Guido Paolini

Comparative Evaluation of Traditional, Ultrasonic, and Pneumatic Assisted Lipoplasty: Analysis of Local and Systemic Effects, Efficacy, and Costs of These Methods

Abstract. Recently ultrasound assisted liposuction (UAL) and pneumatic assisted liposuction (PAL) have been introduced as an attempt to improve the results and reduce the pitfalls of standard liposuction (SAL). Until now no studies comparing, at the same time, UAL, PAL, and SAL have been published. The aim of this study was to analyze these methods from the surgeons point of view, focusing not only on aesthetic results but also on local and systemic trauma, efficacy, handling, and cost. Forty-five cosmetic patients affected by local lipodystrophy, divided into three equal groups, have undergone liposuction with the three above-mentioned techniques. Quantitative and qualitative analysis of lipoaspirates, together with blood chemistry, local and systemic complications, time to aspirate 100 cm3, distress, fatigue, and costs of the procedures, has been recorded. Our results showed bloodier lipoaspirates in SAL and a higher percentage of triglycerides in UAL lipoaspirates. Blood tests revealed a slight decrease in the postoperative Hb in SAL only. Early complications observed were four erythemas in PAL, three ecchymoses in SAL, and one long-lasting edema in UAL. Aesthetic results rated by independent viewers were similar for all methods. Efficacy was higher in the PAL group (4 min × 100 cm3 fat aspirated) than in SAL (7 min × 100 cm3 fat) and UAL (10 min × 100 cm3 fat). Surgeons distress was higher in PAL than in SAL and UAL. Surgeons fatigue was much lower in the PAL group than in the others. Costs expressed as multiples of 1 unit (1 unit =

Prospective computerized analyses of sensibility in breast reconstruction with non-reinnervated DIEP flap.

500 U.S.) were highest for UAL, low for PAL, and lowest for SAL. In conclusion, PAL and UAL caused reduced vascular injury, UAL being more selective for adipocyte removal. Complications of UAL and PAL were mostly related to the longer learning curve of these methods. The UAL procedure was much more expensive than PAL and, especially, SAL. PAL proved to be a handy technique, with the most favorable cost/benefit ratio, and seems to be the best option for busy liposuction practices or fast office procedures, even though the choice of the ideal technique always depends on the surgeons preference.

Preliminary experience in reconstruction of the vulva using the pedicled vertical deep inferior epigastric perforator flap.

Background: The deep inferior epigastric perforator (DIEP) flap is considered the definitive standard for autologous breast reconstruction because of its ability to restore shape, its consistency, and its static and dynamic symmetry, but the degree of spontaneous sensory recovery is still widely discussed. To clarify the real need for sensitive nerve coaptation, return of sensibility in DIEP flaps was investigated using a pressure-specifying sensory device. Methods: Thirty consecutive patients with breast cancer scheduled for modified radical mastectomy, axillary node dissection, and immediate reconstruction with cutaneous–adipose DIEP flaps without nerve repair were enrolled in the study. Sensibility for one and two points, static and moving, was tested preoperatively on the breasts and abdomen, and postoperatively at 6 and 12 months on the DIEP flaps. A t test was used for comparison of paired data and to investigate which factors affected sensory recovery. Results: Preoperative healthy breast and abdomen pressure thresholds were lower for two-point than one-point discrimination and for moving discriminations compared with static ones at 6 and 12 months. Although they were significantly higher than those for contralateral healthy breasts (p < 0.05), pressure thresholds in DIEP flaps at 12 months were lower than at 6 months, showing a significant progressive sensory recovery (p < 0.05). At 12 months postoperatively, the best sensibility recovery was found at the inferior lateral quadrant, the worst at the superior medial quadrant. Age and flap weight were factors related to the performance of sensory recovery. Conclusions: DIEP flap transfer for immediate breast reconstruction undergoes satisfactory progressive spontaneous sensitive recovery at 6 and 12 months after surgery, and operative time spent dissecting sensitive perforator branches and their coaptation in recipient site could be spared.

Transplantation of autologous cultivated conjunctival epithelium for the restoration of defects in the ocular surface.

