Ernesto Maria Buccheri

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.

Outcome Evaluation after 2023 Nipple-Sparing Mastectomies: Our Experience

Background: Although quadrantectomy and lumpectomy help diminish the psychological and physical devastation inflicted, mastectomy is still elected in 20 to 30 percent of breast cancers. Although initially inciting controversy over heightened risk of local recurrences, recent studies maintain that nipple-sparing mastectomy can be used in any patient qualifying for total mastectomy and also improves aesthetic and psychologic outcomes. The manner in which mastectomy influences reconstructive implant outcomes has been documented by several groups. This report details the authors’ experience performing nipple-sparing mastectomy with immediate implant-based breast reconstruction, focusing attention on patient characteristics and aspects of surgical mastectomy that influence reconstruction outcomes. The aim of the study was to examine various issues, such as surgical access, mode of tissue dissection, and flap thickness, clearly linked to development of complications and poor results. Methods: A retrospective study was conducted, analyzing patients with breast cancer. An external three-surgeon panel served to generate average scores for predefined parameters. Based on total scores, outcomes were designated excellent, good, moderate, or poor. Results: The authors’ cohort included 1647 patients. Overall, 2023 nipple-sparing mastectomies were performed, including bilateral procedures in 376 patients. After a minimum follow-up period of 12 months, the authors’ cohort was stratified by scored outcomes. Significant impact of body mass index, skin incision, flap thickness, and grade of ptosis has been demonstrated. Conclusions: The authors’ data suggest that proper patient selection and well-executed operations are mandatory to limit complications. They also indicate that aesthetic outcome is clearly dependent on surgical proficiency and some patient characteristics. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

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.

Modified Punch Technique for Incomplete Earlobe Cleft Repair

The use of ear piercing currently is a common practice in different cultures. Among the several associated complications comprising infections and dermatitis, the complete and incomplete earlobe clefts are those that for aesthetic and functional reasons (use of the same hole is impossible) require a surgical correction. Many articles describe the repair for complete [17,1113] and incomplete earlobe cleft [3,810]. The choice of technique depends on the cleft dimension and position, and is dictated by the need for a good quality and the least visible scar possible. As such, although it seems adequate and acceptable to repair nearly complete earlobe clefts simply by producing a complete one and repairing the defect with any of the commonly used techniques, this practice turns out to be excessive and complex for medium or minimally elongated incomplete earlobe clefts. Among the techniques described for such deformities, we found the punch technique described by Hersh [9] to be a good option for obtaining a minimally visible and good-quality scar. An important step in the use of the punch technique is proper alignment of the punch device. We modified Hershs technique using a guide to prevent the possible unequal, tangential excision of the clefts epithelial lining, obviating the need for a second pass should residual shards of epithelium still be present.

The ring stitches, a useful method to manage vaginal stent in male-to-female transsexuals

In male-to-female transsexuals, a cavity has to be created between the urethra, prostate, seminal vesicles and rectum to construct a neo-vagina. This cavity has to be lined with epithelium and various methods to achieve this goal have been described. In our department, vagina construction in male-to-female transsexuals is performed by penile and scrotal skin flap inversion with preservation of the glans penis as a clitoris. All patients operated on for vagina construction need insertion of a vaginal stent, a vibrator or a sheet of foam rubber rolled around a plastic tube, to achieve an adequate dilatation and to prevent vagina stenosis, in the early postoperative period. Stenosis of the vagina occurs in up to 36% of cases and it may occur due to inadequate dilatation or no dilatation at all, loss of the stent, occult bleeding, infection and rectovaginal fistula, which leads to collapse and retraction of flaps

The Balcony Technique of Breast Augmentation and Inverted-T Mastopexy With an Inferior Dermoglandular Flap

Background Optimal breast augmentation-mastopexy involves a reliable technique, fast recovery, minimal complications, and aesthetic results that are excellent and enduring. Objectives The authors sought to determine whether the balcony technique of augmentation-mastopexy was safe and yielded satisfactory long-term outcomes in patients with breast ptosis and hypoplasia. Methods The authors conducted a retrospective review of 207 patients who underwent subglandular augmentation and inverted-T mastopexy with a customized Wise keyhole resection pattern and an inferior flap. Patient satisfaction was assessed anonymously on a visual analog scale via a questionnaire administered 4 years postoperatively. Results A total of 182 women received follow-up for 48 months and were included in statistical analyses. High levels of satisfaction were determined using Fischer exact test for breast shape, size, and symmetry, but not for other items, such as scar appearance, body perception, or self-esteem. The most common complications were Baker II capsular contracture and wound dehiscence. No patient experienced nipple loss or skin flap necrosis. Conclusions The results of this long-term analysis demonstrate that the balcony technique of augmentation-mastopexy is suitable for patients with breast ptosis and hypoplasia. Level of Evidence 4.

