme frustration for the patient and the surgeon. The aim of our study is to propose a useful and reliable technique to employ in case of recurrence or severe inverted nipple. During 2000 and 2010, the study was conducted on 19 patients treated with this procedure: 10 patients (20 nipples) having severe inverted nipple (grade III according to Han and Hong classification) and 9 patients (15 nipples) presenting with relapses. One nipple could not be corrected. One patient developed a temporary loss of sensibility. No major complications (necrosis, infection, hematoma, and permanent numbness), no recurrences, and no noticeable scars have been reported at follow-up. In our series, the shape and the projection after the procedure were evaluated as satisfactory by the patients, remained consistent over time, and no protective devices were required. In conclusion, although our technique is not the best in terms of invasiveness, it is one of the few truly effective ones in treating relapses. For patients who have already undergone surgery, the priority is certainly to solve this clinical anomaly and the psychological sequelae; a “microincision” or a scar-free technique is the secondary aspect to be taken into account.

Dermal histomorphology in postbariatric patients: bilopancreatic diversion versus gastric bypass.

To the Editor: W e read with great interest the article recently published in your journal entitled ‘‘Changes in Dermal Histomorphology following surgical weight loss versus dietinduced weight loss in the morbidly obese patient’’ by Fearmonti et al. It is a relevant article from a scientific point of view comparing the histomorphological differences between patients who previously underwent gastric bypass and diet. As mentioned in the article, obesity is a widely spread disease, associated with a series of problems, both psychological and physical. This is the reason why morbidly obese people are more frequently addressing the treatment that ensures them the best results in terms of weight loss durability and entity: bariatric surgery. However, it is strictly linked to numerous sequelae, mainly an excess of skin necessitating body contouring operations. One problem plastic surgeons usually face when operating on bariatric patients is the relatively high wound complication rate. Despite many theories that have been postulated, an adequate explanation is still awaited. A multifactorial origin can be hypothesized. In recent articles by our team researchers, malnutrition, reduction of tissue protein, and hydroxyproline plus microscopic and macroscopic skin modifications were simultaneously involved in the aberrations of wound healing in bariatric patients. In particular, the histological modifications documented in these patients are probably partly responsible for such disturbances. As clearly stated by Fearmonti et al, the excess skin laxity in bariatric patients is due to adipose tissue resorption and remodeling. In addition, elastic fibers are responsible for retractile properties of the skin. In the study, they observed a mixture of normal and fragmented elastic fiber architecture. There was also a trend toward normal elastic fiber composition and mild inflammation, in association with an increased wound complication rate with regard to the nonsurgical group. Although no gross histological differences in the subcutaneous fat were revealed between the 2 groups, previous studies did. In particular, Levy et al showed small, poorly defined lobuled and tenuous fibrous connections to the deep dermal layer with a disorganized superficial fascial system in bariatric patients. Previously, examining cutaneous and subcutaneous tissue samples taken from the horizontal scar during abdominoplasty, our group documented anomalies of the dermal elastic (overgrowth, disarray, greater dimensions, serpiginous and polyfragmented aspect, occasional increment in number) and collagen (thickened, hyperosinophilic, and sclerodermoid) fibers. Moreover, modifications involving the subcutaneous tissue such as diffuse sclerosis, collapsed adipocytes, fibrous septum thickening, and pseudocysts were noted. Finally, in the extracellular matrix, there was evidence of persistent inflammation (Fig. 1). Our experience with body contouring for massive weight loss after bariatric surgery primarily involved biliopancreatic diversion, a mainly malabsorptive bariatric procedure. However, in a recent preliminary study we performed on postgastric bypass patients, a restrictive technique, patients revealed differences in terms of histological results: dimensional and numerical increase of elastic fibers, which appeared as irregular polyfragmented clusters (similar to elastic nevus), moderate hypereosinophilic collagen fibers having a great distance among them, fibroblasts incremented in number, hypertrophic adipocytes (miming lipoma) with septum thinness dividing them, and absolute absence of inflammation (Fig. 2). It is of great interest that differences are noticeable among patients undergoing different surgical bariatric techniques. Moreover, discordant results are also documented in patients after the same operation. In fact, in postgastric bypass patients, no substantial aberrations were evidenced by Fearmonti et al in the subcutaneous tissue. By contrast, mild inflammation was prevalent. This is probably due FIGURE 1. Skin histologic features of a postbariatric patient who had previously undergone biliopancreatic diversion. See text for details.

S-shaped brachioplasty: an effective technique to correct excess skin and fat of the upper arm.