The perineum is a difficult area to reconstruct because of its multiple functional and cosmetic roles. It functions as the pelvic floor, and it hosts the anus, the vulva, and the urethra. The benefits of using well-vascularized tissue in perineal reconstruction, such as the gracilis musculocutaneous flap, were recognized as early as 1976.1 It is useful to fill the dead space following resection, so as to reduce the risk of abscess formation and chronic wound drainage and to prevent the small bowel from descending. It is especially helpful in previously irradiated areas, which are otherwise prone to breakdown and prolonged secondary healing. Easier and shorter reconstructions were later described using the rectus abdominis musculocutaneous flap,2 the pudendal thigh flap,3 and the groin flap,4 as well as innervated island flaps sliding from the pubis or elevated from the gluteal folds.5,6 All of these techniques are useful, with different indications for perineal reconstruction, but mainly cutaneous flaps are indicated in vulva reconstruction. Reconstruction of total vulvar defects requires bilateral local flaps, which make simultaneous closure of the donor area impossible and therefore lengthen the procedure. Nevertheless, bilateral flaps might be not enough for a very large defect caused by extensive vulvar resection. We present a procedure for reconstructing very large defects following extensive vulvar resection. It is based on the use of a single skin island flap, does not include muscle transfer, and has a distant donor area to allow for simultaneous closure as well as a shorter operation. PATIENTS AND METHODS

Predictive and protective factors for partial necrosis in DIEP flap breast reconstruction: does nulliparity bias flap viability?

Ocular surface disorders are often characterised by partial or complete loss of corneo-conjunctival epithelium, which causes dramatic functional and cosmetic problems. Depletion of stem cells and the scarcity of donor tissue available make large or bilateral defects challenging to reconstruct, and usually require the transplantation of heterotopic or allogeneic grafts. We investigated the feasibility of restoring severely damaged ocular surfaces with autologous cultivated conjunctival epithelium. Conjunctival cells were harvested from the healthy eyelid bed of four patients with oculopalpebral diseases. An epithelial sheet reproducing the original conjunctival epithelium was generated by serial cell culture. This was transplanted for the first time ever to our knowledge on to the ocular surface of the same patients. Take was excellent and the cultivated epithelium was stable, resulting in great improvement of patients symptoms and cosmesis. Transplantation of cultivated conjunctival cells opens new perspectives in the treatment of severe ocular surface disorders.

The “type V” Skin-sparing Mastectomy for Upper Quadrantskin Resections

AbstractAlthough success rate of deep inferior epigastric perforator (DIEP) flap breast reconstruction has greatly improved, complications still occasionally occur. Perfusion-related complications (PRCs) (ie, fat necrosis and partial flap necrosis) are the most frequent concern, affecting aesthetic final result of the reconstructed breast.The aim of our study was to retrospectively investigate 287 consecutive DIEP flap breast reconstructions to investigate predictive and protective factors for PRCs.From May 2004 to February 2012, 287 DIEP flap breast reconstructions were performed on 270 patients; 247 unilateral flaps, including Holm vascular zones I to III, were retrospectively selected and analyzed. Tobacco use, mean blood pressure over the first postoperative 48 hours, superficial epigastric vein drainage, medial/lateral row perforator, nulliparity, crystalloid versus combined crystalloid/colloid intravenous fluid infusion therapy, and learning curve were evaluated by univariate and multivariate logistic regression analyses.Perfusion-related complications occurred 32 (12.9%) times, 79 (31.9%) patients were smokers, 48 (19.4%) showed postoperative mean blood pressure less than 75 mm Hg, 29 (11.7%) were nulliparous, and 173 (70%) had superficial epigastric vein drainage. Selected perforators were 110 (44.5%) from lateral row, 137 (55.5%) from medial row; 91 (36.8%) received crystalloid fluid infusion, whereas 156 (63.2%) combined crystalloid/colloid fluid infusion. From univariate analysis emerged significance of nulliparity, perforator row and intravenous fluid infusion for PRC. Nevertheless, multivariate model confirmed only nulliparity as a significant risk factor (P = 0.029), although variable correlations to other predictors were found: both medial row perforator and combined crystalloid/colloid fluid infusion potentially decrease the PRC risk of 11.6% and 27.6%, respectively. Learning curve did not show significant decrease of PRC risk over time.Our study first proved nulliparity as a statistically significant predictor for PRCs in DIEP flap breast reconstruction, possibly due to different superficial abdominal perfusion between pluriparous and nulliparous women, with potential weaker pattern of perforators and smaller angiosomes in the latter. The choice of medial row perforators and combined crystalloid/colloid fluid infusion might reduce PRC risk.