Hemostasis in skin surgery.

Hemostasis is an essential but sometimes tedious and timeconsuming aspect of cutaneous surgery. The importance of achieving hemostasis is stressed in numerous textbooks on cutaneous surgery, but details on the efficient attainment of that goal are not [1, 3]. However, Boyer [1] described hemostasis assisted by two skin hooks. The surgical assistant uses the two hooks in unison to provide broad visualization of the wound bed and undermined skin flap, which is reflected for complete exposure. Hafner and Hohenleutner [2] proposed a flat plastic cylinder from a disposable syringe, which effectively achieved hemostasis in carbon dioxide laser surgery. They found that the pressure provided in this way was particularly useful in achieving a bloodless operation field. In 1983, Wheeland, Gilmore, and Morgan [4] described basically the same technique using a nonconductive acryl ring. Sharquie and Al-Rawi [5] reported on a series of prepared stainless steel rings of different shapes and sizes that they used successfully to control profuse bleeding in different situations of dermatologic surgery. We suggest using the eye ring of any available instrument in the surgical set (e.g., scissors, artery forceps, mosquito) (Fig. 1). This technique stops or reduces the bleeding from the skin by simple pressure around the surgical field. This helps the surgeon evaluate the source of the bleeding and thus perform hemostasis only when and where necessary. Another advantage of this method is the ability it offers to handle the eye ring with one hand, pushing and releasing it completely or just on one side, and to sponge the tissues and ordinarily obtain hemostasis with the other hand. In summary, we describe a safe, simple, reproducible, and inexpensive technique for achieving hemostasis in skin surgery that require a minimal learning curve and instrumentation.

A tie-over dressing for the ear skin graft.

Dermatologic surgery of skin tumors on the ear often is followed by local flaps and partial cartilage amputation to achieve closure of the defect that maintains the shape of the ear. Excisional biopsy surgery does not require a cartilaginous excision, and when the perichondrium has been spared during surgery, the defect can be skin grafted. The natural concavities and convexities of the ear often make preparation of tie-over dressings difficult, resulting in reduced adhesion of the graft and poor outcomes. To maximize tissue adhesion between the graft and the threedimensional anatomy of the auricular cartilage, we propose suturing the graft with ‘‘U-shaped stitches’’ from the opposite side of the ear to be grafted (Fig. 1).

A trick for dressing after liposuction.

Liposuction has become the most common aesthetic pro-cedure worldwide for excess fat removal [3] thanks to itsrelative safety and ease of performance after appropriatetraining. Over the years, numerous changes and innova-tions have improved this procedure [1]. Several papersfrom the literature stress postoperative care using com-pression garments or other compression devices to mini-mize postoperative bleeding and edema.Mladick [3] has modernized the concept of postopera-tive massage to reduce edema through the application ofsequential compression devices during the postoperativeperiod. This approach requires that the patient use thesequential compression devices as much as possible, atleast at night, with firm stockings used during the day for2 months [2].In our department, we perform tumescent liposuction,which frequently requires locoregional anesthesia, seda-tion, or general anesthesia. For this reason we often arefaced with the well-known problem of putting on thedressing garments when the patient is not collaborative atthe end of the surgery.We propose a simple and reliable method for putting onthe dressing garments easily just at the end of the surgery.We suggest using nonsterile Vaseline cream, appliedover the skin area, to facilitate sliding of the garment andcorrect positioning of the compression device.We use the Caromed Lycra garment (Mentor, Rome,Italy). This type of dressing garment is easily washable andtherefore reusable. Moreover, we have not observed anyimpairment of the garment’s mechanical strength causedby the Vaseline cream.Although we always suture the surgical incision with 4/0nylon, patients sometimes have some bleeding. Even onthese occasions, they have never reported discomfort orproblems associated with the emolience of blood andVaseline at the beginning of the postoperative period. Thistrick, based on our medical practice, is safe and has verygood patient compliance.References