Study on the Aging Dynamics of the Periorbital Region: From Observation to Knowledge of Physiopathology.

PURPOSE: Several anatomical and physio-pathologic studies of eyelid region have allowed the creation of theories on facial tissues aging dynamics, which have not been clarified yet. We assessed the signs of aging in the region over the time by observing the characteristics in the same person at different times of his/her life. METHODS: We compared the position of the main anatomical landmarks of the eyelid region of 80 patients by overlaying their photographs when they were 20, 40, and 60 years old. Then we made comparisons in the group of men (40 people) and in the group of women (40 people) and between men and women. RESULTS: The medial portion of the eyebrow was higher in the photograph taken at 60 years of age than in the one taken at 20 years old in 56.2% of cases; it was higher in 47.5% of cases when comparing the images at 20 and 40. The lateral portion of the eyebrow was seen higher in women in the 20 to 40 group, and it was seen lower in men at 60 years in statistical significance. In more than half of the patients observed, there was not a real descent of the eyebrow and the presence of a more or less accentuated form of upper eyelid's ptosis in the photograph at 60 (globally 47.5%, 55.0% of women and 40.0% of men). This condition was observed in 27.5% of the photographs at 40. There were changes in the horizontal dimension of the palpebral fissure (shortening in 53.7%, preserved in 33.7%, and increased in 12.5% of cases at 60 years old). The position of lateral canthus appeared lower in 40.0% of patients photographed at 60, but it was stable in those photographed at 40. The herniation of the upper eyelid bags was observed in 31.2% of the patients photographed at 60 years old but only in 13.7% at 40. Dermatochalasis of the upper eyelid was present in 67.5% of the people at 60 years old and in 55.0% of those seen when they were 40. Comparing men and women groups 20 to 40, dermatochalasis is more present in men than women at 40 years old with statistical significance. The eyelid-cheek junction was seen to be lower in 75.0% of cases at 60 and in 48.7% of cases at 40, and it is more represented in men than in women. CONCLUSION: We have highlighted some interesting elements, partly agreeing with the data already recorded by other authors', and our data suggest an important role of the eyelid structures senescence and its impact on the surrounding structures.

Posterior lamellar reconstruction: a comprehensive review of the literature.

The aim of the review is to describe the different techniques and materials available to reconstruct the tarsoconjunctival layer of the eyelid; to analyze their indications, advantages, and disadvantages. We searched the Cochrane, PubMed, and Ovid MEDLINE databases for English articles published between January 1990 and January 2017 using variations of the following key words: "posterior lamella," "eyelid reconstruction," "tarsoconjunctival," "flap," and "graft." Two reviewers checked the abstracts of the articles found to eliminate redundant or not relevant articles. The references of the identified articles were screened manually to include relevant works not found through the initial search. The search identified 174 articles. Only a few articles with a therapeutic level of evidence were found. Techniques for the posterior lamellar reconstruction can be categorized as local, regional, and distant flaps; tarsoconjunctival, heterotopic, homologous, and heterologous grafts. Several techniques and variations on the techniques exist to reconstruct the posterior lamella, and, for similar indications, there's no evidence of the primacy of one over the other. Defect size and location as well as patient features must guide the oculoplastic surgeon's choice. The use of biomaterials can avoid possible complications of the donor site.

The Use of Meshed Dermal Autograft in Breast Reconstruction.

The advantages and disadvantages of acellular dermal matrix (ADM) in breast reconstruction have been well documented. ADM is commonly used in breast reconstruction, but it adds cost to the procedure and has been associated with an increased risk of seroma, flap necrosis and infectious complications. A dermal autograft may be a useful alternative to matrices, and it has a lot of advantages: more biocompatible and more likely to be retained as a free graft, low cost, well tolerated, readily available and integrated. This report discusses a new surgical technique that uses an autologous dermis, which was harvested from the controlateral breast in patients having simultaneous breast reduction/mastopexy. Before the insertion, the autologous dermal matrix was meshed at a ratio of 3:1 to increase the graft surface area, to provide additional draining and to improve the engraftment of the autologous dermal matrix. Consequently, the resulting meshed graft allows for the cover of the inferior pole of a larger breast size implant and decreases the complication rate. In our clinic, this method was used on five women; there was one limited necrosis of the mastectomy flaps. The described technique is straightforward and reliable, it adds minimally to the operative time, and it eliminates costs and covers a bigger part of the prosthesis and promises good results. No Level Assigned 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 Contents or the online Instructions to Authors www.springer.com/00266 .

