Manuel Francisco Castello

Modified Superficial Musculoaponeurotic System Face-Lift: A Review of 327 Consecutive Procedures and a Patient Satisfaction Assessment

BackgroundA conventional superficial musculoaponeurotic system (SMAS) face-lift is well established because it allows the skin envelope to be rotated in a bit more lateral direction than the cephalad redirection of the SMAS flap. This ensures an individualization of the treatment plan according to the needs of the patient and avoids a postoperative stretched look. However, this technique has some limitations with respect to its long-term effects on the sagging tissue, inadequate lifting of the malar fat pad, and flattening of the nasolabial fold.MethodsThe procedure described by the authors consisted of a modified approach to conventional SMAS flap dissection for 327 patients with facial aging signs undergoing a face-lift. A pointing tongue-shaped flap of zygomaticotemporal fascia was dissected and preserved in the posterior half of the upper edge of the SMAS flap and anchored to the deep temporal fascia, enhancing the vertical support of the facial soft tissues. Outcomes were determined by case notes, clinical review, and a questionnaire.ResultsThe study investigated 327 consecutive modified SMAS face-lifting procedures. Few complications were observed. Only two patients experienced small hematomas needing evacuation. Some patients reported bearable pain in the temporal region and tension during mouth opening. Temporary weakness in the branches of the facial nerve experienced by two patients resolved completely within some months. Two patients presented with dehiscence of the scar, and one patient experienced punctual retroauricular skin necrosis, which healed uneventfully with conservative treatment. Two patients reported that the knot in the temporal region was palpable through the skin. One patient experienced retroauricular infection. Only two patients required additional procedures. One mild hypertrophic scar responding to steroid injection over the mastoid area was observed in the entire series. With the reported technique, the authors achieved pleasing, natural, durable results with minimal morbidity and an overall complication rate of 3.9%. All the patients were sent a satisfaction questionnaire or contacted for a telephone interview. A total of 235 patients replied. The patients reported high levels of satisfaction after treatment.ConclusionsThe authors believe that the rhytidectomy technique described in this report has several beneficial attributes. High vertical elevation of the SMAS flap delivers a long-lasting benefit and addresses the problem of neck laxity and platysma redundancy, leading to a correction of the neck contouring and jowls. Nasolabial folds appear to be smoothed, and malar flattening is restored by imbrications of the SMAS flap over the cut edge in the malar prominence. This investigation demonstrates that the rhytidectomy technique is safe and produces highly predictable results.

Osteoarthritis in the hands of Michelangelo Buonarroti

Davide Lazzeri, Manuel Francisco Castello, Marco Matucci-Cerinic, Donatella Lippi and George M Weisz Plastic Reconstructive and Aesthetic Surgery, Villa Salaria Clinic, Rome, 00139 Italy Center for Medical Humanities, Department of Experimental and Clinical Medicine, University of Florence, 50134 Italy Department of Experimental and Clinical Medicine, Division of Rheumatology AOUC, University of Florence, 50134 Italy School of Humanities, University of New South Wales, Sydney, 2052 Australia School of Humanities, University of New England, Armidale, 2351 Australia Corresponding author: Davide Lazzeri. Email: davidelazzeri@gmail.com

Goiter in portraits of Judith the Jewish heroine.

Judith was a legendary Hebrew heroine who beheaded the general Holofernes and saved the children of Israel from destruction by the Assyrian army. In the Book of Judith, which is still present in the Catholic and Orthodox Christian Bibles, Judith is presented as an illustrious woman who defeated the enemy using her virtue and fortitude. The present investigation has revealed 24 portraits in which Judith has been depicted with variable grades of thyroid gland enlargement on the scene where she decapitates Holofernes. There is no doubt that the integration of a slight thyroid enlargement in the paintings is a stylistic hallmark that portrays an idealized female beauty with a balanced neck and graceful body. The large extended goiter was probably depicted by the artists as a symbol of a powerful masculine body and her courage, and at the same time, it probably also reflects better anatomic accuracy and knowledge of artists from that period.

