Juri Tassinari

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.

The retroangular flap in facial reconstruction: the exhaustive point of view.

further refinement. We describe a simple modification of suture techniques (antihelix mastoid sutures) that can be used to reinforce the repair of a prominent ear. The combined technique presented is safe, easy to perform, and can be used for treating patients with any magnitude of defect. Forty-four patients with prominent ears (80 ears) underwent otoplasty performed by the senior author at the Iaso Hospital of Athens between 2007 and 2009. Inclusion in this study required the use of at least one antihelix mastoid suture. Typically, a row of three or four 3-0 Prolene (Ethicon, Inc., Somerville, N.J.) sutures on a round-bodied needle was inserted to recreate the fold of the antihelix (in the fashion of Mustardé), starting caudally. The ends were not cut and an artery clip was applied to each suture. Another suture, 2-0 or 3-0 Prolene, was then placed between the concha and the mastoid periosteum to decrease the concha-scaphoid angle (in the manner of Furnas). With the sutures (at least one) that were used to recreate the antihelix fold, a second bite was taken on the mastoid periosteum and was tied with the desired tension (Fig. 1). In all of our patients, we did not overcorrect, but we attempted to achieve a natural appearance (Fig. 2). The concept of this extra bite of mastoid periosteum is to approximate the antihelix to the mastoid with a second secure and tight knot. The ear deformity is almost invariably greater at the superior pole than inferiorly, and therefore this extra knot is more useful at the upper pole of the ear. Patients were invited to a follow-up clinic (1 month and 1 year after surgery), where recurrence and suture extrusion were evaluated. The clinical recurrence rate was 1.25 percent (one ear). This one patient had undergone revision surgery. The suture extrusion rate was 7.5 percent (six ears), three of which required local anesthetic procedures for removal of sutures. There was no hematoma or skin necrosis. Patients were generally satisfied with the results in terms of shape and symmetry. It seems that this variation maintains a relatively simple and safe otoplasty that avoids irreparable complications and has a reproducible final cosmetic outcome. DOI: 10.1097/PRS.0b013e3182419b07

Superior Pedicle Mammaplasty without Parenchymal Incisions after Massive Weight Loss.

ABSTRACT Background: After considerable weight loss, the breast suffers significant deformation. The ptotic breast is characterized by a lack of superior pole, tissue excess in the inferior pole, down-migration of nipple-areola complex (NAC) with redundancy of skin tissue. The authors describe a mastopexy technique based on a modulated and progressive reshaping, back rotation, and suspension of mammary gland parenchyma without parenchymal incisions. Methods: Forty-five patients with bilateral moderate or severe breast ptosis underwent mastopexy from January 2011 to January 2014 with complete detachment of breast from the pectoralis major muscle and the plication of parenchyma without any parenchymal incision. Patients were followed up for one year, reporting any complication, and measuring the jugulum–NAC distance. The outcomes were assessed by the patients as well as the surgical team. Results: The aesthetic outcomes were good or excellent in all patients. The new mammary contour and the distance between the jugular fossa and the nipple were stable during this time with a good filling of upper pole. No major complications were reported. Conclusions: This technique gave good breast shape, long-term projection, and upper pole fullness, without parenchymal incisions. It restores breast shape and projection, especially in post-bariatric patients. A similar technique has not been described yet.

A case of extramammary inguinal Paget disease in a male patient: surgical treatment with an abdominal advancement cutaneous flap

Extramammary Paget disease (EMPD) is a rare neoplasm. The clinical case of a 55-year-old man with a two-year history of a pruritic, painless erythematous skin rash on the inguinal region and scrotum is described. After a delay due to improper diagnosis and improper treatments, the patient came to the attention of the Division of plastic surgery. He underwent a punch biopsy and the pathology report came back as EMPD. Surgical excision was carried out, and an abdominal advancement cutaneous flap was performed for the defect repair. This is the first description of a reconstruction after surgical removal of inguinal EMPD with a flap of this type and we think that this type of treatment can be useful and reliable for disease localization in the groin area, especially for patients that present an excess of abdominal skin. (www.actabiomedica.it)