An Efficient Method for Hair Containment During Head and Neck Surgery.

The authors present a simple technique for operations around hair-bearing areas such as during a rhytidectomy. Hair surrounding the surgical field is twisted into bundles and clipped with duckbill clips. The authors repeat the procedure for each strand of hair. Between 5 and 7 duckbill clips may be required per surgery.The clippers are faster, easily applicable, and well performing. They can be used with different hair lengths, and they do not require any additional trimming or shaving; clips also keep the hair firmly in place, and they do not loosen up in the process.This technical note explains a very simple, economical, and less time-consuming method to control hair located around the surgical site. It may be applied to all procedures within the field of the hair-bearing scalp, including craniofacial and maxillofacial surgery.

Reduction Mammaplasty for Breast Symmetrisation in Implant-Based Reconstructions.

BACKGROUND: Healthy breast surgery constitutes an important step to achieve symmetry in unilateral implant-based reconstructions. We analysed long-term results of breast symmetry obtained with reduction mammaplasties, and we evaluated whether different glandular pedicles may better preserve long-term stability. METHOD: Between 2006 and 2012, 90 patients underwent mastectomy and immediate reconstruction with tissue expanders and simultaneous contralateral reduction mammaplasty. In 30 patients, a superior nipple-areola pedicle was harvested (GROUP A), in another 30 patients a medial pedicle was performed (GROUP B), and an inferior pedicle was used in the remaining 30 women (GROUP C). An objective evaluation of the reconstructed breast and the reduced one was performed at 1 and 24 months after surgery. One-way ANOVA and Tukey's HSD tests were used for analysis. Furthermore, three independent plastic surgeons filled out a questionnaire to assess aesthetic results. RESULTS: Measurements of the reconstructed breasts showed similar variations between 1- and 24-month evaluations within the three groups with no significant difference (P value >0.05). Measurements of the reduced breast at the 1- and 24-month follow-up (Tukey's test) revealed significant differences among the three groups. Patients from GROUP C showed a significantly higher decrease in Δ nipple-lower clavicle margin distance and Δ nipple-inframammary fold compared to GROUP A and B (P value = 0.01). Surgeons' assessments revealed no statistically significant difference between the three groups. CONCLUSION: Superior or medial pedicle reduction mammaplasties seem to better preserve breast shape and position, and they maintain a more similar appearance to the contralateral prosthetic breast over time. LEVEL OF EVIDENCE IV: 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 Contents or the online Instructions to Authors www.springer.com/00266 .

The Use of "Precapsular Space" in Secondary Breast Reconstruction.

BACKGROUND: Periprosthetic capsule formation is a physiological phenomenon occurring around breast implants. In case of capsular contracture, several surgical techniques are described; among them, total capsulectomy is considered the gold standard, but it is not free of complications. A more conservative procedure is the use of "precapsular space", leaving intact the preexisting capsule. The method presents minor complications and further advantages over total capsulectomy. METHOD: From November 2010 to June 2014, we treated 92 postmastecttomy patients who previously underwent implant-based reconstruction. They presented implant malposition (bottoming-out, double bubble deformity, upward migration) and different degrees of capsular contracture. The implant was repositioned in a neoprecapsular pocket. Sixty-eight out of 92 patients presented a follow-up longer than 24 months, and they are included in the present study. They were evaluated with a questionnaire 1 month before surgery, at 6 months and 2 years postoperatively. Moreover, two independent plastic surgeons completed the same questionnaire at 6 months and 2 years after surgery. RESULTS: Mean follow-up is 29 months. Baker III-IV capsular contracture occurred in 9.5 % of the patients, implant malposition in 2.9 % of the cases and no implant displacement rotation was observed. Patient self-assessment preoperatively and postoperatively (at 2 years) revealed improved cosmetic outcomes (p < 0.01). Surgeon assessment correlated with patient self-assessment. CONCLUSION: The use of precapsular space, first described for aesthetic augmentation, is a valid alternative to total capsulectomy for the treatment of capsular contracture or implant malposition, even in the reconstructive field. LEVEL OF EVIDENCE IV: This journal requires that the 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 .

A Simple and Effective Technique of Breast Remodelling After Conserving Surgery for Lower Quadrants Breast Cancer.

