Paolo Bogetti

Surgical Treatment of Rhinophyma: A Comparison of Techniques

Abstract. Rhinophyma is a rare disease that primarily affects Caucasian men in the fifth to seventh decades of life, characterized by a progressive thickening of nasal skin, which produces a disfiguring soft-tissue hypertrophy of the nose. Severe cosmetic deformity and impairment of breathing may coexist, making the surgical treatment necessary.The authors are conscious that in literature there is not agreement about the ideal treatment of rhinophyma, nevertheless they wish to give their contribution according to their experience with different treatment modalities such as the scalpel, the electrocautery, the dermabrader, and the carbon dioxide laser. The authors believe the scalpel, in association with bipolar electrocautery and local infiltration of dilute epinephrine to reduce bleeding, is the safest means to preserve the underlying sebaceous gland fundi and permit a spontaneous re-epithelialization scarring-free.

Distally Based Fasciocutaneous Sural Flap for Foot Reconstruction: A Retrospective Review of 10 Years Experience:

Background: The treatment of soft tissue defects of the foot is a problem mainly connected to the thickness of the coverage tissues, to the poor circulation, and to the frequent involvement of muscle, tendon, and bone. The authors present their experience with the sural flap, also in some particular cases. Materials and Methods: The authors treated 33 patients for small- and medium-size defects of the foot, caused by work, home, and road accidents, and by venous or diabetic ulcers. In all cases, the flap was cut in its fasciocutaneous variant; an extension of the sole portion of fascia was added in 5 patients. The flap was transferred under a subcutaneous tunnel in 10 cases, with an open incision in 20 cases, and in 3 cases the pedicle was kept external for 4 weeks, then resected. Results: One patient showed a complete necrosis of the flap and another showed a superficial necrosis preserving the deep fascia; in the remaining 31 cases, the flap incorporated without any major complication. The flap provided proper coverage of the defects from both an aesthetic and functional point of view as evidenced clinically and through a baropedographic test. Conclusion: The advantages of this flap include: dissection is fast and easy, it is not necessary to sacrifice important arterial pedicle or muscular units as it can be used in traumatized limbs without further damage to main arteries, and a wide rotation arc is possible. Disadvantages include the sacrifice of the sural nerve and the covering of the donor region with skin grafts.

Otoplasty for prominent ears with combined techniques

Prominent ears is the most common congenital malformation in the head and neck region, and over 200 different correction techniques have been published. This demonstrates both the substantial effort devoted to ensuring an harmonious, natural, stable result and the lack of agreement over the approaches to achieve this goal. We present our experience in 42 patients using a combined technique that includes: (a) a large cutaneous excision in the upper part of the helix and in the lobule area to make the ear lie closer to the head, instead of the conventional elliptical excision, (b) closed anterior scoring, according to Stenstroms technique, to reconstruct the antihelix, possibly combined with Mustardé sutures, (c) removal of the posterior auricular muscle to make the concha fit to the mastoid in a stable way, and (d) a semilunar excision of conchal cartilage by Mustardés technique if the concha does not fit satisfactorily. This technique has proven to be safe, not particularly difficult to perform, with few complications, and can be used even for very prominent ears with good, stable long-term results.

Bergamo 3D Rhinoplasty Software: Select, Store, and Share Surgical Maneuvers in a Three-Dimensional Nasal Model

Background: Rhinoplasty is considered the most challenging chapter of plastic surgery due to its variability and the continuing evolution of surgical maneuvers. Worksheets became essential to unequivocally record surgical steps and to demonstrate their reciprocal effects/interactions during the follow-up period. After 1989, no other software was created to upgrade the Gunter Rhinoplasty Diagrams, the forefather and benchmark of the rhinoplasty “virtual” worksheet maker. Methods: The authors built a new standard three-dimensional nasal framework model in STL format. All the basic components were modified to simulate the interaction among sutures, grafts, and the most common maneuvers performed during rhinoplasty. The authors created a total of 669 (99 built-in units and 285 unilateral units) three-dimensional figures which can be selected by the surgeon from among 230 options. The interface for the surgeon is Bergamo 3D Rhinoplasty Software. Results: Bergamo 3D Rhinoplasty Software is made up of the database section, which gathers all the patient’s personal information and documents, and the surgery section, which groups multiple selection lists in 10 surgical areas. Eighty percent of the options modify the original shape of the three-dimensional model. Several options help the surgeon to tailor the final result and to export it both in desktop software and in a real three-dimensional printed model. Conclusions: Bergamo Rhinoplasty Software revolutionizes the concept of patient and surgical data storage. Furthermore, the immediacy of three dimensions facilitates communication with patients, allows case sharing with colleagues, simplifies teaching, and encourages the surgeon’s self-analysis and professional growth. Customization of the original model and of the maneuvers is the main limitation of the software, because of the currently existing technology in 2014.

