Marco Mazzocchi

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.

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.

Evidence-Based Evaluation Technique to Assess Augmentation Mammaplasty Results: A Simple Method to Objectively Analyze Mammary Symmetry and Position

BACKGROUND Despite the great variety of mammaplasty techniques, outcome assessment remains a challenging issue. OBJECTIVES The authors devised an objective method to evaluate mammary symmetry based on statistical analysis of objective manual breast measurements and validated the method by applying it to results of a randomized controlled trial on the correction of breast asymmetry. METHODS Sixty consecutive patients with hypoplastic breasts and small-volume asymmetry were enrolled in the study and randomly assigned to 1 of 2 groups. One group received a fixed-volume implant in 1 breast and an adjustable-volume implant in the other. The other group received 2 fixed-volume implants of different sizes. The differences in specific breast and chest measurements, obtained before surgery and during follow-up, were analyzed statistically with the Wilcoxon signed rank test. RESULTS Correction of the asymmetry resulted in the reduction of the differences between left and right values for each specific breast measurement. Placement of an adjustable implant on 1 side yielded better symmetry than placement of 2 fixed-volume prostheses of different sizes. Patient and physician satisfaction was high for both groups. CONCLUSIONS This objective analysis of clinical parameters enables comparing results for different patients in large clinical trials and for the same patient at different follow-up periods. LEVEL OF EVIDENCE 3.

Retention of polyurethane foam fragments during VAC therapy: a complication to be considered

Vacuum‐assisted closure (VAC) therapy is a closed‐loop, non‐invasive active system, characterised by a controlled and localised negative pressure applied on porous polyurethane absorbent foams. It promotes healing of acute and chronic wounds. Therapeutic effects of VAC therapy have been proved and demonstrated; however, this method can have some disadvantages. Even if it is a quite versatile device, only qualified medical/paramedical personnel should use it in order to avoid possible complications that can occur after an improper application. In this report, 11 cases of foam‐fragment retention within the wound are presented. This rare complication did not promote healing, but further hindered it. On the basis of our experience, it is mandatory to define the indications, benefits and limitations of VAC therapy.

Surgical treatment of nasal non-melanoma skin cancer in elderly patients using dermal substitute.

Abstract Conclusions: The nose is often involved by non-melanoma skin cancer (NMSC) and the increase in the incidence of such tumors, the morbidity and treatment-related costs represent a significant burden to healthcare systems. A bioresorbable dermal substitute (Hyalomatrix®) has been used for immediate dermal coverage and nose restoration after excision of infiltrating nasal NMSCs in elderly ASA III patients. Further studies on dermal substitutes are needed to improve benefit to patients. Objective: Surgical treatment of nasal non-melanoma skin cancer (NMSC) in elderly patients. Materials and methods: Ten elderly ASA III patients with nasal defects after resection of infiltrating NMSC were reconstructed in a two-stage strategy. The surgical protocol targeted an initial wide tumor excision and apposition of a dermal induction template (Hyalomatrix®) and successive full thickness skin autograft. Results were documented by photography, visual analog scale for patient satisfaction, and Vancouver scar scale for evaluation of final graft characteristics. Results: All patients were tumor-free during the 2 years follow-up. The procedure achieved acceptable nose reshaping and graft scarring evolution. Patient satisfaction was good-to-high.

Association between abdominal separation and inguinal or crural hernias: Our experience and surgical indications

Abstract Abdominal wall weaknesses present several causative factors, both local and systemic and, as a consequence, abdominal hernias may develop in more than one site. Also, simultaneous hernia repair has been rarely reported in published reports. In the present study, the association of multiple weaknesses of the abdominal wall in patients undergoing conventional abdominoplasty or hernia repair were evaluated, and the advantages of simultaneous repair in a single operation are discussed. In a 3-year time period, all patients undergoing abdominoplasty or abdominal hernia repair were clinically and instrumentally evaluated for the association between median abdominal wall weakness and inguinal and/or crural hernias. The body mass index (BMI) was also considered and photographic documentation was taken before the operation and during the follow-up. When this association was confirmed, patients underwent contemporary correction of both conditions using an abdominoplasty approach. The presence of inguinal and/or crural hernias was observed in 10% of all patients undergoing conventional abdominoplasty and in 14.5% of patients with laparocele in the institution. The BMI was higher in patients with the association than in those without. Good aesthetic and functional results were achieved and the complication rate was low. The role of obesity as a triggering factor of abdominal wall weaknesses is confirmed by the higher BMI in patients with associated diseases. These observations remark the fact that the association between median abdominal wall weakness and inguinal or crural hernias should always be investigated. If this association is confirmed, it is preferable to treat both conditions simultaneously.

