Pierfranco Simone

Digital Photography in Plastic Surgery: How to Achieve Reasonable Standardization Outside a Photographic Studio

Accurate photographic documentation has become essential in reconstructive and cosmetic plastic surgery both for clinical and scientific purposes. Digital imaging systems currently are popular, being reasonably affordable and much improved in quality. They offer multiple advantages in terms of quality, easy image storage and retrieval. Nevertheless, obtaining standardized, consistent, and relevant digital images is not easy outside a photographic studio. The purpose of this report is to define guidelines for accurate image capture in different anatomic areas, following elementary general criteria based on practical issues beyond the purely theoretical, to obtain reasonable standardization, consistency, and reproducibility.

Reconstructive Plastic Surgery

Obesity is a complex mixture of psychological, environmental, social, cultural, economic, geographic, and genetic influences with little discrimination regarding age, ethnicity, or gender. Bariatric surgery may help in massive weight loss but often determine significantly alteration to the body profile with functional impairment. Reconstructive plastic surgery interventions correct post-bariatric surgery deformities and must be included in morbid obesity management as body contouring helps long-term weight control. As a general rule, contouring operations should be done after weight loss is complete, as wound complications tend to be higher when surgery is performed in patients who are still obese. The authors present a description of personal surgical approaches to abdominoplasty, mastopexy, brachioplasty, and inner-thigh lift.

Pelvic and perineal reconstruction following abdominoperineal resection: the role of gracilis flap.

Pelvic and perineal cancer can arise from different structures: genitourinary system, bowel, or skin. The optimal approach to these patients, to ameliorate their immediate and long-term prognosis, implies a multidisciplinary team of specialists, such as oncologic surgeons, plastic surgeons, oncologists, and radiotherapists, working together to tailor an individualized treatment planning for each patient. Nowadays, sphincter-preserving operations are the treatment of choice for rectal cancer in the majority of patients, and seldom an abdominoperineal resection (APR) is necessary, mainly because of early diagnosis and the widespread use of neoadjuvant treatments. Conversely, APR is mandatory when cancer sphincter involvement is demonstrated either from rectal or anal cancer or in case of recurrent rectal carcinoma with sphincteral muscle invasion. APR was first performed by Miles in 1908; it consists of resection of the rectum and of the anal canal, incorporating a variable tract of sigmoid colon and en bloc removal of perianal skin. Radiation therapy, often delivered in the neoadjuvant setting to reduce tumor bulk to achieve safer margins, causes important and irreversible alterations to irradiated tissues. These procedures lead to wide loss of substance, with surgical scars and postactinic sclerosis. Following oncologic surgery, reconstruction is accomplished either through direct closure, or, if this is not feasible, by means of advance, rotation, transposition, or free flaps. In our experience, gracilis flap (GF) is the first choice for pelvic-perineal reconstruction. It was one of the first flaps used in perineal reconstruction, described by Bartholdson and Hulten in 1975, even though in 1972, Orticochea had already used the musculocutaneous version of this flap for penile reconstruction. In 1976, McCraw et al used it as a musculocutaneous flap for vaginal reconstruction. Its localization in the vicinity of the defect and easy elevation account for its common use. No functional impairment follows as other adductor muscles of the thigh supersede its function. Moreover, the gracilis donor site is commonly outside the field of irradiation and thus provides healthy tissues for reconstruction. Gracilis muscle can be used to perform unilateral or bilateral, muscular, or musculocutaneous flap reconstruction. The aim of the present study is to compare retrospectively the outcomes of 2 homogeneous groups of patients with rectal carcinomas, undergoing APR, in whom the perineal wound was closed either directly or with a GF.

Wedge Excision of the Nail Fold in the Treatment of Ingrown Toenail

Abstract:Many treatment modalities of ingrown toenail are reported in the literature, often associated with unacceptably high recurrence rate. The authors present their technique, which aims at reducing the convexity of the nail fold. After complete removal of the nail plate and accurate debridement of the granulomatous tissue, a wedge-shaped ellipsis of skin and subcutaneous tissue, lateral to the affected nail fold, is removed. Approximation of the margins of the resulting defect determines eversion of the nail fold. One hundred twenty ingrown toenails were treated with the wedge excision of the nail fold at the outpatient clinic of the department of plastic surgery, Campus Bio-Medico University, Rome, Italy, between January 1998 and January 2002. Six recurrences were observed. In addition to the high cure rate, short postoperative pain duration, and morbidity as well as low risk of postoperative infection, the remarkable esthetic results achievable with this method are indicated.

Implant Breast Reconstruction After Salvage Mastectomy in Previously Irradiated Patients

The most common surgical approach in case of local tumor recurrence after quadrantectomy and radiotherapy is salvage mastectomy. Breast reconstruction is the subsequent phase of the treatment and the plastic surgeon has to operate on previously irradiated and manipulated tissues. The medical literature highlights that breast reconstruction with tissue expanders is not a pursuable option, considering previous radiotherapy a contraindication. The purpose of this retrospective study is to evaluate the influence of previous radiotherapy on 2-stage breast reconstruction (tissue expander/implant). Only patients with analogous timing of radiation therapy and the same demolitive and reconstructive procedures were recruited. The results of this study prove that, after salvage mastectomy in previously irradiated patients, implant reconstruction is still possible. Further comparative studies are, of course, advisable to draw any conclusion on the possibility to perform implant reconstruction in previously irradiated patients.

