Serena Ghezzi

Experience of Immediate Ambulation and Early Discharge After Tumescent Anesthesia and Propofol Infusion in Cosmetic Breast Augmentation

We read with great interest the article titled ‘‘Experience of Immediate ambulation and early discharge after tumescent anesthesia and propofol infusion in cosmetic breast augmentation’’ by Pang et al., describing their experience with breast augmentation using tumescent anesthesia [1]. We congratulate the authors for their interesting retrospective study involving a very large cohort of patients and taking meticulously into account all the patients’ vital parameters. Furthermore, we appreciate and we agree with the authors’ effort to reduce the aggressiveness of anesthesia procedures, but we have some points to discuss. Why do the authors use lidocaine rather than chiral-local anesthetics? Is there a specific reason? Don’t the authors think that the use of isomeric anesthetics in the tumescent solution delays the occurrence of postoperative patients’ discomfort and consequently the need of pain medications including opiods? Does the use of postoperative morphine increase the post-op side effects such as nausea or vomit? As stated in the literature, isomeric anesthetic, such as ropivacaine and levobupivacaine, delay the occurrence of post-op pain, shows less cardioand neurotoxicity and, at the same concentration, provides a better and longer anesthesia rather than lidocaine. We congratulate the authors for their rapidity in performing breast augmentation surgery; an average of 20.4 ? 4.1 min is really a very short time for breast augmentation! The authors reported that they support the infiltration and the surgical time with propofol infusion. Do the authors maintain that midazolam can adequately support the patient’s comfort during the operation time instead of propofol that reducing its side effects? In our practice, we administrate propofol only during the infiltration of anesthesia, while midazolam is administrated during the operative time. Furthermore, the absence of hematomas among such as large population: 1200 procedures (probably 2400 breasts) performed by different surgeons, is very impressive data. Do the authors retain that this element is a direct consequence of their anesthesiologic procedure? Do the authors take into consideration that this anesthesiological procedure can be applied to other breast surgical procedures such as mastopexy or breast reduction [2–5]? However, we fully agree with the authors that nowadays surgical and anesthesiological procedures should be less invasive as possible, preserving patients’ awareness, maintaining their higher comfort, allowing for faster recovery, reducing hospital stays with rapid return to their lifestyle. Furthermore, we retain that nowadays local anesthesia may increase the appeal of aesthetical procedures, thereby enrolling a larger population. & Alessandro Innocenti innocentialessandro@alice.it

Comment to: “Complications and Outcomes After Gynecomastia Surgery: Analysis of 204 Pediatric and 1583 Adult Cases from a National Multi-center Database”

No Level Assigned This journal requires that authorsassign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of

Clinical Characteristics of Asymmetric Bilateral Gynecomastia: Suggestion of Desirable Surgical Method Based on a Single-Institution Experience

Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of

Stenotic Breast Malformation and Its Reconstructive Surgical Correction: A New Concept from Minor Deformity to Tuberous Breast

Dear Sir, We read with great interest the article titled: ‘‘Stenotic breast malformation and its reconstructive surgical correction: a new concept from minor deformity to tuberous breast’’ by Klinger et al [1]. Tuberous breast is a rare congenital breast deformity appearing during puberty [2, 3]. It appears in different and extremely polymorphous clinical aspects consisting in various degrees of a single pathological entity, and the minor forms are not always easy to recognize. The authors proposed an interesting classification for tuberous breast malformation including all the minor forms of the deformities based on three main clinical parameters: type of stenosis, glandular trophism and ptosis. Introducing the concept of stenotic breast, the authors proposed an appropriate surgical strategy to correct each type of malformation and, considering all the anatomical features, described eight different categories of stenotic breasts. To date, classifications reported in the literature are based mainly on the localization of defect, excluding the minor form. We totally agree with the authors that an ideal classification must include all the types of tuberous breasts, taking also into account the quality, the quantity and the consistency of the parenchyma to suggest the most appropriate surgical planning. All these clinical features are not only theoretical, but represent essential elements that must be evaluated preoperatively. Besides the localization of the defect, the volume, the quality and the consistency of the parenchyma must be considered. In cases of low quantities of parenchyma, a breast implant can adjust the hypotrophic volume. Ptosis, if present, can be correct with a mastopexy, and the consistency of the skin envelope can be improved by lipofilling. We believe that the evaluation of the breast consistence is mandatory and cannot be underestimated or missed in a complete classification scheme. An exhaustive classification system must include all the clinical elements to identify immediately the correct diagnosis and the consequent surgical correction [4, 5]. However, we maintain that meticulous consideration at the inframammary fold is mandatory during tuberous breast correction because it is the real stigmata of the deformity. It also represents the main clinical feature that distinguishes simple ptosis of the breast from actual tuberous breast.

