Marco D'Ettorre

“Kris Knife” Brachioplasty After Bariatric Surgery and Massive Weight Loss

Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of

Recurrent inverted nipple: a reliable technique for the most difficult cases.

AbstractThe inverted nipple is a frequent pathologic condition, involving up to 10% of women. This deformity results in a negative self-image for the affected patient. Recurrence after corrective surgery is possible and may represent extreme frustration for the patient and the surgeon. The aim of our study is to propose a useful and reliable technique to employ in case of recurrence or severe inverted nipple. During 2000 and 2010, the study was conducted on 19 patients treated with this procedure: 10 patients (20 nipples) having severe inverted nipple (grade III according to Han and Hong classification) and 9 patients (15 nipples) presenting with relapses. One nipple could not be corrected. One patient developed a temporary loss of sensibility. No major complications (necrosis, infection, hematoma, and permanent numbness), no recurrences, and no noticeable scars have been reported at follow-up. In our series, the shape and the projection after the procedure were evaluated as satisfactory by the patients, remained consistent over time, and no protective devices were required. In conclusion, although our technique is not the best in terms of invasiveness, it is one of the few truly effective ones in treating relapses. For patients who have already undergone surgery, the priority is certainly to solve this clinical anomaly and the psychological sequelae; a “microincision” or a scar-free technique is the secondary aspect to be taken into account.

Dermal histomorphology in postbariatric patients: bilopancreatic diversion versus gastric bypass.

To the Editor: W e read with great interest the article recently published in your journal entitled ‘‘Changes in Dermal Histomorphology following surgical weight loss versus dietinduced weight loss in the morbidly obese patient’’ by Fearmonti et al. It is a relevant article from a scientific point of view comparing the histomorphological differences between patients who previously underwent gastric bypass and diet. As mentioned in the article, obesity is a widely spread disease, associated with a series of problems, both psychological and physical. This is the reason why morbidly obese people are more frequently addressing the treatment that ensures them the best results in terms of weight loss durability and entity: bariatric surgery. However, it is strictly linked to numerous sequelae, mainly an excess of skin necessitating body contouring operations. One problem plastic surgeons usually face when operating on bariatric patients is the relatively high wound complication rate. Despite many theories that have been postulated, an adequate explanation is still awaited. A multifactorial origin can be hypothesized. In recent articles by our team researchers, malnutrition, reduction of tissue protein, and hydroxyproline plus microscopic and macroscopic skin modifications were simultaneously involved in the aberrations of wound healing in bariatric patients. In particular, the histological modifications documented in these patients are probably partly responsible for such disturbances. As clearly stated by Fearmonti et al, the excess skin laxity in bariatric patients is due to adipose tissue resorption and remodeling. In addition, elastic fibers are responsible for retractile properties of the skin. In the study, they observed a mixture of normal and fragmented elastic fiber architecture. There was also a trend toward normal elastic fiber composition and mild inflammation, in association with an increased wound complication rate with regard to the nonsurgical group. Although no gross histological differences in the subcutaneous fat were revealed between the 2 groups, previous studies did. In particular, Levy et al showed small, poorly defined lobuled and tenuous fibrous connections to the deep dermal layer with a disorganized superficial fascial system in bariatric patients. Previously, examining cutaneous and subcutaneous tissue samples taken from the horizontal scar during abdominoplasty, our group documented anomalies of the dermal elastic (overgrowth, disarray, greater dimensions, serpiginous and polyfragmented aspect, occasional increment in number) and collagen (thickened, hyperosinophilic, and sclerodermoid) fibers. Moreover, modifications involving the subcutaneous tissue such as diffuse sclerosis, collapsed adipocytes, fibrous septum thickening, and pseudocysts were noted. Finally, in the extracellular matrix, there was evidence of persistent inflammation (Fig. 1). Our experience with body contouring for massive weight loss after bariatric surgery primarily involved biliopancreatic diversion, a mainly malabsorptive bariatric procedure. However, in a recent preliminary study we performed on postgastric bypass patients, a restrictive technique, patients revealed differences in terms of histological results: dimensional and numerical increase of elastic fibers, which appeared as irregular polyfragmented clusters (similar to elastic nevus), moderate hypereosinophilic collagen fibers having a great distance among them, fibroblasts incremented in number, hypertrophic adipocytes (miming lipoma) with septum thinness dividing them, and absolute absence of inflammation (Fig. 2). It is of great interest that differences are noticeable among patients undergoing different surgical bariatric techniques. Moreover, discordant results are also documented in patients after the same operation. In fact, in postgastric bypass patients, no substantial aberrations were evidenced by Fearmonti et al in the subcutaneous tissue. By contrast, mild inflammation was prevalent. This is probably due FIGURE 1. Skin histologic features of a postbariatric patient who had previously undergone biliopancreatic diversion. See text for details.