Nipple-Areola Complex Reconstruction

The reconstruction of the nipple-areola complex (NAC) is the reconstructive procedure used in patients who have undergone a non-nipple-sparing mastectomy and, in general, in all the patients who need the reconstruction or creation of the nipple for traumatic damage or congenital absence/malformation. Several methods for the reconstruction of the nipple-areola complex were described. The nipple can be reconstructed using a local flap, a local flap of material with a grafting autologous/allogeneic/synthetic inside, a skin graft, or a subdermal pocket with grafted material inside. The areola can be reconstructed using skin graft from hyperpigmented areas or tattoo. The prosthesis (internal or external) and the three-dimensional tattoo allow the reconstruction of the NAC in one time and with a single method.

Melanoma in situ mimicking a Lichen planus-like keratosis

The incidence of melanoma has steadily increased over the past three decades. Melanoma in situ (MIS), defined as melanoma that is limited to the epidermis, contributes to a disproportionately high percentage of this rising incidence. Amelanotic melanoma presents as an erythematous macule or plaque and may initially be misdiagnosed as an inflammatory disorder. We report a case of amelonatic MIS raised on non-sun-exposed skin, inducing a lichen planus-like keratosis as inflammatory reaction, which clinically masked the melanoma. (www.actabiomedica.it)

Complications associated with brachioplasty: a literature review

Background: Paralleling the growth of bariatric surgery, the demand for post-bariatric body-contouring surgery is increasing. Weight loss is the main cause, although not the only one, that drives patients to arm lift surgery. Several surgical techniques have been proposed over the years. Our aim was to consider the complications and outcomes according to the performed technique, through a wide review of the literature. Methods: A search on PubMed/Medline was performed using “brachioplasty”, “upper arm lifting”, and “techniques” as key words. Embase, Medline (OvidSP), Web of Science, Scopus, PubMed publisher, Cochrane, and Google Scholar were searched as well. As inclusion criteria, we selected the clinical studies describing techniques of brachioplasty. We excluded the papers in which complications related to brachioplasty were not specified. We also excluded literature-review articles. Results: We found 27 studies from 1995 to 2015. Overall, 1065 patients were treated. Different techniques were applied. Complications were observed in 308/1065 patients (28.9%). The most frequent complications were hypertrophic scarring, seroma and hematoma. Surgical revision rate ranged from 0 to 21 percent. Nerve damage occurred in a modest percentage of patients (16/1065, 1.5%). No major complications, such as thromboembolism and sepsis, were observed. Conclusions: Brachioplasty is a safe surgical procedure. All the brachioplasty techniques showed positive outcomes, in term of patients’ satisfaction and clinical results. Nevertheless, minor complications occurred in a high percentage of patients, regardless the performed surgical procedure. Patients should be informed about the possible formation of hypertrophic scars and nerve injuries. (www.actabiomedica.it)

Fat Grafting in Primary Cleft Lip Repair.

