Francesco Farace

Ultrastructural anatomy of contracted capsules around textured implants in augmented breasts

The development of a capsule around an implant is part of the physiological response to a foreign body. Capsular contracture is the most specific and frustrating complication of augmentation mammaplasty, and a lot of studies have been devoted to it. The aim of the current study is to examine the fine architecture of the contracted capsule around textured implants in humans. Eight capsules from augmented and contracted breasts with gel-filled, textured-surface silicone implants were studied after standard preparation for light and scanning electron microscopy, and after partial digestion in sodium hydroxide. Two capsules from contracted breasts around smooth implants and two noncontracted capsules around textured implants were prepared and studied in the same fashion as controls. A multilayer structure of the contracted capsule was seen, and the architecture of the various layers is described. The inner surface presents irregular craterlike depressions. The arrangement of collagen fibers varies in capsule layers. The effect of a textured-surface implant on the mechanism of capsule contraction based on the observed capsular architecture is that only part of the capsule is effective mechanically in producing a contracting force. A thin vascular layer was identified near the inner surface in contracted capsules around textured implants, and the authors’ think that this layer is probably the key structure in the histological development and growth of the capsule.

Anterior scoring of the upper helical cartilage as a refinement in aesthetic otoplasty

BackgroundAnterior scoring with the use of simple or dedicated instruments, toothed forceps, endoscopic carpal tunnel release instruments, and needles has been described previously. The upper third of the ear easily maintains the original shape because memory and elasticity are stronger than in the middle or the lower part of the ear. This report describes a further refinement to the Chong-Chet anterior scoring technique, consisting of anterior scoring of the upper helical cartilage to correct the helical radix upper prominence.MethodsA retrospective study analyzed 20 surgeries for prominent ears. All the subjects had undergone otoplasty softening the helix.ResultsThere were no residual ear prominence/upper third prominence or cartilage irregularities at the 1-year follow-up evaluation. Anterior auricular cartilage scoring is an effective technique for controlling the degree and position of the antihelical fold. Furthermore, the upper third of the pinna seems to have a stronger memory than the middle third. To prevent this late complication the authors routinely perform anterior scoring up to the helix, weakening that cartilage usually untouched with other procedures.ConclusionThis refinement, in combination with other procedures is safe, easy, and fast, giving reproducible and good aesthetic results.

The arrow flap for nipple reconstruction: Long term results

Figure 1 The modified arrow flap technique. Nipple Areola Complex reconstruction is the final step in breast reconstruction. Although it could be considered a minor surgical procedure, it has an important impact on the whole procedure. Today, above others, local flap-based techniques are the most popular one. Commonly, the reconstructed nipple flattens over time: as a consequence, nipple projection is the critical parameter to evaluate nipple reconstruction during the followup. Despite a lot of publications on this subject, there is a lack of evidence-based data. Momeni, in 2008, from a total of 10,476 published original articles in four plastic surgery journals over a 16-year period, identified only one RCT and one CCT addressing nipple reconstruction. The only RCT found by Momeni was our modification of Thomas technique, the arrow flap, that proved to have a higher residual projection than the modified star flap. In this paper, we report a prospective observational longitudinal study in order to assess if residual projection of arrow flaps is stable over time. Forty women, operated on for mammary reconstruction after breast cancer mastectomy, were enrolled for this study. All patients were informed about the study and their consent obtained. All patients underwent nipple reconstruction using the modified arrow flap. The operative technique was the same as described in the original article. The nipple is considered as a cylinder (Figure 1) with a base diameter of D and a height H. It can be unfolded in the plane to a circle of diameter D, representing its top, with a rectangle, that measures pi D H, attached. The rectangle height is 150% of the final required nipple projection and a triangular area above the circle is added. This area will be de-epithelised before flap raising. The flap pedicle is centrally located, on the opposite side. One extremity of the rectangle will be marked as an arrow point, the other side as an arrow tail; the arrow tail will be de-epithelised; the flap is harvested with a little superficial subcutaneous fat to preserve sub-dermal blood supply. The

Is mammary reconstruction with the anatomical Becker expander a simple procedure? Complications and hidden problems leading to secondary surgical procedures: a follow-up study.

Debate over the role of Becker expander implants (BEIs) in breast reconstruction is still ongoing. There are no clear indications for BEI use. The main indications for BEI use are one-stage breast reconstruction procedure and congenital breast deformities correction, due to the postoperative ability to vary BEI volume. Recent studies showed that BEIs were removed 5 years after mammary reconstruction in 68% of operated patients. This entails a further surgical procedure. BEIs should not, therefore, be regarded as one-stage prostheses. We performed a case-series study of breast reconstructions with anatomically shaped Becker-35™ implants, in order to highlight complications and to flag unseen problems, which might entail a second surgical procedure. A total of 229 patients, reconstructed from 2005 to 2010, were enrolled in this study. Data relating to implant type, volume, mean operative time and complications were recorded. All the patients underwent the same surgical procedure. The minimum follow-up period was 18 months. During a 5-year follow-up, 99 patients required secondary surgery to correct their complications or sequelae; 46 of them underwent BEI removal within 2 years of implantation, 56 within 3 years, 65 within 4 years and 74 within 5 years. Our findings show that two different sorts of complications can arise with these devices, leading to premature implant removal, one common to any breast implant and one peculiar to BEIs. The Becker implant is a permanent expander. Surgeons must, therefore, be aware that, once positioned, the Becker expander cannot be adjusted at a later date, as in two-stage expander/prosthesis reconstructions for instance. Surgeons must have a clear understanding of possible BEI complications in order to be able to discuss these with their patients. Therefore, only surgeons experienced in breast reconstruction should use BEIs.

