Luca Andrea Dessy

Conservative management of local Mycobacterium chelonae infection after combined liposuction and lipofilling.

A case of Mycobacterium chelonae infection in the buttock after combined liposuction and lipoinjection is presented. The real possibility of contamination from operating room equipment was the potential etiologic factor of this infection. The clinical presentation of the disease was typical. The difficulty confirming the diagnosis was solved by specific culturing techniques. Successful treatment with limited debridement and irrigation combined with prolonged specific antibiotic therapy effected a long-term cure.

Innervated island pedicled anterolateral thigh flap for neo-phallic reconstruction in female-to-male transsexuals

Many techniques have been described to create an aesthetic and functional neo-phallus after penile amputation or in female-to-male transsexuals. Microsurgical free-flap phalloplasty seems to be the preferred method of penile reconstruction. For many years the radial forearm free flap has been considered the best procedure, but other flaps have been attempted to minimize donor site morbidity and optimize outcome. Pedicled flaps are considered to be reliable and to decrease the risk of total failure. Recently, a one-stage non-microsurgical technique was described for phallic reconstruction in a young male patient. We report successful total phallic reconstruction in a female-to-male transsexual patient using an island pedicled anterolateral thigh (ALT) flap. Urethral reconstruction was left as a possible further procedure due to patients preference. A malleable soft silicone penile prosthesis was inserted within the flap and the lateral cutaneous femoral nerve stump was sutured to the dorsal clitoris branch from the pudendal nerve for flap sensation. After 6 months, the patient demonstrated successful aesthetic and functional reconstruction referring to satisfactory sexual activity. To our knowledge, this is the first report of an innervated island pedicled ALT flap used for female-to-male penile reconstruction in a transsexual patient. The pedicled ALT flap may be a reliable option to avoid visible scarring at the donor site on exposed parts of the body, and reduce the risk of total flap failure from microsurgical procedures for reconstruction of a neo-phallus in this increasing population of patients.

Treatment of muscular contraction deformities with botulinum toxin type A after latissimus dorsi flap and sub-pectoral implant breast reconstruction

Unusual and probably underestimated complications following breast reconstruction with a latissimus dorsi (LD) flap and sub-pectoral implant are the LD muscle twitching and the breast contour deformities from pectoralis major (PM) muscle contraction. Surgical muscle denervation is usually indicated for these complications. Botulinum toxin A (BTX-A) infiltration has been described in reducing breast contour deformity in sub-pectoral implant after breast augmentation or reconstruction. Between January 2002 and April 2006, 71 consecutive patients underwent delayed unilateral breast reconstructions with LD flap and sub-pectoral implant after mastectomy. All patients reporting discomforting signs and symptoms from muscle contraction in the reconstructed breast were included in this prospective study. Thirteen patients (18.3%) were selected and treated with BTX-A percutaneous local injections. Signs and symptoms were evaluated, after 4, 8 and 12 months, by the patients and by a panel of three physicians not involved in the study, using a five-point scale. During the study period all patients reported a decrease or disappearance of the signs and symptoms. After 12 months, 11 patients received three BTX-A infiltrations, demonstrating considerable improvements compared to the pre-treatment status. Wilcoxon matched pairs rank sum test showed a statistical difference between pre-treatment and post-treatment scores after 14 days (P<0.01) and 12 months (P<0.001). Our experience shows that muscular contraction deformities after breast reconstruction with a LD flap plus implant are not uncommon complications. The use of BTX-A infiltrations is an effective, not surgical, low cost and low risk procedure to treat these complications. It is an easy procedure to be performed on an outpatient basis with a temporary effect but safely repeatable and reproducible; it avoids hospitalisation or further surgical procedures and demonstrates tolerable latency with satisfactory outcomes.

Reconstruction of anterior auricular conchal defect after malignancy excision: Revolving-door flap versus full-thickness skin graft