Closed-Suction Drains After Subcutaneous Mastectomy for Gynecomastia: Do they Reduce Complications?

Dear Sir, We read with great interest the article titled: ‘‘Comment on ‘‘Closed-suction drains after subcutaneous mastectomy for gynecomastia: do they reduce complications?’’ by Chao et al. [1]. The authors investigate the effects of drain placement on preventing or reducing seroma and hematoma after subcutaneous mastectomy for gynecomastia, evaluating the occurrence of complications 30 days postoperatively. We appreciate this interesting authors’ retrospective study, and we fully agree with the efficacy of closed-suction drains after male breast surgery in reducing the occurrence of hematoma complications in the early postoperative period, but we have some elements to discuss. Certainly, we believe that drain placement is useful in reducing fluid accumulation, such as hematomas, in the early postoperative time, but we have some doubts about its efficacy in 30-day postoperative seroma prevention. In gynecomastia surgical correction, seroma is a collection of fluid under the surface of the adipocutaneous flap, usually collecting in the late post-op period. Typically, it is related to the amount of adipose tissue damage during the surgical procedure. It occurs more frequently in extensive procedures compared to minor surgical procedures. Because the risk of seroma depends mainly on the amount of disrupted tissue, the type and the entity of gynecomastia play a main role in the occurrence of seroma. Based on our experience, severe gynecomastia in overweight patients showed a higher risk of seroma than the glandular disorder in the athletic population [2]. Consequently, we maintain that in high-risk seroma patients, surgical dissection with scissors rather than electrocautery is recommended [3]. Besides the amount of excised tissue and the patient’s body type, the dimension of the undermined surgical area also heavily influences the risk of seroma, especially if liposuction is performed. Therefore, in cases of widely undermined surgical surfaces, the use of ‘‘Baroudi’’ stitches reducing the dead spaces and improving the adherence of the adipocutaneous flap to the thorax can dramatically decrease the incidence of seroma [4]. However, the vacuum used in closed-suction drains as well the postoperative compressive medical dressings can support successfully the efficacy of quilting stitches [5]. On the other hand, as the authors reported in their paper, the risk of hematoma occurrence strictly depends on the surgeon’s accuracy during hemostasis and last but not the least, on the correct patient postoperative attitude and lifestyle.

Refinements in Tear Trough Deformity Correction: Intraoral Release of Tear Trough Ligaments: Anatomical Consideration and Clinical Approach

BackgroundCorrection of tear trough (TT) deformity is a crucial aspect of facial rejuvenation. Because the anatomical origins of TT deformity lie in the TT ligaments, which firmly attach the dermis to the periosteum, the release of TT ligaments should be considered when performing an etiological correction. The aim of this paper is to propose an alternative method for TT deformity correction, comprising use of filler together with the release of TT ligaments. This technique was compared to the procedure of only percutaneous filler.MethodsFrom January 2014 to December 2015, 10 patients were enrolled in the study for recurrence of TT deformity. All the patients underwent TT ligament release and filler injections; all had been previously treated with percutaneous hyaluronic acid injection without ligament release. Under local anesthesia, the TT ligaments were detached using a blunt cannula introduced directly in the supra periosteal plane through an intraoral access. Once the ligament was released, the TT depression was evenly recontoured with a very small amount of filler. The clinical data, digital images, evaluations of outcomes, including patient satisfaction rates were collected and compared.ResultsAdding the procedure of TT ligament release to filler injections showed satisfactory results, avoiding an unnatural puffy appearance. The comparison between the two different methods showed improved outcomes and increased patient satisfaction with minor patient discomfort among those who underwent TT ligament release.ConclusionBecause TT ligaments are among the etiologic factors of TT deformity, they have a strong impact on procedures that are designed to improve TT deformity; therefore, TT ligament release should always be considered to obtain satisfactory, natural results.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Achilles Region Soft-Tissue Defects: A Reconstructive Algorithm Based on a Series of 46 Cases