A scanning electron microscope study and statistical analysis of adipocyte morphology in lipofilling: comparing the effects of harvesting and purification procedures with 2 different techniques.

BackgroundThe aim of this study was to evaluate the effects on adipocyte morphology of 2 techniques of fat harvesting and of fat purification in lipofilling, considering that the number of viable healthy adipocytes is important in fat survival in recipient areas of lipofilling. MethodsFat harvesting was performed in 10 female patients from flanks, on one side with a 2-mm Coleman cannula and on the other side with a 3-mm Mercedes cannula. Thirty milliliter of fat tissue from each side was collected and divided into three 10 mL syringes: A, B, and C. The fat inside syringe A was left untreated, the fat in syringe B underwent simple sedimentation, and the fat inside syringe C underwent centrifugation at 3000 rpm for 3 minutes. Each fat graft specimen was processed for examination under low-vacuum scanning electron microscope. Diameter (&mgr;) and number of adipocytes per square millimeter and number of altered adipocytes per square millimeter were evaluated. Untreated specimens harvested with the 2 different techniques were first compared, then sedimented versus centrifuged specimens harvested with the same technique were compared. Statistical analysis was performed using Wilcoxon signed rank test. ResultsThe number of adipocytes per square millimeter was statistically higher in specimens harvested with the 3-mm Mercedes cannula (P = 0.0310). The number of altered cells was statistically higher in centrifuged specimens than in sedimented ones using both methods of fat harvesting (P = 0.0080) with a 2-mm Coleman cannula and (P = 0.0050) with a 3-mm Mercedes cannula. Alterations in adipocyte morphology consisted in wrinkling of the membrane, opening of pore with leakage of oily material, reduction of cellular diameter, and total collapse of the cellular membrane. ConclusionsFat harvesting by a 3-mm cannula results in a higher number of adipocytes and centrifugation of the harvested fat results in a higher number of morphologic altered cells than sedimentation.

A new contrast agent for radiological and dissection studies of the arterial network of anatomic specimens

PurposeThe aim of the present study is to propose a new contrast agent that can be easily applied both to CT and dissection studies to replace lead oxide based formulas for comparative anatomical analyses of the vascularisation of cadaveric specimens.MethodsThe infusion material was an epoxy resin, especially modified by the addition of barium sulphate to enhance its radiopacity. The final copolymer was toxicologically safe. To test the properties of the new material, several cadaveric limb injections were performed. The injected specimens were both CT scanned to perform 3D vascular reconstructions and dissected by anatomical planes.ResultsThere was a perfect correspondence between the image studies and the dissections: even the smallest arteries on CT scan can be identified on the specimen and vice versa. The properties of the epoxy allowed an easy dissection of the vessels.ConclusionsThe new imaging techniques available today, such as CT scan, can evaluate the vascular anatomy in high detail and 3D. This new contrast agent may help realising detailed vascular studies comparing CT scan results with anatomical dissections. Moreover, it may be useful for teaching surgical skills in the field of plastic surgery.

A Case Series Study on Complications After Breast Augmentation with Macrolane

BackgroundThe use of Macrolane™ seems to have several advantages compared to the other standard methods for breast augmentation: it is faster, less invasive, and requires only local anesthesia. Nevertheless, various complications associated with the use of Macrolane™ have been described, e.g., encapsulated lumps in breast tissue, infection, and parenchymal fibrosis. We report the results of our case series study on the clinical and imaging evaluations of patients who came to our attention after breast augmentation with Macrolane™ injection and evaluate the effect of this treatment on breast cancer screening procedures.MethodsBetween September 2009 and July 2010, seven patients, treated elsewhere with intramammary Macrolane™ injection for cosmetic purposes, presented to our institution complaining of breast pain. In all patients, Macrolane™ had been injected under local anesthesia in the retromammary space through a surgical cannula.ResultsOn mammography, nodules appeared as gross lobulated radiopacities with polycyclic contours. On breast ultrasound, the nodules showed hypo-anaechogenic cystlike features. In all cases, image analysis by the radiologist was hindered by the presence of the implanted substance, which did not allow the complete inspection of the whole breast tissue.ConclusionsFrom our experience, although safe in other areas, injection of Macrolane™ into breast tissue cannot be recommended at this time. Our study, along with other reports, supports the need to start a clinical trial on the use of injectable fillers in the breast to validate their safety and effectiveness.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.

