Gian Vittorio Campus

Surgical treatment of balanitis xerotica obliterans.

Balanitis xerotica obliterans, or kraurosis penis, is a chronic progressive scleroatrophic process of the penis, prepuce, and urethral meatus. This syndrome is due to lichen sclerosus et atrophicus of the genital region. We have observed 32 patients, whose ages ranged from 24 to 78, with different clinical and pathologic findings. Clinical symptomatology consisted of painful erection with secondary impotence, burning, itching, and urinary disorders. The treatment in the early stages is pharmacologic; stenosis of the meatus, phimosis, scar adhesions, fissures, and erosions of glans and prepuce prescribe a surgical treatment. We have performed modified circumcision, meatotomy and meatoplasty, removal of the scleroatrophic tract and subsequent grafting. The functional results were satisfactory.

Evaluation of peripheral microcirculation improvement of foot after tarsal tunnel release in diabetic patients by transcutaneous oximetry

According to recent studies, peripheral nerve decompression in diabetic patients seems to not only improve nerve function, but also to increase microcirculation; thus decreasing the incidence of diabetic foot wounds and amputations. However, while the postoperative improvement of nerve function is demonstrated, the changes in peripheral microcirculation have not been demonstrated yet. The aim of this study is to assess the degree of microcirculation improvement of foot after the tarsal tunnel release in the diabetic patients by using transcutaneous oximetry.

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.

Extremely high HDL levels in a patient with multiple symmetric lipomatosis

An extreme form of hyperalphalipoproteinemia was studied in a patient affected by multiple symmetric lipomatosis (MSL); four relatives and three MSL controls were also evaluated. Plasma lipids and apolipoproteins were measured and overall lipoprotein profile was assessed by density gradient ultracentrifugation. The patient showed a plasma HDL-cholesterol of 138 mg/dl and an apo A-I of 218 mg/dl; moreover significantly high HDL levels were found in two unaffected relatives. The hypobetalipoproteinemia trait was also found both in the patient and in one of his daughters. We suggest that some pre-existing conditions may enhance lipoprotein metabolism alterations in this lipid storage disease.

Staphylococcus aureus and Staphylococcus epidermidis Virulence Strains as Causative Agents of Persistent Infections in Breast Implants

Staphylococcus epidermidis and Staphylococcus aureus are currently considered two of the most important pathogens in nosocomial infections associated with catheters and other medical implants and are also the main contaminants of medical instruments. However because these species of Staphylococcus are part of the normal bacterial flora of human skin and mucosal surfaces, it is difficult to discern when a microbial isolate is the cause of infection or is detected on samples as a consequence of contamination. Rapid identification of invasive strains of Staphylococcus infections is crucial for correctly diagnosing and treating infections. The aim of the present study was to identify specific genes to distinguish between invasive and contaminating S. epidermidis and S. aureus strains isolated on medical devices; the majority of our samples were collected from breast prostheses. As a first step, we compared the adhesion ability of these samples with their efficacy in forming biofilms; second, we explored whether it is possible to determine if isolated pathogens were more virulent compared with international controls. In addition, this work may provide additional information on these pathogens, which are traditionally considered harmful bacteria in humans, and may increase our knowledge of virulence factors for these types of infections.

Microsurgical Training with the Three-Step Approach

Background Microsurgery is very challenging, requiring a high degree of dexterity and manual skills that should be fully trained outside of the operating room. Common microsurgery courses usually follow a stepwise training approach beginning practice on nonliving models and proceeding with live rats. However, training on live rats raises certain issues, including ethical concerns as well as the associated costs. As such, there is an increasing drive toward alternative models. The current article describes a three‐step training approach (latex glove‐endovascular prosthesis‐human placenta), which aims to prepare trainees for the clinical direct application. Also, to validate it, this approach was compared with microsurgical training on rats. Methods Overall, 20 residents were randomly assigned to two different microsurgical training courses, each based on one of the aforementioned approaches. Residents were evaluated in terms of correct handling of the instruments, correct use of the microscope, adventectomy, triangulation technique, posterior wall technique, success of the end‐to‐end anastomosis, and ability in assisting the tutor during the arterial anastomosis. Results The three‐step and the live rats groups evidenced similar scores in term of acquired basic skill levels. Conclusions The three‐step model allows to progressively gain skills on microsurgical techniques and to perform a good vascular anastomosis without the need of further steps on rats. The availability of both endovascular prosthesis and human placenta makes this training model definitely accessible from a practical and logistical point of view.

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

Flap monitoring with continuous oxygen partial tension measurement in breast reconstructive surgery: A preliminary report

The best method for the postoperative monitoring of flaps in reconstructive surgery is still a matter of debate. The aim of this study is to evaluate the usefulness of an oxygen partial tension monitoring system for the postoperative follow‐up of a series of breast flaps, in addition to the traditional periodical clinical evaluations.

Posterior tibial perforators relationship with superficial nerves and veins: A cadaver study

Most authors have evaluated the location of lower leg arterial perforators, but little is still known about the relationship between the arterial network and great saphenous vein (GSV) and saphenous nerve (SN). The aim of this study is to evaluate the relationship between the arterial network of the posterior tibial artery perforators, the cutaneous nerves, and the superficial venous system in the lower one third of the leg.