Fat Grafting in Primary Cleft Lip Repair Sir: W have read with great interest the article entitled “Fat Grafting in Primary Cleft Lip Repair” by Dr. Zellner et al.1 In the article, the authors hypothesized that immediate fat grafting during primary cleft lip repair may be of benefit and compared patients who underwent primary cleft lip repair with and without immediate fat grafting. Final scar analysis revealed statistically significant improvement in scar appearance and contour of the fat-grafted cleft lip repair, concluding that immediate fat grafting may be a promising strategy for improving lip appearance, contour, and scarring during primary cleft lip repair. In cleft lip repair surgery, the goal is a normal-appearing lip and nose, with minimal visible stigmata; however, all surgical repairs leave a cutaneous scar, and unpredictable healing may occur despite the incision pattern chosen and the surgical technique performed. Many authors have reported how autologous fat grafting could modulate scar formation and enable soft-tissue augmentation.2–4 Fat grafting provides softtissue augmentation, enhances contour and structure, and improves skin quality and scar appearance.5 Actually, we routinely perform autologous fat grafting to improve the contour of the lip and piriform area in patients who were previously submitted to cleft lip repair, especially in bilateral cases where there is more need for soft-tissue volume, because of the increased tension across the approximated lip flaps that can result in a pronounced scar. In our experience, autologous fat injection performed several months (at least 6 to 8 months) after primary surgery offers the advantage of allowing recognition, with precision, of the depressed areas that are often not easily recognizable during the first stage. Scarring is a constant and unavoidable aspect of wound healing, and several factors likely contribute to scar quality, and isofurans during ischemia/reperfusion of the leg in patients undergoing knee replacement surgery. Free Radic Biol Med. 2011;50:1171–1176. 4. Turan R, Yagmurdur H, Kavutcu M, Dikmen B. Propofol and tourniquet induced ischaemia reperfusion injury in lower extremity operations. Eur J Anaesthesiol. 2007;24:185–189. 5. Saricaoglu F, Dal D, Salman AE, Doral MN, Kilinç K, Aypar U. Ketamine sedation during spinal anesthesia for arthroscopic knee surgery reduced the ischemia-reperfusion injury markers. Anesth Analg. 2005;101:904–909. 6. Yagmurdur H, Ozcan N, Dokumaci F, Kilinc K, Yilmaz F, Basar H. Dexmedetomidine reduces the ischemia-reperfusion injury markers during upper extremity surgery with tourniquet. J Hand Surg Am. 2008;33:941–947. 7. Hand R Jr, Riley GP, Nick ML, Shott S, Faut-Callahan M. The analgesic effects of subhypnotic doses of propofol in human volunteers with experimentally induced tourniquet pain. AANA J. 2001;69:466–470. 8. Coulthard P, Rood JP. An investigation of the effect of midazolam on the pain experience. Br J Oral Maxillofac Surg. 1992;30:248–251. including suture type, duration of suture placement, tissue tension, and the child’s intrinsic healing capacity. We never use fat graft injection in primary cleft repair, but we think that the use of intraoperative autologous fat injection should be an excellent procedure, to improve not only the contour but also the cicatrization process, because of the benefits of fat in the first phase of the healing process. In conclusion, we think that the innovation introduced by the authors should be taken into consideration and that injecting at the time of surgery offers a chance to optimize healing of the scar. DOI: 10.1097/PRS.0000000000001665

Revisiting the Role of Columellar Strut Graft in Primary Open Approach Rhinoplasty.

701e Primary Open Approach Rhinoplasty” by Dr. Bitik et al. The authors retrospectively analyzed a series of 100 consecutive primary rhinoplasty cases performed without the use of columellar strut grafts, to determine preoperative, morphed, and actual postoperative changes in nasal tip position.1 Controlling and maintaining the position and shape of the nasal tip is one of the most important aspects of successful rhinoplasty.2 In the article, the authors concluded that preoperative goals regarding nasal tip projection, nasal profile proportions, and columellar integrity could be consistently achieved without using columellar strut grafts. As several authors have reported, we also believe that, for nasal tip support, the integrity of the natural supporting structures is fundamental and should be revaluated to avoid postsurgery tip ptosis.3,4 In our experience, the presence of a support of septum cartilage is fundamental for maintaining correct tip projection. Ha and Byrd reported the use of an extension graft as an alternative to use of a columellar strut graft5; actually, we used septal extension in several cases of traumatic short nose, where there was deficient nasal septal cartilage, and we observed good long-term improvement of nasal tip projection. In the article, the authors performed all rhinoplasty surgery by closed technique, and this is an advantage when there is the necessity to restore the natural support structures of the nose such as the paramedian and median support ligaments. We believe that it is not easy Fig. 1. Patient with overcorrected Müller muscle resection before and after eyelid stretching.

Cutaneous Plasmacytoma Associated with Squamous Cell Carcinoma of the Sacro-Coccygeal Region

We describe the case of a patient who received the diagnosis of squamous cell carcinoma of the radio-treated skin of the sacrococcygeal region where an extramedullary plasmacytoma had been identified one year before. We think that the plasmacytoma was born by a malignant transformation of a host-inflammatory reaction to a not-detected epithelial tumor. It can also hypothesized that plasma-cell dyscrasia or post-radiation infiammatory reaction had promoved the squamous cell carcinoma occurrence.