A Simple Method to Inset and Position Polyurethane-Covered Breast Implants

AbstractBackground Polyurethane-covered breast implants have been used increasingly for cosmetic and revision breast surgery. The incision for insertion should be of minimal length and the placement of these implants in the pocket can be more difficult than that of conventional implants because of the highly adherent textured surface of the polyurethane external layer that grasps the surrounding tissues. The use of a sterile plastic insertion sleeve that is open on both sides is suggested by the manufacturer to overcome the friction between the polyurethane implant and the skin and surrounding tissues.MethodsA new method to facilitate polyurethane implant insertion and adjustment in all cases of primary breast augmentation and revision surgery is presented. After the implant, which is in the sleeve, is located in the pocket, the plastic sleeve is filled with saline and antibiotics so the solution lubricates the surface around the implant. The sleeve is then twisted so that the solution is squeezed inside the pocket while the sleeve itself is pulled back and removed.ResultsBetween 2010 and 2013, this method was used in 73 cases of primary augmentation and revision breast surgery without any complications.ConclusionThe method described here allows for easier removal of the plastic sleeve during polyurethane implant insertion without any complications or evidence of implant migration or rotation at follow-up.Level of Evidence IVThis journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266.

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.

The Mystery of Michelangelo Buonarroti’s Goiter

Whilst painting the vault of the Sistine Chapel, Michelangelo Buonarroti left an autographical sketch that revealed a prominence at the front of his hyper-extended neck. This image was recently diagnosed as goiter. The poet Michelangelo in a sonnet dated 1509 described himself as being afflicted by goiter similarly to the cats in the northern Italian Lombardy, a region with endemic goiter. Several narratives extended this sonnet into a pathological theory. The analyses of Michelangelo’s works, however, his portraits and self-portraits, of poems and major biographies, have not indicated the likelihood of goiter. This investigation makes an attempt to assess the diagnosis on clinical as well as iconographical grounds.

Breast Mass in a Rubens Painting.

Deformity of the breast and axilla observed in famous paintings is a fascinating field for the medico-artists. The attempt of a retrospective diagnosis of breast tumors is highly challenging. This paper deals with a Rubens painting portraying the heroine Judith with a visible but previously unreported left breast mass. Though speculative, the present medico-artistic diagnosis is of a tumor likely to be of benign nature. It is of interest that the present case is the sixth breast disease discovered in Rubens’s works.

Three-dimensional Superficial Liposculpture of the Hips, Flank, and Thighs.

Background: In the last 3 decades, liposuction has become a mainstay of the plastic surgeon’s armamentarium, and the technique has evolved considerably. We retrospectively review all of the liposuction procedures that we performed over the past 20 years. Methods: The principles of superficial 3-dimensional liposuction with respect to preoperative, intraoperative, and postoperative management of patients scheduled to undergo liposuction of the hips, flanks, and thighs were described. Results: A total of 4000 patient charts were reviewed. The results indicated that 50 patients experienced a postsurgical seroma that was resolved after syringe aspirations. One patient developed a major mycobacterial infection that was resolved after antibiotic therapy. Twenty patients complained of minor asymmetries that were corrected 6 months later under local anesthesia; 18 patients suffered from minor skin irregularities, which improved after lipofilling. In 6 cases, transient hyperpigmentation (6–12 months) of the skin before the use of suction drainages in the removal of large adiposities in patients with light skin was experienced, and in 2 cases, transient paresthesia (8 and 10 months) was experienced. No skin necrosis, deep vein thrombosis, or death occurred. Conclusions: If performed correctly, 3-dimensional superficial liposuction of the trunk, hips, and thighs can yield very satisfying outcomes because of the excellent contour and the enhanced skin retraction provided by the thin cutaneous adipose flap. Three-dimensional liposuction is a reliable method with proven results. A careful application of the technique combined with accurate surgical planning, a thorough preoperative explanation of real expectations, and postoperative care is crucial.