Background Several options have been described for soft‐tissue reconstruction in Achilles tendon region (ATR). The best procedure should be customized according to any single case taking into account the number of structures involved, the quality of the neighboring skin, and patients general condition. The aim of this article is to describe a simplified reconstructive algorithm based on personal experience and reviewing literature. Methods Forty‐four patients, who underwent ATR soft‐tissue reconstruction between 1998 and 2016, have been retrospectively reviewed. Etiologies of the defect include the following: 18 posttraumatic, 10 postoncologic, 14 dehiscence/infection, and 2 chronic ulcers. Follow‐up ranges between 12 and 96 months. Free flaps have been used in 30 cases (including two secondary surgeries due to propeller flap failure) and propeller flaps have been used in 16 cases. Results Thirty‐six flaps survived uneventfully (78.3%). Total flap necrosis occurred in three cases (6.5%), namely, two propeller flaps and one free flap. Partial necrosis of the flap was observed in seven cases (15, 2%): three in the free flap group and four in the propeller group. The functional recovery was very good in all the patients without involvement of the tendon and also all the patients who underwent a simultaneous reconstruction of the tendon with different techniques recovered a full weight bearing and a satisfactory range of motion. Conclusion Propeller flaps are a valuable option for skin reconstruction in case of defects of small and medium size not involving the tendon. In case of larger defects and when a simultaneous ATR reconstruction is required, a free flap seems to be a better option.

Comment on “A Modified Levator Resection Technique Involving Retention of the Levator Palpebrae Superioris Muscle Suspension System for Treatment of Congenital Ptosis”

We read with great interest the article entitled ‘‘A modified levator resection technique involving retention of the levator palpebrae superioris muscle suspension system for treatment of congenital ptosis’’ by Zuo et al. [1]. The authors clearly highlight the importance of protecting as much as possible the integrity of the eyelid structure to prevent instability and postoperative discomfort for patients. We appreciate the effort to preserve the anatomy of the Whitnall ligament and of the medial and lateral horns, conserving the suspensory system of the levator palpebrae superior muscle (LPS), and we congratulate the authors for the large series of cases and for the excellent results. We fully agree that LPS is the most important muscle for elevating the upper eyelid. Its management is the ideal method for correcting congenital ptosis, but its function, excluding the frontalis muscle contribution, should be considered with the degree of the ptosis in preoperative planning. Furthermore, preoperative asymmetry represents one of the most popular risk factors for reoperation and it must be carefully investigated preoperatively. The compensatory retraction of the minor affected eye makes it difficult to adjust the balance between the two eyes. Compensation for the superior visual field loss by the recruitment of the frontalis muscle should be also assessed considering, at the same time, the degree of levator functional excursion. Recently, we published an article to evaluate long-term-follow-up results after blepharoptosis correction with external levator advancement, considering both functional and esthetic results [2]. The former can be evaluated based on post-op upper lid margin reflex distance (uMRD) measurement, while the symmetry represents one of the most important esthetic goals [3]. According to The British Oculoplastic Surgery Society National Ptosis Survey, a successful outcome can be considered when uMRD was between 3 and 5 mm. Symmetry was achieved when all the following 3 different criteria were met [4]:

Comment on: “Surgical Masculinization of the Breast: Clinical Classification and Surgical Procedures”

