Francesco D’Andrea

Changing the Metabolic Profile by Large-Volume Liposuction: A Clinical Study Conducted with 123 Obese Women

Adipose tissue is a metabolically active tissue. The hypertrophic fat cells of obese patients produce increased quantities of leptin and tumor necrosis factor-α (TNF-α) and are less sensitive to insulin. This study aimed to determine whether aspirating large amounts of these subcutaneous fat cells by large-volume liposuction (LVL), could change the metabolic profile in 123 obese women. All the patients had a main central body fat distribution (waist–hip ratio, 0.91±0.01) and a body mass index of 32.8 ± 0.8 kg/m). They were studied for 90 days after LVL to determine their changes in insulin sensitivity, resting metabolic rate, serum adipocytokines, and inflammatory marker levels. During 3 months of follow-up evaluation, LVL resulted in a significantly improved insulin sensitivity, resting metabolic rate, serum adipocytokines, and inflammatory marker levels. Such parameters correlate with a decrease in fat mass and waist–hip ratio. Interestingly, no significant changes were seen between the first (21 days) and second (90 days) metabolic determinations after LVL. However, these findings, confirm other preliminary data published previously, and could change the actual role of LVL in the multidisciplinary treatment of obesity.

Self-Perception and Self-Esteem of Patients Seeking Cosmetic Surgery

Cosmetic surgery represents a particular application of plastic surgery, in which the operative competence of the discipline is focused not on the correction of pathological disorders, but on the correction of some morphologic traits not accepted by the patients, or not adherent with the aesthetic canons of the time, although they are absolutely compatible with the norm. As a consequence, cosmetic surgery recognizes subjective indications. According to a particular literature on the subject, patients seeking these interventions would live a dualism between (their own) body image and inner self-image. Very psychotic case histories would come out of this. A base psychological approach adopted by the surgeon, competent both in the surgical and the psychological level, is absolutely needed. In this study, the psychological features of patients seeking cosmetic surgery were explored in an attempt to define common profiles or prevalent characteristics, and to isolate major psychiatric disorders. Patient self-esteem and physical self-perception also were investigated.

Platelet-Rich Plasma Mixed-Fat Grafting: A Reasonable Prosurvival Strategy for Fat GraftS?

BackgroundOne of the most interesting developments in practical applications of fat grafting in recent years is the use of prosurvival strategies to improve maintenance of volume. Platelet-rich plasma (PRP) plays a decisive role in the repair and regeneration of different tissues via the activation and secretion of a great variety of growth factors and other cytokines stored in the alpha-granules of the platelets. This review aimed to assess the efficacy of PRP mixed-fat grafting as a prosurvival strategy for fat grafts.MethodsOnline searches of the Cochrane Library and MEDLINE until January 2014 were conducted. The review included studies with at least one clinical end point in which the effect of PRP on the absorption and viability of the fat graft could be assessed.ResultsThe review comprised 6 preclinical studies with a control group and 9 clinical studies of humans. It also included comparative studies performed with other prosurvival strategies for fat grafts, such as combination with the stromal vascular fraction and second-generation PRP, also called “platelet-rich fibrin.” The results indicate that PRP may have a dose-dependent positive effect on fat grafts and suggest low complication rates.ConclusionsThe development of new growth factor delivery systems or cell therapies to enrich fat grafts is an area that merits further research.No Level AssignedThis 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 www.springer.com/00266.

Poland Syndrome: Description of an Atypical Variant

Poland syndrome comprises a unilateral absence of the large pectoral muscle, ipsilateral symbrachydactyly, and occasionally other malformations of the anterior chest wall and breast. The condition is more frequent among males, and usually occurs on the right hemithorax in the unilateral form. The syndrome is believed to be caused by a genetic disorder that reduces the embryonal circulation in the interior chest artery: the stronger the interaction, the more severe the pathology. This article analyzes an unusual pathologic case in which the 17-year-old patient lacked the large pectoral muscle on the left side, but showed no arterial alteration. This case raises questions as to the true pathogenesis of this syndrome.

Histologic Effects of External Ultrasound-Assisted Lipectomy on Adipose Tissue

This study aimed to observe the effects of ultrasound waves at different frequencies on abdominal fat tissue. External ultrasound-assisted lipectomy (XUAL) via both histologic and immunohistochemic examinations was used to assess adipose tissue alterations, including cells and collagenic fibers. The results, at the immunofluorescence level, show that ultrasound used at 1 MHz with a potency of 3 W resulted in no alterations or only limited cell destruction with collagen fibers intact. In contrast, when the ultrasound was 2 and especially 3 MHz, adipocyte alterations usually were evident. Massive adipose tissue destruction, confirmed using Oil red-O staining, was observed. In addition, at the immunofluorescence level, diffuse collagen fiber retraction was detected. This was particularly evident in comparisons with biopsies of intact control samples, which showed normal adipose tissue and intact collagen fibers. The results obtained using morphologic techniques, which do not allow fixation artifacts and include collagen observations, demonstrate that with the XUAL technique, ultrasound at 1 MHz does not induce cellular alterations. In contrast, both 2- and 3-MHz frequencies are capable of causing complete fat tissue disruption, including destruction of adipose cells and collagenic fibers.

Stahl syndrome in clinical practice.