S-shaped brachioplasty: an effective technique to correct excess skin and fat of the upper arm.

675e S-Shaped Brachioplasty: An Effective Technique to Correct Excess Skin and Fat of the Upper Arm Sir: W read with interest the article by Aboul Wafa entitled “S-Shaped Brachioplasty: An Effective Technique to Correct Excess Skin and Fat of the Upper Arm”1 published recently in the Journal. In the article, the author proposes a procedure granting good contour and a fine noncontracting scar, resembling an S line located on the medial side. He also agreeably states that there is no universal technique addressing all arm contour deformities. In fact, attention must be paid in case of surgically induced massive weight loss patients, whose extreme tissue laxity deserves proper management. Our team, greatly experienced with bariatric patients, recently proposed an innovative, safe, and repeatable surgical technique, called “kris knife” brachioplasty, recalling the name of the Asian wavy blade.2 As demonstrated previously, the aforementioned category of patients is at higher risk for complications. Therefore, the safety and reliability of any body contouring techniques should be tested on them. In our study, on 33 patients, only six minor complications were recorded. According to our technique, preoperative skin markings are better defined by Steri-Strips (3M, St. Paul, Minn.), used to evaluate the skin excess to be removed. After infiltration with a solution of 200 cc of cold saline and 1 mg of adrenaline, liposuction is performed. Brachial incision is drawn so that the axis line, which will be the final scar after closure, results not in a straight line but in a sort of S-shaped, tension-free pattern. An ellipse is also drawn in the axilla, to correct ptosis and skin excess. By joining the lateral edge of the axillary ellipse with the brachial one, it is possible to create two V flaps (Figs. 1 and 2). Despite an apparently similar incision, a few points differ and deserve mention. It is mandatory to define in advance the amount of skin excess to be removed. In particular, we proposed the use of Steri-Strips, minimizing the risk of overresection or underresection. Moreover, to better deal with vertical and transverse redundancy, we opted for an elliptical resection in the axilla too. No scars are visible and a better lift effect is elicited. In addition, the brachial skin incision does not reach the anterior side of the arm; thus, the result can be easily hidden. Liposuction is agreeable, reducing skin retraction, facilitating tissue undermining, and minimizing nerves and lymphatic structure injury. Minimal undermining results in no dead space, no effusion, and proper healing. Moreover, brachial compressive dressings can minimize the accumulation of fluids and secretions. As a result, the incidence of seromas also decreases. Another very important element contributing to our low complication rate is probably the limited use of electrocautery, as we prefer a cold blade. In fact, this approach prevents tissue from necrotizing and ischemic action and possible drawbacks such as skin necrosis. Accurate hemostasis is mainly guaranteed by initial infiltration with adrenaline, allowing a bloodless operating field. The technique described in this communication has shown usefulness for correcting arm deformities in post–bariatric surgery patients, providing stable results. It is safe and reliable and linked to a low rate of complications, which have been minor. DOI: 10.1097/PRS.0b013e31829fe259

A suspected squamous cell carcinoma in a renal transplant recipient revealing a rare cutaneous phaeohyphomycosis by Alternaria infectoria.

Background: Squamous cell carcinoma of the skin is the most common neoplasm after organ transplantation. In addition, fungal infections are increasingly described in immunocompromised patients, such as kidney recipients. Method and Results: We report a case of a 64-year-old woman with a renal transplant presenting with 6-month-old skin lesions. In other centers, she had undergone previous biopsies, the results of which were suggestive of squamous cell carcinoma and aspecific inflammation. Therefore, she came to our center for surgical excision. Only our clinical experience and a detailed clinical history allowed us to doubt previous diagnoses and perform further examinations. Our investigation revealed an extremely rare fungus infection: phaeohyphomycosis by Alternaria infectoria. It was successfully treated with oral terbinafine until a complete regression of the lesions was achieved. At a 16-month follow-up visit, no recurrence of the skin lesion was observed. Conclusion: Despite a difficult diagnosis and rare occurrence, physicians and surgeons should be aware of infection with this emerging fungus in immunocompromised patients.