BACKGROUND: Quadrantectomy is an oncologically safe procedure for the treatment of early-stage breast cancer, but it often results in poor aesthetic outcomes such as breast shape deformity, which is more visible if the tumour is located in the lower pole. We recommend the use of the transverse incision, which retains the oncological advantages of the quadrantectomy while leading to better aesthetical results. METHOD: We evaluated the clinical results of 24 patients with breast cancer who underwent quadrantectomy of the lower breast pole and volume replacement with remodelling through three posterior scorings from January 2012 to January 2014, with cosmetic evaluations performed according to the criteria set by the Japanese Breast Cancer Society. RESULTS: Minimum follow-up after surgery was 2 years, with an average of 28.4 months. Among treated patients, the percentage of complications was extremely low and the degree of satisfaction fairly good. Moreover, the assessment of the medical team matched patient self-assessments. CONCLUSION: Immediate breast reconstruction of a defect performed after a quadrantectomy of the lower breast pole using the "posterior scoring technique" provided better cosmetic results compared to the transposition of residual breast tissue. This technique provides reliable and reproducible results, and it also appears to be rather successful on patients with small-moderate breasts in the absence of a certain degree of ptosis, therefore increasing its already considerable appeal. LEVEL OF EVIDENCE V: This journal requires that the 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 .

Suture With Resorbable Cones: Histology and Physico-Mechanical Features.

BACKGROUND: Silhouette Sutures (Kolster Methods, Inc., Corona, CA) exhibit different biological characteristics at various time points after their placement. OBJECTIVES: The goals of this study were to understand the biological reactions of Silhouette Sutures in human tissues at different time intervals and to determine the index of resistance of the sutures in subcutaneous tissue. METHODS: Histologic examination was performed on section soft tissue containing the sutures at 1 month, 3 months, 6 months, and 1 year after suture placement. The study comprised 8 patients, each of whom received 4 sutures in the lower abdomen under local anesthesia. The sutures were placed exactly 1 month, 3 months, 6 months, and 1 year before planned post-bariatric abdominal surgery. Dynamometric evaluation was performed on a never-used suture and on sutures removed from 1 year after placement. The scar process around the threads was also examined. RESULTS: A progressive increase in scar tissue around the sutures was observed. One year after placement, there was a reduction of 16.7% in yield and tensile strength and a reduction of 14.29% in elongation at break, relative to the never-used suture. By 1 year, the cones in polylactic and glycolic acids had been replaced by scar tissue. CONCLUSIONS: Fibrous tissue around the sutures increased progressively over time, and was most prominent at the level of the nodes. Cones were completely resorbed within 6 months. A reduction in the index of resistance of the suspension sutures occurred over 1 year.

Suspension sutures in facial reconstruction: surgical techniques and medium-term outcomes.

The purpose of this study was to assess the medium-term results of using thread-lift sutures as a means to support soft tissues in facial reconstructive surgery. The rationale for the introduction of this method was to provide support for tissues used in the reconstruction in cases where this would otherwise have been difficult to achieve, or would have demanded major additional surgery in patients already undergoing major surgical procedures. The outcome of the procedure was assessed 12 and 24 months after surgery. Patients were satisfied with the results. Judging from the findings of this study, Silhouette sutures are a valuable asset in facial reconstruction surgery when associated with a scrupulous technique and used for the right indications.

Common Peroneal Nerve Injury Related to Small Saphenous Vein Surgery: Report of 2 Cases and Review of the Literature.

Although iatrogenic damage is less often involved, deep nerve injuries are reported especially as a result of small saphenous vein (SSV) dissection. Complete or partial division of the common peroneal nerve (CPN) during varicose vein operations causes substantial and serious disability. Most CPN injuries recover spontaneously; nonetheless, some require nerve surgery. Treatment depends on the nature of CPN injury. This report chronicles 2 instances of CPN injury after SSV surgery, addressing treatment strategies and therapeutic gains. The pertinent literature is also reviewed.

Prepectoral Implant-Based Breast Reconstruction Using Meshed ADM.