Novel decision algorithm for the diagnosis of silicone gel breast implant ruptures

BackgroundThe main complications of breast implantation are caused by capsular contracture and implant rupture. Although the evaluation of implant rupture is primarily driven by patient symptoms, including change in breast shape, size, or firmness, most patients with breast implant rupture do not clinically manifest significant symptoms, thereby developing a so-called silent rupture. For all these reasons, its diagnosis generally relies on imaging techniques such as mammography, ultrasound, and magnetic resonance imaging.MethodsWe conducted a retrospective non-randomized study, carried out between March 2013 and August 2017. In this study, we evaluated 30 symptomatic patients who underwent mono or bilateral prosthetic breast reconstruction, a total of 51 implants after skin-sparing mastectomy or nipple-sparing mastectomy for breast cancer and following breast implant removal or replacement due to suspicious rupture or capsule contraction.ResultsUltrasound suspected ruptures in 32/51 (62.7%) implants, while 19/51 implants resulted intact upon ultrasound examination. The sensitivity and specificity of ultrasound were 90 and 80% respectively. Magnetic resonance imaging suspected ruptures in 30/51 (58.8%) implants, while 21/51 (41.1%) implants resulted intact. The magnetic resonance imaging sensitivity and specificity were 87 and 85%, respectively.ConclusionsUltrasound evaluation may be the first level exam in case of suspicious symptomatic breast implant rupture. Importantly, our results demonstrate that magnetic resonance imaging could be avoided in all those cases where an extracapsular rupture has been diagnosed using ultrasound.Level of Evidence: Level IV, diagnostic study.

Reconstruction Approach to a Rare Case of Acquired Scrotal Giant Muscular Hamartoma

Summary: Acquired scrotal giant muscular hamartoma is an uncommon benign lesion with fewer than 10 documented cases all over the world. It is characterized by a proliferation of dermal smooth muscle bundles of scrotum dartos fascia. The authors report a rare case of acquired scrotal giant muscular hamartoma, which occurred in a 70-year-old severely obese and diabetic man presenting with a progressive scrotal enlargement and swelling in the last year, causing marked reduction in quality of life and cosmetic problems. The patient underwent a wide excision of the hamartomatous lesion, and then, a reductive scrotoplasty and autologous skin grafting of penis were performed. Anatomopathological examination showed an acquired scrotal giant muscular hamartoma arising from muscular fascia of dartos. This surgical technique is a valid, safe, effective, and minimally invasive option to treat this pathology, achieving both excellent functional and aesthetic results, with a marked improvement of the patient’s quality of life.

Senologic Oncology and Reconstructive Surgery

A century of breast cancer surgery has seen the evolution of a number of techniques for the surgical treatment of breast carcinoma by surgery. New knowledge of the natural history of breast carcinoma, the introduction of adjuvant therapies and increasingly early diagnosis have naturally led to a change in surgical treatment. The principal stages along this pathway have basically been three. First, the entity of surgical demolition has been reduced as well as the morbidity associated with it. From Halsted’s radical mastectomy, through the variants proposed by Patey and Madden, we arrived at the removal of the glandular structure only, with dissection of axillary lymph nodes. Crile’s studies in the sixties demonstrated the systemic nature of the disease, disproving Halsted’s principle of en bloc removal of suspect tissue, and thus opening the door to conservative surgery [1].

Reconstruction of the abdominal wall after excision of a bulky desmoid tumor and postoperative electromyography investigation to demonstrate its integrity

The reconstruction of the abdominal wall following the removal of a bulky desmoid tumor involving the left rectus abdominis muscle from the xiphoid to the umbilicus is presented. After the tumor was removed, only the lateral third of the left rectus abdominis remained intact and, consequently, the muscles of the abdominal wall were mobilized according to the Ramirez technique. A polypropylene mesh was placed between the two rectus abdominis muscles and their posterior sheaths, the muscles having been sutured in the midline without tension. The anterior abdominal wall was further reinforced by using an inferiorly pedicled dermal flap in the cutaneous area between the umbilicus and the pubis. This is an area commonly removed in an abdominoplasty. An electromyographical study demonstrated that the muscles involved were functioning perfectly – both at rest and under stress – about 40 days after the surgery.