Nicola Kefalas

The Plastic Surgeon in the Treatment of Obesity

Obesity is an increasingly common disease, whose complex treatment often terminates with the patients discontinuation of therapies. The authors suggest how to improve a multidisciplinary approach to the obese, to increase compliance with therapy. A characterization of obesity is a helpful initial step. It consists of an accurate anatomic definition of fat distribution, which can more accurately be performed by imaging (U/S, CT, MRI). The patients obesity should also be identified based on the physical characteristics that we propose. The plastic surgeons intervention is often required and beneficial in every type of obesity. Many body areas are appropriate for contouring. Apart from providing a gain in esthetic appearance, plastic surgery also results in several benefits for the patients general health.

Launois-Bensaude Syndrome: An Unusual Localization of Obesity Disease

BackgroundLaunois-Bensaude syndrome is a rare pathology consisting of adipose masses symmetrically distributed mainly in the superior part of the body. Men are especially affected between age of 30 and 60 as well as chronic alcohol abusers. Etiopathogenesis is attributable to mutations or deletions of mitochondrial DNA, and alcohol is a possible cofactor.MethodsThe current treatment of the disease is described based on the authors’ experience. Four cases treated in our department are retrospectively reviewed regarding comorbidities and type of surgery performed.ResultsA relevant and long-lasting reduction of fat bulges has been obtained in all cases with no major complications except for a mild anemia.ConclusionLaunois-Bensaude syndrome causes a functional rather than esthetic concern due to the peculiar localization of fat bulges. Currently, the only effective therapy is surgery, through lipectomy or liposuction of adipose bulges.

Galea-including forehead flap for lower one-third nasal reconstruction.

The first choice for internal mucosal restoration of the nose is a septal mucosal or vestibular local flap. The forehead flap, raised including the galeal layer, is an alternative option for large nasal defects. It can be used in any difficult situation in which septal or vestibular flaps are not adoptable, such as complete loss of lower one-third. The authors intend to describe the inclusion of galea in the traditional median forehead flap for nasal lining reconstruction. Thirteen patients treated with a forehead flap including galea for lower one-third nasal reconstruction were retrospectively reviewed. No complete flaps necrosis occurred. In 1 case, lining was lost due to infection. In 2 cases a moderate nostril stenosis was observed as late complication. The forehead flap with galea is a good option for large nasal full-thickness defects, involving the lower one-third.

Closed Rhinoplasty with Marginal Incision: Our Experience and Results

Supporters of traditional rhinoplasty and promoters of open rhinoplasty have debated their approaches for many years. From among different possible techniques, a surgeon must always choose the approach that provides the best aesthetic result. The surgeon’s experience and artistic sense are essential for the closed technique, whereby most of the corrections are performed without exposing the nasal frame. The open technique allows a greater operating range with a direct view of the nasal structure, resulting in improved precision in modeling the cartilages. However, the absence of intact skin cover exposes the surgeon to a less precise overall aesthetic evaluation. This report highlights the marginal technique, described in 1990 by Guerrerosantos, which uses a two-sided circular incision permitting complete dissection of the alar cartilages and the overhead skin cover of the columella. This approach, together with the extramucous technique, permits complete exposure of the skin and nasal septum without a columella incision. Therefore, the marginal technique is suitable for primary rhinoplasty cases in which complex modeling of the nasal tip and an excellent aesthetic result are required.

Aulus Cornelius Celsus and his pre-modern patho-physiologic notions on obesity-associated morbidity and mortality

Dear Editor, Notions of reduction in life expectancy because of obesityrelated diseases are more and more often issue of scientific discussion nowadays, because of the vertiginous increase in obese patients’ prevalence during the last decades, as recently emphasized by Yach et al. (1). Even though considered one of the evils of modern age in Western civilization, in fact, obesity is a pathology known and treated by human society from ancient times (2). Obviously in the past, the importance of obesity as a mortality reason was far less relevant than it is nowadays, as life expectancy was shorter and more numerous diseases affected and brought people to death. Nevertheless, middle age obesity was known even in the antiquity. Hippocrates’ pioneering observation pointed out that excessive weight causes a risk of sudden death (3). Some centuries later another celebrated Latin doctor and writer whose name is Aulus Cornelius Celsus wrote about obesity. He lived by the 1st century ad but was already aware of weight excess consequences on life quality and duration. His De Medicina is an essay describing medical knowledge at Roman times. This primordial medical encyclopaedia can be considered an open window on ancient life. The level and quality of notions reported are a sort of prelude to modern semeiotics for their pre-scientific objectivity and accuracy. ‘[ . . . ] Obesi plerumque acutis morbis et difficultate spirandi strangulantur subitoque saepe moriuntur; quod in corpore tenuiore vix evenit’, i.e. obeses are affected by multiple acute diseases, respiratory dysfunctions and often die from unexpected death, because in their weaker body health is impaired (4). Celsus bases his knowledge on purely clinical observations with no pathophysiologic substrate; however, he shows a good intuition of nowadays acquired notions about heavy implications of obesity on vital functions. Dyspnoea and risk of sudden death are perfectly noted by our ancient colleague. Although the cardiovascular bases of unexpected decease are not mentioned, we cannot state whether these notions were not possessed or simply omitted. Nevertheless, by putting near the two observations ‘difficultate spirandi strangulantur’ and ‘subitoque saepe moriuntur’, Celsus shows to have an initial correct perception of hypossiemic mechanisms leading to myocardial damage and sudden death.

Fat grafting used for the prevention of cardiac implantable electronic devices (CIED) exposure. Preliminary report of a clinical study

BackgroundSubcutaneous cardiac devices can sometimes undergo exposure, and often, the removal and contralateral repositioning of a new device is necessary. Pressure sores of the device cause a gradual thinning of the cutaneous and subcutaneous layers resulting in implant exposure. Our department has developed a closed collaboration with the Department of Cardiology in order to prevent the exposure of subcutaneous devices and to avoid the more risky and invasive surgery necessary for implant removal and reposition.MethodsThirty selected cardiopathic patients presenting pressure sores of the device, without exposure, were selected for lipofilling. The selection of patients is a key moment to ensure the success of the procedure. The surgery was performed under local anaesthetic without epinephrine.ResultsThere was an improvement of local conditions, and none of the patients, after a year, were subjected to a removal operation of the implant. No cases of infection were observed.ConclusionsAdipose tissue graft improved cutaneous trophism and increased the thickness of the subcutaneous tissue, reducing the risk of implant exposure.Level of Evidence: Level IV, risk/prognostic study.