Preliminary report on the effect of cyanoacrylates on the maturation process of hypertrophic scars.

Preventive and therapeutic treatments for pathologic scarring are reported. More than 100 clinical studies on pathologic scar therapy have been published over the last 25 years, although few of these have been prospective controlled studies based on corroborated data. Nevertheless, every attempt must be made to prevent or treat pathologic scars. An accurate surgical technique and prevention of postsurgical infection are of primary importance. Moreover, special attention should be paid to high-risk patients.

Merkel cell carcinoma in the orbitopalpebral region.

Trabecular carcinoma is a rare cutaneous neuroendocrine carcinoma that probably originates from the Merkel cells that are usually found in the basal layer of the epidermis. The treatment of Merkel cell carcinoma is controversial and there is no specific therapeutic protocol because of the small number of cases that have been published. The procedures used to treat Merkel cell carcinoma must be tailored to minimise morbidity while maximising survival. Because the condition is so rare and difficult to diagnose and treat, we report three cases of orbitopalpebral tumours that confirm the local and regional aggressiveness and the high metastatic potential of this tumour.

Skin cancers and dermal substitutes: Is it safe? Review of the literature and presentation of a 2‐stage surgical protocol for the treatment of non‐melanoma skin cancers of the head in fragile patients

Non‐melanoma skin cancers (NMSC) represent the most common skin tumours of the head region. We describe the use of dermal substitute in a 2‐stage surgery protocol for selected fragile patients to remove NMSC of the head region. A review of the literature focusing on dermal substitutes’ safety after skin tumours excision is provided. A total of 45 fragile patients with NMSC in the head region were selected and scheduled for the 2‐stage surgical protocol. The first stage consisted of traditional surgical excision and immediate coverage with Hyalomatrix (Fidia Advanced Biopolymers, Abano Terme, Italy). After histology confirmed diagnosis and clearance of the margins, full‐thickness skin autografts were performed. All of the patients reached complete tumour excision and wound healing. No local recurrences were registered during 24 months follow up. The 2‐stage surgical therapeutic‐diagnostic‐reconstructive approach represents a less stressful and oncologically safe surgical protocol in selected fragile patients. When patients cannot tolerate invasive and long surgical procedures, general anaesthesia, and long hospitalisation, skin grafting following temporary skin substitute coverage can achieve oncological clearance and provide good functional and aesthetic results. The use of dermal substitutes represents a valid alternative surgical option in cases of ASA III, fragile patients non‐eligible for complex reconstructive surgery. To our knowledge, this is the first paper reviewing literature focusing on dermal substitutes’ applications and safety after skin tumour excision.

The Double-Opposing “Y” Technique for Umbilicoplasty in Abdominoplasty and for Umbilical Reconstruction After Omphalectomy

Umbilical reconstruction is a main step during abdominoplasty; surgeon aims are minimal visible scars and natural-looking result. Scar evidence or retraction with umbilical stenosis may occur. A modified technique for umbilicoplasty, with a double-opposing “Y” incision on abdominal flap, is described. Surgical technique: in case of repositioning, umbilical skin is vertically incised; umbilical dermis is attached to abdominal rectus fascia; the site of umbilicus repositioning is determined by its projection on abdominal flap; a small double-opposing “Y” skin incision is made at this point. In case of previous or concurrent one omphalectomy, in the estimated new umbilical site, a double-opposing “Y” incision is performed on the abdominal flap, and the dermis of the opposing flaps is directly sutured to the abdominal deep fascia. The vertical size of a double-opposing “Y” is approximately the same of the original umbilicus; the angle and the size of the four lateral incisions can be modified according to the width to be obtained; defatting is essential. This technique gives a natural depth appearance, ensures optimal position, pulls scars deeply, avoiding visible scars, and recreates different shapes according to patient’s habitus. Any umbilical size, either in obese or thin patients, can be created. The double-opposing “Y” incision reinforces the vertical shape, creates natural umbilical dimpling, and prevents stenosis with stable results.