A technique to make spreader graft fixation easier

1. Lunatschek C, Schwipper V, Scheithauer M. Soft tissue reconstruction of the nose. Facial Plast Surg. 2011;27:249–257. 2. Yoshihiro S, Kenichi N, Toshiaki N. Reconstruction of larger nasal defects together with the nasal lining and the upper lip using the split-scalping forehead flap: A new technique. J Plast Reconstr Aesthet Surg. 2011;64:1108–1110. 3. Kheradmand AA, Garajei A, Motamedi MH. Nasal reconstruction: Experience using tissue expansion and forehead flap. J Oral Maxillofac Surg. 2011;69:1478–1484. 4. Fujioka M, Tasaki I, Yakabe A, Komuro S, Tanaka K. Reconstruction of velopharyngeal competence for composite palatomaxillary defect with a fibula osteocutaneous free flap. J Craniofac Surg. 2008;19:866–868. 5. Nakatsuka T, Harii K, Asato H, et al. Analytic review of 2372 free flap transfers for head and neck reconstruction following cancer resection. J Reconstr Microsurg. 2003;19:363–368; discussion 369. 6. Henry EL, Hart RD, Mark Taylor S, et al. Total nasal reconstruction: Use of a radial forearm free flap, titanium mesh, and a paramedian forehead flap. J Otolaryngol Head Neck Surg. 2010;39:697–702. 7. Tsiliboti D, Antonopoulos D, Spyropoulos K, Naxakis S, Goumas P. Total nasal reconstruction using a prelaminated free radial forearm flap and porous polyethylene implants. J Reconstr Microsurg. 2008;24:449–452. 8. Swartz WM, Banis JC, Newton ED, Ramasastry SS, Jones NF, Acland R. The osteocutaneous flap for mandibular and maxillofacial reconstruction. Plast Reconstr Surg. 1986;77:530– 545. 9. Koshima I, Tsutsui T, Nanba Y, Takahashi Y, Akisada K. Free radial forearm osteocutaneous perforator flap for reconstruction of total nasal defects. J Reconstr Microsurg. 2002;18: 585–588; discussion 589–590. 10. Keck T, Lindemann J, Kühnemann S, Sigg O. Healing of composite chondrocutaneous auricular grafts covered by skin flaps in nasal reconstructive surgery. Laryngoscope 2003; 113:248–253. 11. Menick FJ, Salibian A. Microvascular repair of heminasal, subtotal, and total nasal defects with a folded radial forearm flap and a full-thickness forehead flap. Plast Reconstr Surg. 2011;127:637–651. 12. Burget GC, Menick FJ. Nasal support and lining: The marriage of beauty and blood supply. Plast Reconstr Surg. 1989; 84:189–202. 13. Walton RL, Burget GC, Beahm EK. Microsurgical reconstruction of the nasal lining. Plast Reconstr Surg. 2005;115: 1813–1829. 14. Atiyeh BS, Hussein MM, Tayim AM, Zaatari AM, Fakih RR. Early microvascular reconstruction of Gustilo type III-C lower extremity wound: Case report. Scand J Plast Reconstr Hand Surg. 1997;31:351–355. 15. Pho RW. Free vascularised fibular transplant for replacement of the lower radius. J Bone Joint Surg Br. 1979;61:362–365.

Abdominal Subcutaneous Mass After Laser-Assisted Lipolysis and Immediate Multiple Treatments with a Dual-Wavelength Laser, Vacuum and Massage Device

UNLABELLED Body contouring by means of minimally invasive procedures is a growing trend. Current approaches to body contouring often involve a combination of surgical techniques (eg, laser-assisted liposuction) and a series of noninvasive device-based treatments aimed at accelerating recovery and improving aesthetic outcomes. In this case study, we describe a 38-year-old woman who presented with an abdominal-wall mass that resembled a tumor when assessed with magnetic resonance imaging. Twenty-six months before presenting to our office, the patient had undergone laser lipolysis and a series of treatments with a device that delivered dual-wavelength laser energy and vacuum-assisted massage. To address the patients concerns, we removed the mass and performed abdominal dermolipectomy. No postoperative complications occurred, and the patient was highly satisfied with the aesthetic outcome. The results of histologic studies indicated that the mass was pseudocystic and fluid-filled, surrounded by a fibrous capsule, and characterized as a foreign-body granuloma. Further analysis is warranted regarding the safety of laser lipolysis without aspiration combined with a device delivering dual-wavelength laser energy and vacuum-assisted massage. LEVEL OF EVIDENCE 5 Risk.

