Matteo Campana

Late-onset gluteal Escherichia coli abscess formation 7 years after soft tissue augmentation with Bio-Alcamid™ in a HIV-positive patient

In 2002, a 41-year-old woman had been treated for severe buttock lipodystrophy resulting from highly active antiretroviral (HAART) therapy medication. During a single session the loss of subcutaneous fatty tissue had been compensated by injections of an undefined quantity of polyalkylimide 4% (Bio-Alcamid , Polymekon Biotech Industry, Milan, Italy). The post-treatment course had been uneventful and the patient had initially been satisfied with the result of this treatment. Seven years later, the patient presented with a redness and swelling of the area (Figure 1) by our unit. The area was hard and extremely painful on touch. All previous antibiotic therapies led only to temporary relief of these symptoms. A bedside drainage of the abscess was performed through a 20-gauge intravenous cannula that was inserted in the thin collagen capsule

Mesotherapy Should not Replace the Surgical Approach in the Treatment of Benign Symmetric Lipomatosis

We comment on the article by Hasegawa et al. [1] entitled Mesotherapy for Benign Symmetric Lipomatosis. Benign symmetric lipomatosis is a rare disorder characterized by multiple, symmetric, nonencapsulated fat masses in different body areas creating significant cosmetic deformity. Brodie [2] first described benign symmetric lipomatosis (BSL) in 1946, and Madelung [3], who named the syndrome, further characterized it, reporting 33 cases in 1888. Madelung disease usually is found between the third and seventh decade of life in middle-aged men of Mediterranean descent with a significant history of alcohol abuse [4]. In type 1 syndrome, the neck region and upper part of the trunk are involved, with a possible extension into the mediastinum. These masses generally are asymptomatic, but dysphagia, airway compression, and functional disability with neck movement limitation often have been described. A diffuse involvement of the body is seen in type 2 disorder, leading to an overweight-like aspect of the patient. Aesthetic deformities and peripheral neuropathy coupled with reports of movement limitation could be considered the major problem of Madelung disease. In only one case has malignant transformation of benign fatty masses been described [5]. At this writing, the true origin of Madelung disease is not clear. The most plausible advanced hypotheses are represented by an enzymatic defect or an alteration in the membrane receptors that would cause a reduction in adrenergic mediated lipolysis [6–9], a sympathetic denervation of brown fat adipocytes that would result in their hypertrophy [7], and mutations in the mitochondrial DNA [6, 8, 10]. In this context, alcohol could work as a cofactor by causing a reduction in both the number and activity of b-adrenergic receptors, promoting lipogenesis. However, alcohol intake certainly could not be the only cause of Madelung disease because the disorder is found also in patients who do not abuse alcohol. Association with several metabolic disorders such hyperuricemia, hyperlipidemia, diabetes mellitus, hypertension, hepatic disease, hypothyroidism, and renal tubular acidosis also is described in the literature [11–13]. Because the real etiology of Madelung disease still is unknown, only symptomatic treatment may be offered to patients. Alcoholic abstinence and correction of associated metabolic abnormalities are advocated to reduce the relapse rate once these patients have undergone surgery, although this has no effect on the dimension of fat masses already developed [6–8, 13]. The use of a b-2 agonist such as salbutamol has been emphasized by some authors [7–13]. Recently, Hasegawa et al. [1] proposed a conservative treatment for BSL. In addition to bilateral surgery at the shoulders, they treated neck masses with mesotherapy. Noninvasive intralesional injection of phosphatidylcholine combined with its emulsifier, deoxycholate (injected into lipomas, it causes focal necrosis, acute inflammation, and hemorrhage histologically) [1], were effective for removing small collections of adipose tissue. Cell lysis, resulting from the detergent action of deoxycholate, may account for this clinical effect of lecithin [1]. We appreciated the outcomes of the case shown in the article by Hasegawa et al. [1], who suggested conservative L. Rosato (&) D. Lazzeri M. Campana M. Vaccaro A. Campa S. Ciappi G. Nisi C. Brandi L. Grimaldi C. D’Aniello Plastic and Reconstructive Surgery Operative Unit, University Hospital of Siena, Policlinico Santa Maria alle Scotte, viale Bracci 1, 53103 Siena, Italy e-mail: chirplastica@gmail.com