COMPARTMENT SYNDROME AT THE FIBULA FLAP'S DONOR SITE AND SALVAGE BY ANEROLATERAL THIGH CHIMERIC FLAP

We report a challenging case of chimeric anterolateralthigh flap reconstruction to cover peroneus longus andcalcaneal tendons exposure as a consequence of a donorsite compartment syndrome after fibula flap harvesting.A 61-year-old patient was referred to the Maxillo-Fa-cial Unit for a squamous cell carcinoma (T4-N3-M0) ofthe buccal mucosa involving the inferior premolar alveo-lar ridge. The patient underwent right emi-mandibulec-tomy, tumor en-bloc excision, and bilateral radical neckdissection. An immediate reconstruction was performedwith a free osteocutaneous fibula flap with two differentskin paddles. The first one was used to reconstruct theskin defect and the second one to reconstruct the mucosaldefect. The donor site was closed by direct suture undertension. A suction drain was positioned.The initial postoperative period was uneventful. Onthe fifth postoperative day, the negative-pressure drainagewas pulled out. A week after surgery, the donor site wasedematous and dark brown fluid flowed from the wound.Only mild pain occurred with active or passive movementof the toes. During the second week after surgery, theswelling and dark fluid secretion from the donor sitebecame more obvious. A necrotic area appeared in thecontext of donor site closure; this area rapidly increasedits dimensions in a few days. The only clinical symptomstill was a mild pain. Two weeks from surgery, the clini-cal diagnosis was compartment syndrome, due to exces-sive tension.This compartment syndrome led to a large loss ofskin and muscles of the lateral compartment of the legwith peroneus longus tendon and part of calcaneal tendonexposure (Fig. 1), then the patient was referred to ourPlastic Surgery Unit in order to plan a repair.After a surgical debridement, a two week of VacuumAssisted Closure

A Technical Refinement to Prevent Supratip Deformity in Aesthetic Rhinoplasty: “The Trapezoid Peak”

BackgroundThe relationship between appropriate caudal dorsum resection and supratip deformity or inadequate tip projection currently is clear. Correct quadrangular cartilage management seems to have a basic role in the final tip aspect after aesthetic rhinoplasty.MethodsPrimary aesthetic rhinoplasty was performed for 38 Caucasian patients. A septal refinement was used for patients requiring extra tip support and not requiring grafts.ResultsThe minimum follow-up period was 1 year. No supratip deformity was noted after surgery. The tip and midvault had adequate projection.ConclusionsThe described maneuver sustains the alar cartilage without sutures, preventing supratip deformity, sustaining soft tissues, and avoiding loss of tip projection.

Reply: An original technique for securing the inflation port in Becker implant-based breast reconstruction.

Reply: An Original Technique for Securing the Inflation Port in Becker Implant–Based Breast Reconstruction Sir: We read carefully and with great interest the original technique described by Dr. Demiri and colleagues for securing the inflation port in Becker implant breast reconstruction. Port displacement, or flip-over, is, in our findings, the most common complication following Becker implant mammary reconstruction.1 In a more recent study regarding our largest Becker reconstruction series (275 implants), we found the port flip-over rate to be much higher than that reported before, at about 15 percent of reconstructed patients.2 We believe port flip-over is scarcely reported in the literature, probably because there are few studies analyzing complications in large series of Becker reconstructions. Therefore, we appreciate every single study trying to reduce or prevent port flip-over. Again, we welcome this new technique developed to secure the Becker port in place. Over the years, we have tried to stabilize the Becker port by securing the connection tube between the expander and the port with a single 4-0 Vicryl stitch directly on the subdermal tissues along the midline at the inframammary sulcus level, just before the beginning of the subdermal pocket. We cannot secure the port directly because of the difficulty working in such a small area as the subdermal tunnel, undermined to allocate the port. Again, we tried to prevent port flip-over using sterile strips directly on the skin around the port, trying to spread far from the port the postoperative edema. Both of these techniques were ineffective in preventing port flip-over. Fixing the port directly on the skin, as described in this interesting work, seems to us a great idea, really effective in preventing port displacement. However, a few concerns arise in reading about this technique. First of all, how do the authors make the needle pass through the subdermal tunnel without damaging the expander or the connection tube? Do they go blindly, or do they enlarge the tunnel so as to see directly where to stitch? Second, sutures lying directly on the skin for more than 2 weeks, even if a bolster technique is used, may sometimes leave unpleasant marks in situ. Did the authors find this complication? Third, might this technique promote bacterial port contamination? Skin stitches could carry bacteria directly to the port. Further study will be necessary to confirm the safety of this technique. In conclusion, we congratulate the authors on their great idea for avoiding Becker port flip-over. Moreover, we thank them again for having focused their attention on this complication that in our experience is much more frequent than has been reported in the literature. DOI: 10.1097/PRS.0b013e31829accdf