Decision making in the treatment of tuberous and tubular breasts: volume adjustment as a crucial stage in the surgical strategy.

Tuberous and tubular breasts, two distinct deformities based on the same anatomic anomaly, are characterized by several morphologic alterations with a wide spectrum of expression. The classifications reported in the literature are based primarily on deformity of shape, but other parameters such as breast volume and symmetry often are underrated. This study aimed to define tuberous and tubular breasts and their management accurately on the basis of multiple anatomic alterations involving breast volume and symmetry as well as shape.The records of 30 patients affected by tubular and tuberous breast were reviewed. Surgical strategy included correction of breast shape through areola and gland alterations, correction of volume asymmetry through parenchyma resection, and volume augmentation through permanent expandable breast implant insertion. All the patients were treated bilaterally.Evaluation using a visual analogic scale confirmed high patient satisfaction with a mean value of 92.6% in the assessment of shape, volume, and symmetry. Correct diagnosis, careful preoperative evaluation, and a comprehensive surgical strategy can achieve, in one surgical procedure, good and long-lasting outcomes in terms of breast shape and volume symmetry.

Medial thigh lift in post-bariatric patients: Our encouraging experience

Abstract Background: A high rate of postoperative complications following inner thigh lift is reported in the medical literature. The authors present the results of a study on the validity of inner thigh contouring, with liposuction and concomitant skin excision, in postbariatric patients. Methods: This study examined the charts of 46 postbariatric female patients, who underwent medial thigh lift with a ‘T’ scar technique and concomitant liposuction, between February 2010 and February 2013. Complications were recorded. A questionnaire was administered to the patients at the 1-year follow-up visit. Preoperative and 1-year postoperative photographs were compared, superimposed, and analysed. Results: This study did not observe major systemic complications, haematoma, seroma, infection, skin necrosis, lymphoceles, or lymphoedema. Minor complications were three cases of wound dehiscence and two cases of deepithelialisation. At the 1-year follow-up visit, caudal scar migration, genital distortion, recurrent ptosis, or deformity of the inner thigh contour were not observed. Questionnaires and a comparison of pre- and 1-year postoperative pictures showed encouraging results. Conclusions: The medial thigh lift technique described and assessed in this article is a straightforward surgical procedure, with considerable functional and aesthetic results. Liposuction, early mobilisation, and appropriate postoperative management are pivotal to reduce postoperative downtime and complications.

Assessment of the 18-month permanence of onlay tip cartilage grafts following rhinoplasty.

Abstract Augmentation rhinoplasty requires addition of materials of various natures to reshape the nasal pyramid. Onlay tip grafts are single or multilayered grafts placed horizontally over the alar domes. The aim of the present study was to assess the 18-month permanence of onlay septal cartilage grafts. Twenty-eight patients underwent rhinoplasty with onlay tip cartilage graft, between June 2008 and November 2008 at the Campus Bio-Medico University in Rome, Italy. They were reviewed and photographed 6 months and 18 months postoperatively. Comparison of 6-month and 18-month postoperative pictures was performed with Adobe Photoshop CS. Measurements on pictures were taken with AutoCAD. Comparison of photographs showed no visible difference in nasal tip projection. Comparison of the measurements of tip projection showed a mean reduction of 0.06 mm (0.19%). Considerable stability of nasal tip projection after rhinoplasty with onlay tip grafts was observed postoperatively. Comparison of standardised digital photographs is a valid procedure to assess contour alterations of various anatomical structures after plastic surgery.

Two-millimeter dermoscopically detected excision margins in the treatment of basal cell carcinoma: an assessment of radicality and recurrence

Eighty-five percent of all basal cell carcinomas (BCCs) are located in the head and neck, with a markedly increased incidence after the age of 40 years. Complete extirpation in the early phase allows to limit skin excision and facilitates reconstruction, reducing consequent scarring. In the medical literature, it is reported that appropriate excision margins should be included between 3 and 10 mm, based on location, dimensions, margins and histology.[1] BCC margins are defined by the discontinuation of well-known dermoscopic features along the skin lesion borders, so separating cancer from healthy skin.[2] The authors conducted a study to assess the effectiveness of preoperative dermoscopic evaluation of BCC peripheral margins, in order to achieve complete excision.

The Inverted “T”, Superior Pedicle Technique, with an Inferiorly-Based Dermal Adipose Flap for Reduction of the Opposite Breast, in Patients with a Breast Reconstructed with an Implant

The Authors describe the marking, technique, and postoperative care of inverted “T”, superior pedicle technique, with an inferiorly-based dermal adipose flap, for reduction of the opposite breast in patients with a breast reconstructed with an implant. This technique has turned out to be remarkably valid, in terms of long-term stability of the aesthetic result and of the degree of symmetry obtained at the time of the operation. Complications concerning the nipple-areola complex vascularization, observed following this technique are in line with the rates reported in the medical literature for superior pedicle techniques. No cases of dermal adipose flap malposition or complications related to the flap occurred.