Skin tumours of the anterior auricular concha are not uncommon. Wider excision and immediate reconstruction are required to reduce the risks of recurrence of the disease, cartilage infection and external ear distortion. Many surgical methods have been described for reconstruction of conchal defects. Post-auricular island flaps, such as the revolving-door (RD) flap, and full-thickness skin grafts (FTSGs) are the most-performed procedures. Although the RD flap has been fully described, it is not widely accepted and many surgeons, in their daily practice, prefer to use FTSG. It is a common experience that FTSGs are more subjected to centripetal contraction, decreasing the structural firmness of the conchal cavity and affecting functional and aesthetic outcomes. Furthermore, FTSGs are more prone to delay in wound healing due to the difficult access to this region that hinders adequate tie-over dressings. Between March 2003 and January 2007, 40 patients affected by T1 and T2 non-melanotic skin cancer and T1 melanoma of the anterior conchal surface of the external ear were included in a prospective study and randomly assigned to the RD reconstructed group or to the FTSG reconstructed group to investigate, compare and define advantages and disadvantages of both the techniques. Visual Analogue Scale (VAS) was used to evaluate the overall outcome and the colour and texture match. No flap or skin graft total loss was observed. Six patients (30%) showed partial failure of FTSG. The RD group demonstrated excellent cosmetic outcome, ideal colour match, adequate structure of external ear, projection and shape. Wilcoxon matched-pairs rank-sum test demonstrated statistically significant higher scores for the RD group compared to the FTSG group (p<0.0001). The RD harvesting technique is easy and quicker than the FTSG technique. RD flap should be considered as the first choice for reconstruction of anterior auricular conchal defects following wider excision of skin tumours.

The propeller flap for chronic osteomyelitis of the lower extremities: a case report

The goals of the treatment of chronic osteomyelitis are infection eradication with systemic antibiotic therapy and local management with radical excision of the infected tissue and obliteration of the remaining dead space. Adequate debridement and coverage with a well-vascularised tissue are mandatory for successful outcomes. Use of muscle covering for chronic osteomyelitis in the lower extremities is considered the best procedure. However, there have been instances where debridement of the bone tissue did not leave a deep cavity along the leg bones and fasciocutaneous flaps can be used in these instances to cover the defect and to restore function without recurrence of the disease. Recently, free non-muscle flaps have been used and assessed for chronic osteomyelitis or covering of exposed bone. Perforator flaps have been shown to be well vascularised due to a structural haemodynamic enhancement. In the light of these findings we report a successful case of chronic osteomyelitis of the right fibula treated with excision of the affected tissue and covering with a propeller flap. Instead of free flap covering, in order to optimise surgical reconstruction, reducing the operative time, donor and recipient site morbidity and risk of total flap failure, local perforator flaps and particularly the propeller flap may be indicated in the treatment of chronic osteomyelitis in selected patients when the defect is limited and there is no need to fill a deep bone cavity or a dead space. To our knowledge, this the first report of the use of a propeller flap in the treatment of chronic osteomyelitis in the lower extremities.

A Clinical Study of Late Seroma in Breast Implantation Surgery

BackgroundThe use of mammary implants may lead to a variety of early and delayed complications. The most common delayed complications are capsular contracture and implant failure. Late seroma has seldom been reported. In a long-term prospective observational study, cases of late seroma were assessed and recorded.MethodsBetween March 2005 and November 2009, suspected cases of late seroma in patients who had undergone breast augmentation or reconstruction with textured implants were evaluated clinically and with instrumental analyses. An ultrasound-guided needle aspiration of the fluid was performed.ResultsIn this study, 13 cases of late seroma (8 augmentations and 5 reconstructions) were observed. The overall incidence of this complication was 1.68%. Chemical analyses confirmed the diagnosis of seroma, which recurred in all the patients within days of evacuation. For 12 patients, a reoperation was performed, during which the implant was removed, a total capsulectomy was performed, and in cases of subglandular breast augmentation, the implant pocket was changed to a submuscular placement before a new prosthesis was inserted. One patient underwent a second ultrasound-guided needle aspiration. No seroma recurrence was observed in any of the patients during the follow-up period.ConclusionIn case of unexpected breast enlargement after prosthesis implantation, the physician should first rule out infection, then investigate possible friction irritation from either a fold in the device or rubbing of a textured implant. According to the authors’ experience and another report, this complication occurs in 1% to 2% of cases. The inclusion of this complication in the informed consent form should be considered. Long-term studies designed to investigate the underlying causes of late seroma are warranted for the prevention and treatment of this complication.

An objective assessment of botulinum toxin A effect on superficial skin texture.

The botulinum toxin A (BTX-A) role on elimination of hyperkinetic wrinkles is consolidated, although relying on subjective methods of assessment. A prospective open-label study was performed on 10 patients to objectively analyze superficial skin texture changes caused by BTX-A in the glabellar area. Skin areas were reproduced by silicon replica technique at baseline, 1 month, and 6 months after treatment. Takahashis parameters (roughness, anisotropy, microsulcus number, and width) were obtained from scanning electron microscopy (SEM) analysis and compared using the Wilcoxon signed rank test. SEM images showed skin texture changes, and software analysis gave parameters for statistical analysis, allowing an objective evaluation. Statistically significant parameter modifications were evidenced. BTX-A effectiveness in wrinkle treatment was confirmed, and no differences in skin texture parameters from baseline to toxin action end were noted.

