Giuseppe Nisi

Octyl-2-Cyanoacrylate Adhesive for Skin Closure and Prevention of Infection in Plastic Surgery

No complete scientific study has yet investigated the incidence of surgical-site infections in plastic surgery operations. However, it has been noted that in the case of wound infection, the aesthetic and sometimes the functional results become invalidated by delay and an alteration of the healing processes, thus necessitating surgical correction. This study aimed to evaluate the effectiveness of applying tissue adhesive on surgical wounds in plastic surgery as a protection capable of reducing the onset of infection, and to verify the existence of a statistically significant difference between treated and untreated wounds, and to determine patients’ satisfaction with their cicatricial results.

Cellulite treatment: a comprehensive literature review

An effective and long‐term treatment of cellulite has not been well established. To our knowledge, no review has analyzed the whole range of treatments for this condition. We conducted a review of in vivo studies on humans adopting the key words “cellulite” and “treatment.” The studies were included according to eligibility criteria. We performed an analysis to estimate the overall effect of cellulite treatments from clinical studies. Medline library was screened up to December 2014 to identify eligible studies. We included 73 original studies in the present review. All of them were clinical studies, in most of them, only women were recruited. Above the studies searched up, 66 tested the effectiveness of an exclusive treatment performed without the association to other procedures: 11 topical agents, 10 shock‐wave therapy, 10 radio frequency, eight laser therapy, five oral therapy, four manual massage therapy, three carbon dioxide therapy, two compressive therapy, two infrared therapy, one dermabrasion, and 11 devices that use an association of multiple treatments. Seven papers tested a combination of two or more treatments. The mean difference of clinical morphologic features and ultrastructural changes between the treated group and the controlled showed significant heterogeneity between studies. It is still difficult to indicate an exclusive and effective single treatment for this condition. Our analysis purposed to obtain a complete overview of the available treatments in cellulite reduction.

Late-onset gluteal Escherichia coli abscess formation 7 years after soft tissue augmentation with Bio-Alcamid™ in a HIV-positive patient

In 2002, a 41-year-old woman had been treated for severe buttock lipodystrophy resulting from highly active antiretroviral (HAART) therapy medication. During a single session the loss of subcutaneous fatty tissue had been compensated by injections of an undefined quantity of polyalkylimide 4% (Bio-Alcamid , Polymekon Biotech Industry, Milan, Italy). The post-treatment course had been uneventful and the patient had initially been satisfied with the result of this treatment. Seven years later, the patient presented with a redness and swelling of the area (Figure 1) by our unit. The area was hard and extremely painful on touch. All previous antibiotic therapies led only to temporary relief of these symptoms. A bedside drainage of the abscess was performed through a 20-gauge intravenous cannula that was inserted in the thin collagen capsule

Abdominoplasty as a reconstructive surgical treatment of necrotising fasciitis of the abdominal wall

OBJECTIVES Necrotising fasciitis (NF) is a potentially fatal, uncommon infection of the soft tissue with rapid progression. This article presents one case of NF of the abdomen wall, describing the presentation, diagnosis and long-term successful treatment. METHODS The defect of the abdominal wall was treated with medical support (antibiotics broad-spectrum coverage), V.A.C. therapy and plastic surgery procedures. RESULTS The coverage of the abdominal wall defect has been achieved by abdominoplasty-type advancement flaps in one step with the preservation of the umbilicus. One month after the surgical procedure, the patient returned to a normal lifestyle with a good quality of life. CONCLUSION The success of this case should be attributed to an early diagnosis, aggressive debridement and a good intensive medical management; these elements are essential to a better prognosis for NF.

Carbon dioxide therapy and hyaluronic acid for cosmetic correction of the nasolabial folds

The main application of hyaluronic acid filling, in esthetic medicine, is the augmentation of soft tissues. The carbon dioxide therapy, instead, improves quality and elasticity of the dermis and increases the oxygen release to the tissue through an enhancing of the Bohrs effect. The aim of the study was to compare the efficacy, tolerability, and effect duration of hyaluronic acid fillers and the use of carbon dioxide therapy plus hyaluronic acid in the cosmetic correction of nasolabial folds.