675e S-Shaped Brachioplasty: An Effective Technique to Correct Excess Skin and Fat of the Upper Arm Sir: W read with interest the article by Aboul Wafa entitled “S-Shaped Brachioplasty: An Effective Technique to Correct Excess Skin and Fat of the Upper Arm”1 published recently in the Journal. In the article, the author proposes a procedure granting good contour and a fine noncontracting scar, resembling an S line located on the medial side. He also agreeably states that there is no universal technique addressing all arm contour deformities. In fact, attention must be paid in case of surgically induced massive weight loss patients, whose extreme tissue laxity deserves proper management. Our team, greatly experienced with bariatric patients, recently proposed an innovative, safe, and repeatable surgical technique, called “kris knife” brachioplasty, recalling the name of the Asian wavy blade.2 As demonstrated previously, the aforementioned category of patients is at higher risk for complications. Therefore, the safety and reliability of any body contouring techniques should be tested on them. In our study, on 33 patients, only six minor complications were recorded. According to our technique, preoperative skin markings are better defined by Steri-Strips (3M, St. Paul, Minn.), used to evaluate the skin excess to be removed. After infiltration with a solution of 200 cc of cold saline and 1 mg of adrenaline, liposuction is performed. Brachial incision is drawn so that the axis line, which will be the final scar after closure, results not in a straight line but in a sort of S-shaped, tension-free pattern. An ellipse is also drawn in the axilla, to correct ptosis and skin excess. By joining the lateral edge of the axillary ellipse with the brachial one, it is possible to create two V flaps (Figs. 1 and 2). Despite an apparently similar incision, a few points differ and deserve mention. It is mandatory to define in advance the amount of skin excess to be removed. In particular, we proposed the use of Steri-Strips, minimizing the risk of overresection or underresection. Moreover, to better deal with vertical and transverse redundancy, we opted for an elliptical resection in the axilla too. No scars are visible and a better lift effect is elicited. In addition, the brachial skin incision does not reach the anterior side of the arm; thus, the result can be easily hidden. Liposuction is agreeable, reducing skin retraction, facilitating tissue undermining, and minimizing nerves and lymphatic structure injury. Minimal undermining results in no dead space, no effusion, and proper healing. Moreover, brachial compressive dressings can minimize the accumulation of fluids and secretions. As a result, the incidence of seromas also decreases. Another very important element contributing to our low complication rate is probably the limited use of electrocautery, as we prefer a cold blade. In fact, this approach prevents tissue from necrotizing and ischemic action and possible drawbacks such as skin necrosis. Accurate hemostasis is mainly guaranteed by initial infiltration with adrenaline, allowing a bloodless operating field. The technique described in this communication has shown usefulness for correcting arm deformities in post–bariatric surgery patients, providing stable results. It is safe and reliable and linked to a low rate of complications, which have been minor. DOI: 10.1097/PRS.0b013e31829fe259

A technique to make spreader graft fixation easier

1. Lunatschek C, Schwipper V, Scheithauer M. Soft tissue reconstruction of the nose. Facial Plast Surg. 2011;27:249–257. 2. Yoshihiro S, Kenichi N, Toshiaki N. Reconstruction of larger nasal defects together with the nasal lining and the upper lip using the split-scalping forehead flap: A new technique. J Plast Reconstr Aesthet Surg. 2011;64:1108–1110. 3. Kheradmand AA, Garajei A, Motamedi MH. Nasal reconstruction: Experience using tissue expansion and forehead flap. J Oral Maxillofac Surg. 2011;69:1478–1484. 4. Fujioka M, Tasaki I, Yakabe A, Komuro S, Tanaka K. Reconstruction of velopharyngeal competence for composite palatomaxillary defect with a fibula osteocutaneous free flap. J Craniofac Surg. 2008;19:866–868. 5. Nakatsuka T, Harii K, Asato H, et al. Analytic review of 2372 free flap transfers for head and neck reconstruction following cancer resection. J Reconstr Microsurg. 2003;19:363–368; discussion 369. 6. Henry EL, Hart RD, Mark Taylor S, et al. Total nasal reconstruction: Use of a radial forearm free flap, titanium mesh, and a paramedian forehead flap. J Otolaryngol Head Neck Surg. 2010;39:697–702. 7. Tsiliboti D, Antonopoulos D, Spyropoulos K, Naxakis S, Goumas P. Total nasal reconstruction using a prelaminated free radial forearm flap and porous polyethylene implants. J Reconstr Microsurg. 2008;24:449–452. 8. Swartz WM, Banis JC, Newton ED, Ramasastry SS, Jones NF, Acland R. The osteocutaneous flap for mandibular and maxillofacial reconstruction. Plast Reconstr Surg. 1986;77:530– 545. 9. Koshima I, Tsutsui T, Nanba Y, Takahashi Y, Akisada K. Free radial forearm osteocutaneous perforator flap for reconstruction of total nasal defects. J Reconstr Microsurg. 2002;18: 585–588; discussion 589–590. 10. Keck T, Lindemann J, Kühnemann S, Sigg O. Healing of composite chondrocutaneous auricular grafts covered by skin flaps in nasal reconstructive surgery. Laryngoscope 2003; 113:248–253. 11. Menick FJ, Salibian A. Microvascular repair of heminasal, subtotal, and total nasal defects with a folded radial forearm flap and a full-thickness forehead flap. Plast Reconstr Surg. 2011;127:637–651. 12. Burget GC, Menick FJ. Nasal support and lining: The marriage of beauty and blood supply. Plast Reconstr Surg. 1989; 84:189–202. 13. Walton RL, Burget GC, Beahm EK. Microsurgical reconstruction of the nasal lining. Plast Reconstr Surg. 2005;115: 1813–1829. 14. Atiyeh BS, Hussein MM, Tayim AM, Zaatari AM, Fakih RR. Early microvascular reconstruction of Gustilo type III-C lower extremity wound: Case report. Scand J Plast Reconstr Hand Surg. 1997;31:351–355. 15. Pho RW. Free vascularised fibular transplant for replacement of the lower radius. J Bone Joint Surg Br. 1979;61:362–365.