Dear Sir, We read with great interest the article entitled: ‘‘Surgical masculinization of the breast: clinical classification and surgical procedures’’ by Cardenas-Camarena et al. [1]. Based on three different anatomical characteristics (amount of fatty tissue, gland tissue and excess of skin), the authors proposed a new clinical classification system and relative surgical procedure for each gland type. We fully agree with the authors that to obtain a masculine breast shape, regardless of patient gender, is the main objective in gynecomastia treatment, and a careful pre-operative physical examination is essential to select the most appropriate surgical technique, but we have some elements to discuss. Recently, we conducted a study to investigate different expectations in a large gynecomastia population [2–5]. Because dissatisfaction with the results represents a common reason for claims, management of patients’ expectations is the key element to achieve a high level of approval as the leading measure of treatment success. Considering patients’ physical appearance is mandatory to maximize postoperative satisfaction. Three different categories can be identified: athletic physiques (high muscle mass and body fat\9%, and a BMI\ 25); normal physiques (not particularly muscular BMI\ 25); and overweight subjects (BMI[ 25). The concept of an ideal chest is dissimilar among these different categories of subjects; it is influenced by the age, personal preference, lifestyle, and different body structure. High-muscle-mass patients want better definition of the pectoralis area that cannot be obtained by simple physical training. Their chest is more scrutinized, especially in body builders; the low percentage of fat tissue renders the gland even more pronounced. They are the most distressed by gynecomastia and are very sensitive to the problem, showing high expectations that can only be satisfied by minimizing the adipo-glandular layer covering the muscle. Normal-body-type patients, as well as females affected by gender dysphoria, suffer from female appearance revealing social limitations, so they require a more masculine chest aspect. Overweight patients feel that gynecomastia is a weight disorder, so they require a slimmer appearance. BMI, representing a crucial feature in treatment of gynecomastia disorder and should be meticulously considered during pre-operative planning, varying between different physical body types and expectations.

Comment to: “The Characteristics and Short-Term Surgical Outcomes of Adolescent Gynecomastia”

Dear Editors, We read with great interest the article titled ‘‘The characteristics and short-term surgical outcomes of Adolescent gynecomastia’’ by Choi et al. [1]. We really appreciated the authors’ effort to establish how surgical management of gynecomastia can be correctly addressed in adolescents. We congratulate them for the excellent results, but we have some elements to discuss. Although gynecomastia can be particularly distressing and cause embarrassment with low self-esteem even in the minor forms, we maintain that the surgery should be performed when the patients are older than 16 years to let patients achieve a total self-awareness and so that growth of the thorax is complete. The ideal chest appearance is dissimilar among different subjects and may be influenced by age. Patients’ expectations vary according to personal preferences, lifestyle and different physiques. Surgical planning should be carefully tailored to patients therefore, even if earlier surgical correction of the deformity may avoid psychological distress in adolescents; older patients achieved a more adequate psychosomatic development. Recently, we conducted a study to investigate different expectations and needs in a large gynecomastia population, ranging from 18 to 52 years old with different body types, including overweight patients affected by the severe form of the disorder [2]. Choi and colleagues selected 71 adolescents who underwent subcutaneous mastectomy under general anesthesia. The authors’ study reported a shorter postoperative hospital stay compared to the current literature, but their gynecomastia population is not evenly distributed, because most patients had a normal body type and excluded the most severe forms of gynecomastia according to the Simon classification system. Therefore, skin removal was not performed because marked skin redundancy was not observed in any patient. In our patient cohort, longer hospitalization was reported, mostly for overweight patients affected by severe forms of gynecomastia. We fully agree with the authors that subcutaneous mastectomy, performed through an inferior emiperiareolar access, represents the best surgical approach to the disorder to avoid recurrence [3, 4]. The combination of subcutaneous mastectomy with liposuction, causing skin retraction, may reduce the need for additional scarring in case of skin redundancy [5], limiting future embarrassment due to unpleasant or extended scars and optimizing the cosmetic results. BMI, representing a crucial feature of gynecomastia, should be meticulously considered. Surgery can be performed in young adolescents, but we retain that patients should be carefully selected and informed of the need for losing weight, if obese, prior to surgery.