Manuela Bottoni

Aesthetic Refinement of the Dog Ear Correction: The 90° Incision Technique and Review of the Literature

The closure of any circular or asymmetric wound results in puckering or excess of tissue known as dog ears. Tissue dynamics, wound geometry, surface contour, and surgical technique affect dog ear formation [1,2]. Despite good preoperative planning for skin management techniques including Burows triangle, V-Y advancement flap, M-plasty [3], and S-plasty [4], and despite following intraoperative procedures including proper undermining of a shallow wound, proper 90° angle of the scalpel blade, precise suture placement, and removal of excess underlying fat, sometimes a dog ear occurs anyhow. Methods for correcting dog ears include excision of the excess tissue in the shape of a triangle, crescent or ellipse; excision of conical folds of tissue at the end of the wound in the same direction as the long axis of the original wound; and excision of the dog ear at a 120° angle to the long axis of the existing excision line in a shape resembling a hockey stick [5]. They are extensively described in the literature, but they all lead to wound extension. Only M-plasty allows for reduction in the scars length but produces a double-tailed scar, so if the total length with the two tails is considered, the new scar is still longer than the original one. We have developed a new and easy technique for dog ear correction without extending the length of the original wound.

Topical use of α‐tocopherol acetate in delayed wound healing

Dear Editors, Vitamin E, first described in 1922 by Evans and Bishop as an essential micronutrient for reproduction in rats (1), is a fat-soluble vitamin with important functions of maintaining the integrity of the intracellular membrane by protecting its physical stability and providing defence against any tissue damage caused by oxidation (2). Molecular and cellular effects of vitamin E have been explained by regulating membranes and proteins activities by specific reactive oxygen species (ROS) and nitrous oxide systems (NOS) or by interacting and regulating specific enzymes and transcription factors and influencing cellular structures such as membranes and lipid domains (3). Vitamin E is present in plants in eight different molecular forms with more or less equal antioxidant potential, nevertheless, in higher organisms only α-tocopherol (α-T) is preferentially retained suggesting a specific mechanism for the uptake for this analogue (4). As the natural vitamin E analogue is relatively unstable, several stabilised vitamin E derivatives [e.g. α-tocopherol acetate (α-TA)] have been synthesised for usage in supplements and cosmetics. These vitamin E derivatives are water-soluble esters of α-T that can be considered to be provitamins that are converted to their natural forms by epidermal esterases (5). A common phenomenon in patients with disorders in wound healing is the acute phase response resulting in elevated levels of inflammatory markers. An imbalance between proand antioxidants is suggested to favour cell damage and to enhance inflammatory process (6). The antioxidant capacity of α-TA and its effect on reprogramming of gene expression allow its topical use in skin diseases in which an inflammatory process is activated. Furthermore, it has been demonstrated that epidermal esterases remove the acetic acid from α-TA that may act against microorganisms simply by lowering the pH and creating an anhydrous environment unsuitable for their growth and multiplication (7). In the last 3 years, we have used α-TA for treatment of superficial burns, post-traumatic superficial ulcers and skin graft donor sites, even in presence of wound infection. The presence of exudate, pain and delayed reepithelialisation, absence of tissue necrosis and/or sepsis were criteria for topical use of α-TA, avoiding conventional treatments such as local antibiotics, polyurethane foams and other occlusive dressings (8). Bacterial growth was assessed in 35 patients; wound tissue cultures were obtained, 20 (57⋅1%) of 35 patients had positive results for bacterial cultures: all of them had a single organism infection. The isolated organisms cultured from the wound tissue were Staphylococcus aureus (N = 6, 17⋅1%), Staphylococcus epidermidis (N = 6, 17⋅1%), Pseudomonas aeruginosa (N = 4, 11⋅4%), Proteus mirabilis (N = 2, 5⋅71%) and Escherichia coli (N = 2, 5⋅71%). Three of the six S. aureus isolated were multiple antibiotic resistant microorganisms. A

Associated use of silicone–vitamin E gauzes and α-tocopherol acetate oil in healing of skin graft donor sites

Split‐thickness skin graft is one of the most used procedures in plastic surgery. This procedure involves numerous painful dressings at the donor site. α‐Tocopherol acetate has anti‐oxidative and anti‐inflammatory properties and it can reduce the local bacterial growth, thereby promoting wound healing. We designed a prospective study to evaluate the effects of two different kinds of dressings at skin graft donor sites. A total of 30 patients were subjected to daily dressings with α‐tocopherol acetate oil and traditional moist gauzes (group 1). Another 30 patients were subjected to dressings every 4 days with α‐tocopherol acetate oil and silicone–vitamin E gauzes (group 2). Healing time, infection rate, patients pain perception and costs were evaluated in both the groups. No statistically significant difference was found in terms of healing time. The infection rate was slightly different in the two groups. Significant reduction of pain perception was detected in group 2. In the same group, significant reduction in the total cost of the treatment was also observed. α‐Tocopherol acetate oil and silicone–vitamin E gauzes may represent a safe, simple, painless and inexpensive method for improving skin graft donor site healing.