Longitudinal Ultrasound Study of Breast Implant Rupture Over a Six-Year Interval.

BackgroundSilicone gel–filled implants as opposed to saline-filled breast implants are the most commonly used breast implants in Europe, and this has recently also become the case in the United States. Modern implants have a multiple layer silicone shell and high to very high levels of cohesive silicone gel inside. Although breast magnetic resonance imaging is at present considered the gold standard imaging method for breast implant rupture detection, breast ultrasound (US) imaging is still the first-step investigation in Europe. The aim of this study was to verify whether or not the stepladder sign at US is still associated to intracapsular rupture among the last generation silicone breast implant. Materials and MethodsIn this study, 156 patients presenting for breast augmentation, mastopexy with implants and breast reconstruction for a total number of 303 breast implants inserted were enrolled.A preoperative breast ultrasonography was performed, and patients underwent a routine US scan every 6 months for 24 months to evaluate the implant status. A final US evaluation 6 years after implantation was also performed. ResultsStepladder signs were seen at 6 years in 170 implants (56%) of the examined implants at US scan, and only 2 implants showed signs of possible rupture because of severe distortion of the implant profile with or without external silicone collection. A third ruptured implant was detected at magnetic resonance imaging by the presence of breach of the shell at the posterior surface of the implant with small external silicon collection and was eventually confirmed at surgery. Therefore, the overall rupture rate found at the United States at 6 years was about 1% (3 of 303 implants).According to our findings, the stepladder sign at the United States is no longer associated to intracapsular rupture. ConclusionsPlastic surgeons, patients, and financial departments of hospitals would also be delighted to know that surgeons should not take patients back to theater for implant explantation when aging signs are not associated with a visible breach of the implant shell or external silicone collections.

A Simple Technique for an Optimal Aesthetic Result after Drain Removal

We read with interest the article by Samy Sawan [1] entitled A Painless Technique for Closing Defects After Drain Removal recently published in your journal. We want to integrate it by proposing a personal technique as painless as the previous one that we consider even more satisfactory to ensure an optimal aesthetic result. In our opinion, to prevent blood or fluid accumulation, it is better to choose as the drain’s point of exit the lower apex for vertical wounds and the end of the suture for horizontal wounds. As already pointed out by Sawan [1], the difference between a well-healed scar and a defect resulting from drain removal healed by secondary intention can be cosmetically remarkable. Furthermore, this difference is even more evident when a perfectly healed scar obtained with a continuous intradermal suture is compared with a drainage hole closed by interrupted knots or healed by secondary intention. Our technique can be considered another simple method for closing the defect that may result after drain removal. It is performed by using a continuous intradermal suture for the entire incision including the area in which the drain is placed. In that area, the thread is neither pulled nor tied (Fig. 1). The free end of the thread is secured by steristrips, and the drain position is maintained by an anchoring suture (Figs. 2, 3). When necessary, the drain is removed, the steristrips are peeled off, and the end of the intradermal suture is pulled (Fig. 4) and secured with new steristrips. The procedure is quick and painless, resulting in an immediate optimal appearance of the wound. The described technique also can be performed when the drain is placed away from the wound to avoid the risk of wound infection. It is required only to pull the free ends of the continuous suture after drain removal (Fig. 5) and to secure both of them by steristrips. We did not experience any cases of clotting or blocking of the drains using this

Fat grafting as adjunct refinement procedure in craniosynostosis management

parison with other materials and devices, such as excellent biocompatibility, minimal inflammatory reactions, easy handling and shaping, reasonable stability, and versatility. Furthermore, they produce minimal imaging artifact on magnetic resonance and CT imaging. Appropriate complex 3D reconstruction of craniofacial defects in nonYload-bearing areas can be obtained. In some cases, titanium micromesh can be used in combination with bone grafts to improve the aesthetic result of these craniofacial reconstructions. However, small bony fragments may be attached to the mesh by lag screwing the bone to the mesh, thus reducing the need for bone graft, as in our case. An important feature of titanium mesh is the low susceptibility to infection, even when in direct contact with paranasal sinuses. This makes it an ideal material for frontal sinus restoration. Our clinical report confirms literature findings, showing a good frontal reconstruction after trauma surgery. In conclusion, titanium mesh may provide excellent frontal contour after severely comminuted anterior wall fractures. No complications were observed, confirming that mesh could be still considered an ideal material for craniofacial defects reconstruction.