Stahl syndrome, known also as “Satiro’s ear”, is a deformation of the auricle described in the nineteeth century by Stahl who included it in a classification of various deformities of ear:-Helix transversus spleniformis-Crus anthelicis trifurcata-Crus superior turgidumAt present Stahl’s ear is included in the second group for the abnonnal cartilaginous pleat which extends from the Crus anthelix to the edge of elix deforming in this way the regular curvature of ear and amplifying the triangular hole. It’s frequently associated to other aesthetic deformities of the auricle itself and above all among oriental peoples; the pathogenetic origin of this deformation has to be connected with an hereditary, familial character confirmed by the diffusion of this deformation among the members of the same family, reaching its highest expression in identical twins where its manifestation is about at seventy-five percent. Besides the hereditary-familial hypothesis, we find a second hypothesis according to which the cartilaginous deformity is connected with an altered growth of an instrinsic muscle of ear, the transverse muscle [1,4]. The solution of the problem is surgical, through the Chongcet technique [9], modified and applied in the post-operating using particular remedies.

Blepharoplasty and Otoplasty: Comparative Sedation with Remifentanil,Propofol, and Midazolam

Three different methods of sedation or sedoanalgesia using remifentanil, Propofol, or midazolam to increase intra- and postoperative comfort and to reduce neuroendocrine stress in patients who had undergone typical ambulatory cosmetic surgery under local anesthesia were studied. A sample of 90 patients who underwent upper and lower eyelid blepharoplasty to correct baggy eyelids or otoplasty to correct protruding ears was selected according to standard criteria for the study. Remifentanil provided the best tolerability profile and the most effective perioperative pain control among the substances studied, demonstrating it to be a valid drug for modern sedoanalgesia aimed at increasing the well-being of patients undergoing ambulatory cosmetic surgery.

Endoscopic reconstruction of partial mastectomy defects using latissimus dorsi muscle flap without causing scars on the back.

BackgroundResults obtained with breast-conserving therapy are not always satisfactory. Reconstruction with a pure latissimus dorsi muscle flap is a useful option. The techniques described for endoscopic dissection of the flap create several scars on the back. As a result, they do not improve on the open approach, which causes a horizontal scar at the level of the bra strap. The authors’ technique avoids all scars on the back using a single incision in the highest folds of the axilla, which also is used for the sentinel node biopsy or lymphadectomy and quadrantectomy.MethodsThe study was performed with 23 patients. The tumor was extracted via a clockwise downward periareolar incision and via another incision in a fold of the axilla. Through this axillary incision, the sentinel lymph node biopsy or lymphadectomy was performed, and the external part of the latissimus dorsi muscle was harvested endoscopically for the reconstruction.ResultsBoth the medical team and the patients reported high satisfaction with the aesthetic and functional results due to the preservation of the breast shape and the absence of any scarring on the back.ConclusionEndoscopy-assisted techniques make either three small scars on the back or one long scar, with the muscle sectioned distally, or a vertical incision in the midaxillary line, which may form a hypertrophic or keloid scar. The authors’ approach avoids the creation of these scars on the back because the endoscopy and the distal sectioning of the muscle flap are performed through the single axillary incision.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Endoscopic management of osteomas of the forehead

Transcutaneous resection is the most common technique for the removal of facial lesions. In recent years, endoscopic techniques have been used in aesthetic surgery of the face, and have achieved good results. We know of few descriptions of this approach. We describe 9 patients who had endoscopic removal of osteomas of the forehead through a single 3 cm incision of the midline, which was concealed 2 cm behind the hairline.

Histologic Analysis of Zafirlukast's Effect on Capsule Formation Around Silicone Implants: some considerations.

We have read with profound interest the article by Bastos and colleagues entitled Histologic Analysis of Zafirlukast’s Effect on Capsule Formation Around Silicone Implants. We have truly enjoyed this study because it focuses on the very important issue of ongoing research toward pharmacologic therapy for the treatment of periprosthetic capsule contracture. The latter has an incidence in the range of 0.5% to 50% [3]. Despite persistent clinical and laboratory investigation, to date, no solution has been developed to solve or prevent this problem. For several years, many investigators have evaluated the use of antileukotriene drugs, which could be effective in the treatment of periprosthetic capsule contracture. Unfortunately, their use still is not evidence based and has no biochemical or biomolecular support. At the same time, the use of drugs with no specific indication is strongly criticized and discouraged for moral, medical, and legal reasons [6]. Investigations into a molecular basis to justify the use of CysLT antagonists have evaluated the potential modification of cysLTR expression in human contracted capsules [2]. The conclusions of the study by Bastos and colleagues are supported by several clinical studies, which are reviewed in their studies. However, the authors failed to review the animal models proposed to date (rabbits, pigs, rats). Although these animal studies are very accurate, they have disadvantages in terms of reproducibility, standardization, and of course translation to the human setting [1, 4, 5, 7]. In all the experiments, the authors tried to induce contracture through different methods (bacterial contamination, fibrin glue), stressing the fundamental cellular and biochemical difference between the contracted capsule and the physiologic periprosthetic capsule. Unfortunately, Bastos and colleagues used an animal model that, in our opinion, is not accurate with respect to a contracted capsule. Indeed, the authors did not induce capsular contracture in their animal model. With the fundamental differences between contracted and uncontracted capsules in mind, the immunohistochemical and histopathology analysis was carried out on periprosthetic physiologic capsules. Thus, the reduced presence of inflammatory cells and the reduced vascular density in the experimental groups (explained by the intrinsic antiinflammatory activity of zafirlukast) cannot definitely be proof of a therapeutic effect of the drug in reducing or preventing capsular contracture. Moreover, it is unclear why the authors decided to remove the prostheses 90 days after the implantation to analyze the capsules, assuming them to be contracted. Despite these criticisms, we thank Bastos and colleagues for focusing their attention on a very serious problem in plastic surgery and for proposing a histologic and immunohistochemical analysis of the development of capsular contraction. We hope that many other investigators will undertake the same approach in fighting against this frustrating problem that afflicts patients, plastic surgeons, and manufacturers.