Mesotherapy Should not Replace the Surgical Approach in the Treatment of Benign Symmetric Lipomatosis

We comment on the article by Hasegawa et al. [1] entitled Mesotherapy for Benign Symmetric Lipomatosis. Benign symmetric lipomatosis is a rare disorder characterized by multiple, symmetric, nonencapsulated fat masses in different body areas creating significant cosmetic deformity. Brodie [2] first described benign symmetric lipomatosis (BSL) in 1946, and Madelung [3], who named the syndrome, further characterized it, reporting 33 cases in 1888. Madelung disease usually is found between the third and seventh decade of life in middle-aged men of Mediterranean descent with a significant history of alcohol abuse [4]. In type 1 syndrome, the neck region and upper part of the trunk are involved, with a possible extension into the mediastinum. These masses generally are asymptomatic, but dysphagia, airway compression, and functional disability with neck movement limitation often have been described. A diffuse involvement of the body is seen in type 2 disorder, leading to an overweight-like aspect of the patient. Aesthetic deformities and peripheral neuropathy coupled with reports of movement limitation could be considered the major problem of Madelung disease. In only one case has malignant transformation of benign fatty masses been described [5]. At this writing, the true origin of Madelung disease is not clear. The most plausible advanced hypotheses are represented by an enzymatic defect or an alteration in the membrane receptors that would cause a reduction in adrenergic mediated lipolysis [6–9], a sympathetic denervation of brown fat adipocytes that would result in their hypertrophy [7], and mutations in the mitochondrial DNA [6, 8, 10]. In this context, alcohol could work as a cofactor by causing a reduction in both the number and activity of b-adrenergic receptors, promoting lipogenesis. However, alcohol intake certainly could not be the only cause of Madelung disease because the disorder is found also in patients who do not abuse alcohol. Association with several metabolic disorders such hyperuricemia, hyperlipidemia, diabetes mellitus, hypertension, hepatic disease, hypothyroidism, and renal tubular acidosis also is described in the literature [11–13]. Because the real etiology of Madelung disease still is unknown, only symptomatic treatment may be offered to patients. Alcoholic abstinence and correction of associated metabolic abnormalities are advocated to reduce the relapse rate once these patients have undergone surgery, although this has no effect on the dimension of fat masses already developed [6–8, 13]. The use of a b-2 agonist such as salbutamol has been emphasized by some authors [7–13]. Recently, Hasegawa et al. [1] proposed a conservative treatment for BSL. In addition to bilateral surgery at the shoulders, they treated neck masses with mesotherapy. Noninvasive intralesional injection of phosphatidylcholine combined with its emulsifier, deoxycholate (injected into lipomas, it causes focal necrosis, acute inflammation, and hemorrhage histologically) [1], were effective for removing small collections of adipose tissue. Cell lysis, resulting from the detergent action of deoxycholate, may account for this clinical effect of lecithin [1]. We appreciated the outcomes of the case shown in the article by Hasegawa et al. [1], who suggested conservative L. Rosato (&) D. Lazzeri M. Campana M. Vaccaro A. Campa S. Ciappi G. Nisi C. Brandi L. Grimaldi C. D’Aniello Plastic and Reconstructive Surgery Operative Unit, University Hospital of Siena, Policlinico Santa Maria alle Scotte, viale Bracci 1, 53103 Siena, Italy e-mail: chirplastica@gmail.com

Carbon Dioxide: Maybe Not the Only One but an Efficient and Secure Gas for Treating Local Adiposities