Computer-assisted evaluation of nipple-areola complex sensibility in macromastia and following superolateral pedicle reduction mammaplasty: a statistical analysis.

Skin-sparing mastectomies (SSMs) are classified according to the type of incision and breast size. In large breasts, if cancer is superficially located in the upper quadrants, SSM type IV is not indicated, because tumor resection interferes with skin flap pattern. For these patients, a modified Wise-pattern SSM has been developed to achieve immediate breast reconstruction. Twenty-four patients, 14 with tumor in the superior-lateral, 7 in the superior-medial, and 3 in the inferior-lateral quadrant, were operated on with modified SSM incisions. To replace the skin area removed with mastectomy from the upper quadrants, a similar size area from the lower pole was used. No local or distant recurrences occurred, with a mean follow-up of 27 months. Natural breast shape was achieved in all cases. Our procedure allows for a skin-sparing mastectomy (SSM type V) with immediate reconstruction, achieving a natural breast shape also in this group of patients previously excluded.

Accessory slip of the palmaris longus muscle.

Background: The authors performed a prospective study quantifying nipple-areola complex sensibility by computer-assisted neurosensory testing in breast hypertrophy before and after superolateral breast reduction. Methods: A superolateral pedicle breast reduction was performed on 30 macromastia patients. The mean age of the patients was 46 years. The cup sizes of the patients were as follows: D, 14 patients; E, 12 patients; and EE, four patients. Ptosis was 3 degrees in 12 and 4 degrees in 18; nipple elevation ranged from 4 to 18 cm; glandular resection ranged from 379 to 1850 g. Static and moving one- and two-point discrimination was tested preoperatively and 6 months postoperatively at the nipple-areola complex, evaluating the impact of breast hypertrophy (D versus E and EE cups), nipple elevation (<9 cm versus ≥9 cm), and glandular resection (<900 g versus ≥900 g). Results: Statistical analyses revealed preoperatively significant higher pressure thresholds in the nipple-areola complex of larger versus smaller hypertrophies and in the nipple of longer nipple-areola complex transposition breasts for static and moving one-point discrimination. Postoperatively, worsening of sensibility was more significant in the nipple-areola complex of smaller versus larger hypertrophies and of shorter versus longer nipple-areola complex transposition breasts for moving one-point discrimination. Conclusions: This study confirms that macromastia patients present a reduced breast sensibility, which is not necessarily worsened by reduction mammaplasty. After reduction mammaplasty with the superolateral pedicle technique, nipple-areola complex sensibility might be slightly reduced, which is less detectable in large-breast hypertrophy because of lower preoperative levels of sensibility and less of a postoperative decrease.

Permanent latissimus dorsi muscle denervation in breast reconstruction.

We discuss the case of a patient presenting an accessory slip of the palmaris longus (PL) muscle, which caused symptoms of median nerve compression on his left forearm. An asymptomatically anomalous distal PL belly contralaterally is also reported, and the clinical relevance and diagnosis of PL anomalies are discussed.

Compression of the digital nerves by a giant periosteal chondroma

BackgroundA retrospective analysis of our series of denervated latissimus dorsi (LD) breast reconstructions showed a high incidence of postoperative LD contraction. Anatomical studies with a prospective clinical trial are set up to outline a successful denervation procedure. MethodsFifteen fresh cadavers were dissected to study thoracodorsal nerve course. Subsequently, 40 consecutive LD breast reconstructions were divided randomly in equal groups and underwent either distal (group A) or proximal (group B) nerve resection and clipping. The presence of postoperative contraction was evaluated clinically and instrumentally at 2-year follow-up. Statistical analysis of data was performed by Fisher exact test. ResultsCadaver dissections showed distal branching of thoracodorsal nerve in 20% of cases. Incidence of postoperative LD contraction was 35% (7/20) in group A and 0% in group B. A significantly lower rate of contraction in group B was demonstrated (P = 0.004). ConclusionsType B proximal nerve resection allows for effective denervation reducing incidence of postoperative contraction (P = 0.004).