Carbon Dioxide: Maybe Not the Only One but an Efficient and Secure Gas for Treating Local Adiposities

Currently, carbon dioxide therapy represents an evidencebased and mini-invasive method for treating local adiposities. Many studies [1–3] performed on both women and men have already demonstrated its effectiveness in decreasing local fat in several anatomical areas. Recently, Balik et al. [4] compared the effects of both CO2 and breathable air injection on subcutaneous tissue in a sample of 28 experimental rats. They concluded that the mechanical effects are the same for both gas injections and the changes in microcirculation documented on laser Doppler flow examination are not statistically significant. With respect their article, we would like to make a few comments. We evaluated in a cohort of 48 [5] and 42 patients [6] the effects of CO2 therapy from a histological (through biopsies of tissues performed after the therapy) and a biochemical point of view by showing changes in the laser Doppler signal in association with the assessment of the concentration of transcutaneous oxygen tension (tcPO2). Both these methods are mandatory to evaluate CO2 effects on the microvascular network [3, 7]. Lee [8] confirmed our findings with a study protocol evaluating some anthropometrical parameters on 101 patients (divided per age) after treatment with CO2 injected in several body areas. Furthermore, the gas injection mode of Balik’s study is not comparable to the described protocols for the treatment of local adiposities by CO2 therapy. Medical CO2 injection treatments in previous clinical studies were administered through certified equipment that guarantees both constant gas delivery and electronic flow control. The paraphysiological hyperoxia that underlies the metabolic CO2 effects needs to be evaluated by following a particular treatment timing. This was not done in Balik’s study and therefore the inefficacy of these methods is not clear in the discussion. The data related to tissue oxygenation certainly need further biochemical studies. Moreover, microvascular effects were not completely and correctly evaluated and not demonstrated by using the previously cited association of laser Doppler flow and tcPO2. In addition, it is important to point out that in our studies, tcPO2 data are constant and highly significant (P \ 0.01), whereas laser Doppler flow evaluations are significant (P \ 0.01) but not constant [5]. These results depend on some technical situation (i.e., patient immobility, constant temperature) not easily reproducible in animal models. The histological data presented by Balik et al. showed direct lipoclasic effects of the studied gas. We also found these effects in our studies but they could not be assessed in humans. It is clear that before demonstrating the effectiveness of an alternative gas (e.g., ambient air) in reducing local adiposities, it is necessary to test its security and absence of toxicity. Because of the proven safety and daily use in laparoscopic surgery [9, 10], CO2 has been injected on voluntary patients after informed consent and the approval of the local ethics committee. The aim of our study was to evaluate both the effectiveness and safety of CO2 injection treatments. In our opinion, CO2 therapy combines the characteristics previously cited (Fig. 1). C. Brandi M. Campana (&) F. Russo A. Brafa G. Nisi L. Grimaldi C. D’Aniello Department of General and Specialistic Surgery, Plastic and Reconstructive Surgery Unit, ‘‘Santa Maria alle Scotte’’ Hospital, University of Siena, Viale Bracci 1, 53100 Siena, SI, Italy e-mail: matteocamp@gmail.com

Selective capsulotomies of the expanded breast as a remodelling method in two-stage breast reconstruction

Abstract The two-stage breast reconstruction with tissue expander and prosthesis is nowadays a common method for achieving a satisfactory appearance in selected patients who had a mastectomy, but its most common aesthetic drawback is represented by an excessive volumetric increment of the superior half of the reconstructed breast, with a convexity of the profile in that area. A possible solution to limit this effect, and to fulfil the inferior pole, may be obtained by reducing the inferior tissue resistance by means of capsulotomies. This study reports the effects of various types of capsulotomies, performed in 72 patients after removal of the mammary expander, with the aim of emphasising the convexity of the inferior mammary aspect in the expanded breast. According to each kind of desired modification, possible solutions are described. On the basis of subjective and objective evaluations, an overall high degree of satisfaction has been evidenced. The described selective capsulotomies, when properly carried out, may significantly improve the aesthetic results in two-stage reconstructed breasts, with no additional scars, with minimal risks, and with little lengthening of the surgical time.