Currently, carbon dioxide therapy represents an evidencebased and mini-invasive method for treating local adiposities. Many studies [1–3] performed on both women and men have already demonstrated its effectiveness in decreasing local fat in several anatomical areas. Recently, Balik et al. [4] compared the effects of both CO2 and breathable air injection on subcutaneous tissue in a sample of 28 experimental rats. They concluded that the mechanical effects are the same for both gas injections and the changes in microcirculation documented on laser Doppler flow examination are not statistically significant. With respect their article, we would like to make a few comments. We evaluated in a cohort of 48 [5] and 42 patients [6] the effects of CO2 therapy from a histological (through biopsies of tissues performed after the therapy) and a biochemical point of view by showing changes in the laser Doppler signal in association with the assessment of the concentration of transcutaneous oxygen tension (tcPO2). Both these methods are mandatory to evaluate CO2 effects on the microvascular network [3, 7]. Lee [8] confirmed our findings with a study protocol evaluating some anthropometrical parameters on 101 patients (divided per age) after treatment with CO2 injected in several body areas. Furthermore, the gas injection mode of Balik’s study is not comparable to the described protocols for the treatment of local adiposities by CO2 therapy. Medical CO2 injection treatments in previous clinical studies were administered through certified equipment that guarantees both constant gas delivery and electronic flow control. The paraphysiological hyperoxia that underlies the metabolic CO2 effects needs to be evaluated by following a particular treatment timing. This was not done in Balik’s study and therefore the inefficacy of these methods is not clear in the discussion. The data related to tissue oxygenation certainly need further biochemical studies. Moreover, microvascular effects were not completely and correctly evaluated and not demonstrated by using the previously cited association of laser Doppler flow and tcPO2. In addition, it is important to point out that in our studies, tcPO2 data are constant and highly significant (P \ 0.01), whereas laser Doppler flow evaluations are significant (P \ 0.01) but not constant [5]. These results depend on some technical situation (i.e., patient immobility, constant temperature) not easily reproducible in animal models. The histological data presented by Balik et al. showed direct lipoclasic effects of the studied gas. We also found these effects in our studies but they could not be assessed in humans. It is clear that before demonstrating the effectiveness of an alternative gas (e.g., ambient air) in reducing local adiposities, it is necessary to test its security and absence of toxicity. Because of the proven safety and daily use in laparoscopic surgery [9, 10], CO2 has been injected on voluntary patients after informed consent and the approval of the local ethics committee. The aim of our study was to evaluate both the effectiveness and safety of CO2 injection treatments. In our opinion, CO2 therapy combines the characteristics previously cited (Fig. 1). C. Brandi M. Campana (&) F. Russo A. Brafa G. Nisi L. Grimaldi C. D’Aniello Department of General and Specialistic Surgery, Plastic and Reconstructive Surgery Unit, ‘‘Santa Maria alle Scotte’’ Hospital, University of Siena, Viale Bracci 1, 53100 Siena, SI, Italy e-mail: matteocamp@gmail.com

IMAGES IN CLINICAL MEDICINE. Madelung's Disease.

A 48-year-old man presented to the clinic for evaluation of dysphagia and limited neck movements (flexion and rotation of the head). The patient was found to have Madelungs disease, also known as benign symmetric lipomatosis or the Launois–Bensaude syndrome.

Complications associated with medial thigh lift: A comprehensive literature review

Medial contouring of the thigh is frequently requested to improve appearance and function of medial thigh deformities, following massive weight loss or aging process. This surgical procedure can be associated with a significant rate of complications. Our aim was to consider the complications and outcomes according to the performed technique, through a wide and comprehensive review of the literature. A search on PubMed/Medline was performed using “medial thighplasty”, “medial thigh lifting” and “technique” as key words. As inclusion criteria, we selected the clinical studies describing techniques of medial thighplasty. We excluded the papers in which complications related to medial thighplasty were not specified. We also excluded literature-review articles. We found 16 studies from 1988 to 2015. Overall, 447 patients were treated. Different techniques were applied. Complications were observed in 191/447 patients (42.72%). The most frequent complications were wound dehiscence(18.34%) and seroma (8.05%). No major complications, such as thromboembolism and sepsis, were observed. Minor complications occurred in a high percent of patients, regardless of the performed surgical procedure. Patients should be informed about the possible occurrence of wound dehiscence and seroma, as common complications associated with this surgical procedure.

A smart and simple idea for blocking the plunger during syringe liposuction.

The use of a syringe connected to an aspiration cannula is one of the techniques used for liposuction, especially in cases that involve small-volume aspiration of localized adiposities, and for fat graft removal from the donor site for lipofilling. The cannula is connected to the syringe, and the plunger is pulled back, thus creating a vacuum that allows aspiration of the fat. To avoid the loss of the negative pressure created in the syringe, the plunger must be blocked when it is withdrawn. This cannot be done manually when large syringes (50 60 ml) are used. For this reason, there are commercial syringes with locking devices that block the plunger in the right position, but they are very often difficult to obtain, especially in various sizes and in appropriately sterile conditions. Other authors [1,2] have reported some ideas for solving this problem by using surgical instruments such as towel clamps or hemostats. These methods really help the surgeon during the aspiration procedure, allowing the manteinance of a good negative pressure. However, they cause an unbalanced weight increase in the whole device. We had the idea to block the withdrawn aspiration syringe plunger with another plunger smaller in size. In our practice, we use 50or 60-ml syringes for aspiration, and when the vacuum is created, we block the plunger with a 10-ml syringe plunger, as shown in Fig. 1. The procedure is really simple, practical, and inexpensive. Moreover, the absence of additional weight in the posterior part of the whole system, due to the surgical instrument used to block the plunger, makes the procedure more comfortable for the surgeon. We recommend it to all our colleagues.