Fat Transfer in Periprosthetic Capsule Contracture in Breast Reconstruction

Capsular contracture is one of the most frequent complications following breast augmentation where the capsule begins to squeeze or contract upon itself. The incidence of this phenomenon varies between 0.5 and 30 %, according to the experience of the plastic surgeon. The authors discuss the use of periprosthetic fat transfer in capsule contracture following breast reconstruction. Lipofilling fits well with the breast tissue over time and it adapts to the patient in a very natural way following weight and structural changes. There is still a lack of standardization in the techniques used, but trends towards time management and simplification of technique are appearing. Two cases are described.

Easy and cheap way to prepare skin extenders

Skin extender is a very useful method to repair wounds when oedema and skin retraction make a direct suture impossible. We have developed a new, simple and cheap way to prepare skin extenders based only on elastic vessel loops and metal clips stapler commonly used for skin suture and available in any operating room.

Lower-pole Shaping of the Breast by Means of a Double Glandular and Cutaneous Advancement Flap: The “Arrow” Flap

Summary: Lower-pole shaping of the breast is sometimes a difficult challenge when performing vertical mammoplasty. The problems mostly encountered are too large breast bases, persistent dog ears, which require long incision, and poor breast projection. We report a modification of the technique that we use in breast reduction so as to better shape the lower pole and to reduce revision surgery.

A Simple, Reliable, and Inexpensive Method for Seroma Drainage

Seromas and hematomas are relatively common complications of a variety of surgical procedures. In plastic surgery, they may occur in the postoperative period of abdominoplasty or abdominal wall reconstruction, mastectomy or breast reconstruction, lymphadenectomy, or voluminous neoplasm excision. Furthermore, in our experience, seromas are particularly common in surgical procedures involving the use of biological substitutes [1]. Clinical treatment of seromas is usually performed by repeated evacuation by means of suction using an appropriately sized syringe (usually 10-50 mL in volume) according to the amount of fluid to be evacuated [2]. In some cases, an ultrasound examination can highlight the depth, volume, and extension of the fluid. In the case of seromas that are more than 100 mL in volume, the use of several syringes is necessary. Whenever a syringe is filled, it should be replaced or depleted by unplugging it from the hypodermic needle, thus exposing the patient to a high risk of infection. Therefore, negative pressure cannot be maintained continuously [3]. In order to avoid these issues, we have developed a new and simple method that allows us to reduce the material used and to minimize the risk of infection. This device involves the use of basic materials that are easily available in every hospital: a hypodermic needle, preferably a 20 G syringe needle, and high-vacuum Redon drainage. For this system, we used a high-vacuum Redon bottle (Drainobag 300V Lock, B-Braun, Melsungen AG, Germany); however, any kind of drainage can be used. First, it is necessary to make an oblique incision in the terminal portion of the rubber connector, taking care not to excessively shape the rubber in order to maintain the negative pressure. It is now sufficient to plug the connector into the needle hub to achieve the drainage system (Figs. 1, ​,2).2). Usually, an accurate plug between the needle and the connector is sufficient to maintain the negative pressure. To avoid disconnections, due, for example, to the stretching of the drainage tube, a plaster may be added to the connection. Fig. 1 Equipment for seroma drainage system: a 20 G hypodermic needle (alternatively a 21 G hypodermic needle or a needle cannula), high-vacuum Redon drainage, and a blade. Fig. 2 The assembled seroma drainage system. In the box, the system with the cannula needle. After pricking the skin and identifying the seroma, it is possible to open the drainage. The liquid will be drained from the drainage system without the use of different syringes. If a change of the drain site is necessary, simply close the Redon, prick the skin in another site, and reopen the drainage. It will suck the liquid without losing the negative pressure. This simple technique offers many advantages such as the availability of the required materials, lower risk of infection due to absence of material changing, a reduction in the risk of losing seromas (possible during the syringe changes), easier handling of the needle as compared to the whole syringe, a reduced number of devices with a decrease in costs, and higher accuracy of the drained fluid volume quantification. This easy drainage method can be used daily for both seromas and liquid hematomas. It is also possible to connect a cannula needle [4] as an alternative to the simple needle. This can be attached to the skin appropriately in order to obtain permanent aspiration. This technique appears to be more accurate and cheaper than traditional drainage methods and can be an excellent alternative in voluminous seroma drains.

Extensive Characterization of Stem Cells Derived from Skin

A stem cell is defined by two main parameters: the ability to have many division cycles maintaining the undifferentiated state (self-renewal) and the ability to differentiate into all mature cell types (unlimited potential). The authors describe the various types of stem cells and their functions.

The Inverted Dual Plane Mastoplasty Technique

Aesthetic breast augmentation is usually performed in a retromammary plane (behind the breast parenchyma), when breast parenchyma is enough to cover the implant or in case of active sport patients, or in a retropectoral plane (behind pectoralis muscle and serratus) in all other cases. In some cases, where mammary gland is mostly located on the lower pole, the implant can be partially placed behind the pectoralis major muscle and partially behind the breast parenchyma (partial retropectoral). The dual plane inverted technique consists, such as in the classical dual plane method, in positioning the prosthesis partially under the pectoralis major muscle and partially under the mammary gland. The difference, compared to the classical method, consists in covering the implant using the lower third of the pectoralis major muscle, thus leaving the implant to be covered by the mammary gland on the upper two thirds, so creating a kind of lifting of the breast, obtaining a mastopexy effect. The technique is described.