Was the Surgeon a Satisfactory Informant? How to Minimize Room for Claims

Patient demand and expectations for plastic surgery have significantly increased over recent decades, leading to an increasing trend in claims. This—arguably, the result of a progressive lack of communication between surgeons and patients—becomes apparent in inadequate informed consent, as previously highlighted by Patel et al.1 Surgeons have the moral and legal obligation to adequately clarify for their patients everything concerning such operations and cannot perform any procedure without written patient consent. In fact, this aspect of the process allows patients to take active part in their own health care.2 Well-informed patients generally have good compliance and few anxieties and malpractice claims to raise. Despite this, the everyday clinical process may offer a different scenario: the legal formula of informed consent often becomes a mere act of hurriedly …

A trick in steri‐strips application: the zig‐zag pattern

Dear Editors, Adhesive strips are a fundamental device to achieve better wound closure, sometimes avoiding superficial sutures. Time-effective removal, easy application and early detection of infections are the key points to fulfill. An easy manner to achieve those goals is herein presented. As stated in a paper by Katz et al., steri strips are used in a number of settings: for adjunctive wound support after stitch removal or in conjunction with buried dermal or absorbable running subcuticular sutures in low-tension wounds (1). Adhesive surgical tape originated as a wound dressing, being laid without tension over and in line with the surgical wound. It evolved as a method of wound closure, applied perpendicular to the wound and with tension. This arrangement increases the inward elastic recoil of the tape, theoretically aiming to relieve outward forces that favour dehiscence of the wound edges. Modern operative surgical techniques recommend, despite a lack of proved evidence, a wound closure method of continuous absorbable subcuticular suture, reinforced by adhesive tape (2,3). Studies have shown that taped closure has the advantages of lower wound infection rates and greater wound tensile strength, but also the disadvantages of skin edge inversion, unsure safety and the time required for meticulous surgical technique. The use of the continuous absorbable subcuticular suture allows accurate skin edge approximation, which increases the safety margin. In our series, double closure technique using both subcuticular sutures and natural skin tone color adhesive strips is usually performed. As evidenced by the literature, steri strips are usually positioned perpendicularly to the wound and parallel to one another in a non-overlapping fashion. Other authors suggest, in certain circumstances, application of adhesive tape parallel to the wound in order to prevent the formation of blisters and shearing effect on the skin (4). However, according to our experience, another useful and effective manner to place them is to arrange them head-to-tail, diagonally to the wound and perpendicular to each other (‘zig-zag’ pattern), such that the underlying wound could be seen. Furthermore, strips of half the width would be sufficient (Figure 1). There are several reasons why this solution is preferable. Firstly, the distribution of tension forces is excellent. All the stitches are positioned in order to create a continuous line, with uniform strength applied all over the wound. Moreover, sliding of the wound margins is prevented, thanks to opposite stabilizing forces. Secondly, removal is extremely easy and rapid. In fact, the advantage of the continuous line is linked to the possibility to pull the tail on one side and a little later to raise the head on the other one. Figure 1 The picture clearly shows the use of a ‘zig-zag’ pattern of steri-strips application, reinforcing a subcuticular suture.

Diagnostic challenge of a proliferative nodule in a desmoplastic hairless hypopigmented nevus

ejd.2012.1820 Auteur(s) : Roberto Bracaglia1, Damiano Tambasco1 damtam@hotmail.it, Ilaria Pennacchia2, Marco D’Ettorre1, Stefano Gentileschi1, Vincenzo Arena2, Giuseppe Fabrizi3, Guido Massi2 1 Department of Plastic and Reconstructive Surgery, 2 Department of Histopathology, Catholic University of the Sacred Heart, University Hospital A.Gemelli, 00168 Rome, Italy 3 Department of Dermatology, University of Parma , Parma, Italy Desmoplastic hairless hypopigmented nevus (DHHN) is an extremely rare [...]