Botulinum Toxin for Glabellar Lines

Facial rhytides represent a widespread aesthetic concern. In particular, glabellar lines are perceived as a sign of aging and may give an erroneous impression of negative emotions. The onset of glabellar lines is closely related to the movements of the underlying muscles. Botulinum toxins inhibit the release of acetylcholine into the synaptic cleft and therefore result in temporary muscle paralysis. The observation that botulinum toxin (BTX) smoothed facial lines when used therapeutically led researchers to study the toxin effect on glabellar lines. Nowadays, the use of BTX to smooth glabellar frown lines represents the leading procedure in aesthetic facial treatments and an increasing number of BTX formulations are becoming available.This article provides a comparative evaluation of currently available BTX options for the treatment of glabellar lines. Toxins have been divided into three groups, based on whether they have obtained approval for cosmetic use (approved treatments) or not (off-label treatments), or whether they are still under investigation (experimental treatments). We examine the basic similarities and differences between available botulinum toxins, and summarize the pharmacokinetics and dosing.All approved treatments consist of BTX type A (BTX-A) and differ in their molecular weight, as some formulations are made of a BTX-A complex of 900 kDa while the latest option on the market is a 150 kDa BTX-A that is free from complexing proteins. As for the dosage, the important aspect that emerges from this comparison is that even within a given serotype, such as BTX-A, formulations are not interchangeable as each possesses distinctive characteristics that are attributed to the unique toxin purification and manufacturing processes.There is a substantial body of published evidence on the use of these approved treatments for facial enhancement, proving efficacy and safety. We investigate the methods of evaluation used for each toxin and review the safety and efficacy data reported in the literature. Minor adverse effects, such as headache, blepharoptosis, and injection-site reactions, are relatively frequent but transient, whilst major adverse effects are rare.Some botulinum toxins, i.e. BTX type B, that are approved for therapeutic applications are used off-label for cosmetic indications, thus without the approval of the health regulatory committees and without sufficient published evidence on safety and efficacy. As for experimental treatments, a number of BTX products are currently in development or have been recently launched for aesthetic applications. These products have been specifically designed to overcome some of the limitations present in the older generation of products. However, some of these toxins may be easily purchased via the Internet, without having any license or approval for cosmetic or therapeutic indications; these products must be considered unsafe and are potentially a severe health risk for patients.

The use of cultured autologous oral epithelial cells for vaginoplasty in male-to-female transsexuals: a feasibility, safety, and advantageousness clinical pilot study.

Summary: Various vaginoplasty methods in male-to-female transsexuals have been described, but none is ideal. The use of cultured autologous oral epithelium to cover the neovagina walls is presented. Six patients were operated on. Complications encountered were one case of low-located rectovaginal fistula that was treated conservatively; one case of partial glans necrosis resulting in a scarred but sensitive clitoris; one case of large labia majora requiring reduction; and one case of short vagina requiring surgical revision with autologous cultured oral cells that was successful. All patients had adequate vagina, experienced sexual intercourse, and were satisfied with results. Autologous cultured oral epithelium transplantation is feasible, safe, and advantageous. Satisfactory neovaginas were provided; the procedure is relatively easy to perform and provides a thin, mucosa-lined neovagina with a sufficient amount of secretion.

Transverse Upper Gracilis Flap with Implant In Postmastectomy Breast Reconstruction: a Case Report

Autologous flaps can be used in combination with prosthesis in postmastectomy breast reconstruction. The deep inferior epigastric perforator (DIEP) flap is considered the preferred choice among autologous tissue transfer techniques. However, in patients with a peculiar figure (moderately large breasts and large thighs with flat stomach), who cannot use their abdominal tissue, the transverse upper gracilis (TUG) flap with implant is investigated as a further option for breast reconstruction. This report presents a patient who underwent the TUG flap plus implant reconstruction. A bilateral skin‐sparing mastectomy was performed removing 340 g for each breast. The volume of the TUG flaps was 225 g (left) and 250 g (right). Preoperative volumes were restored by placing under the TUG muscle a round textured implant. No complications occurred during the postoperative period both in the recipient and donor site and the outcomes of the procedure were good. In cases where the use of the DIEP flap is not possible because of past laparotomies or inadequate abdominal volume, the TUG flap plus implant may be considered as a valid alternative.