Prepectoral prosthetic breast reconstruction has been widely reassessed in recent years and is taking on an increasingly important role in the field of immediate breast reconstruction. We report here a case series of 32 patients who underwent nipple-sparing mastectomy for breast carcinoma and prepectoral breast reconstruction involving an acellular dermal matrix (ADM) treated by means of a skin-graft mesher in our hospital from January 2015 to March 2016. The indications for this type of reconstruction were body mass index (BMI) less than 30 kg/m2; no history of radiotherapy; no active smokers; moderate grade breast; and good viability of mastectomy flap: normal skin colour, active bleeding at the fresh cut edges, and thicker than 1 cm mastectomy flaps; the viability of lower thicknesses was ascertained by the fluorescent dye indocyanine green xenon-based imaging technology (4 patients). The mean age of the patients was 56.4 years (range: 39-77 years). Their mean BMI was 27.4 kg/m2. Until the end of follow-up (mean: 17 months), major complications requiring reoperation occurred in 9% of patients and minor complications in 22% of patients. The mean of the 3 pain visual analogue scale scores taken in the first 24 hours after surgery was 1.8. Mean duration of hospital stay has been 2.2 days. Our complication rate was similar to those reported in other studies on prepectoral breast reconstruction featuring total ADM coverage of the implant.

La reconstruction par prothèse mammaire prépectorale a été largement réévaluée ces dernières années et joue un rôle de plus en plus important dans le cadre des reconstructions mammaires immédiates. Les auteurs rendent compte d'une série de 32 patientes qui ont subi une mastectomie d'épargne cutanée à cause d'un carcinome du sein et d'une reconstruction mammaire prépectorale touchant la matrice du derme acellulaire traitée par une ampligreffe à l'hôpital entre janvier 2015 et mars 2016. Les indications pour ce type de reconstruction étaient un indice de masse corporelle inférieur à 30 kg/m2, aucun antécédent de radiothérapie, aucun tabagisme actif, des seins de dimension modérée, une bonne viabilité du lambeau de mastectomie, une couleur normale de la peau, un saignement actif aux bordures fraîchement coupées et des lambeaux de mastectomie de plus de 1 cm. La viabilité de l'épaisseur inférieure était évaluée par la technologie d'imagerie par fluorescence du vert d'indocyanine à base de xénon (chez quatre patientes). Les patientes avaient un âge moyen de 56,4 ans (moyenne de 39 à 77 ans) et avaient un indice de masse corporelle moyen de 27,4 kg/m2. Jusqu'à la fin du suivi (moyenne de 17 mois), 9 % des patientes ont souffert de complications majeures exigeant une réopération, et 22 % ont subi des complications mineures. La moyenne de trois scores de douleur sur l'échelle analogique visuelle calculés dans les 24 heures suivant l'opération s'élevait à 1,8. Le séjour hospitalier était d'une durée moyenne de 2,2 jours. Le taux de complication était semblable à celui déclaré dans d'autres études sur la reconstruction mammaire prépectorale touchant l'intégralité de la matrice dermique acellulaire de l'implant.

Full-thickness lower eyelid reconstruction with a conchal chondro-perichondral graft and local coverage with Mio-cutaneous flaps--our divisional experience.

BACKGROUND: Eyelid reconstruction represents a challenge because of the complexity of this structure. Full-thickness eyelid defects demand the reconstruction of 2 fundamental elements: anterior and posterior lamellae. The available reconstructive techniques are all associated with the attention to restore the support and responsibility of eyelid stability, represented physiologically by the tarsus. In 1987, Matsuo proposed a reconstructive technique that involved the use of a chondro-perichondral graft harvested from the auricular concha to reconstruct the posterior lamella, and an adjacent skin flap to restore the anterior lamella. MATERIALS AND METHODS: We report our divisional experience of a series of 28 patients operated on from 2000 to 2004, whose eyelid restoration was achieved with the use of Matsuo's technique modified with the purpose to avoid complications such as ectropion or lagophtalmus. RESULTS: All the grafts survived, and no major complication such as ectropion or lagophthalmos has been detected. Our specialistic judgment has ranged from good to excellent regarding symmetry, eyelid closure, and donor site morbidity. Patients were entirely satisfied with the functional result obtained, and generally with the esthetic outcome also, judged as ranging from good to extremely satisfactory. CONCLUSIONS: The success of eyelid reconstruction using modified Matsuo's technique depends, in our minds, on an adequate knowledge of traditional eyelid reconstruction methods, and on a few technical fine points that help to reduce postoperative complications and to optimize the quality of the end result; hence, this technique has become the gold standard in lower eyelid reconstruction in our division.

An efficient method for the correction of iatrogenic symmastia: A case series.

BACKGROUND: Symmastia is a medial confluence of the breasts, produced by a web of skin and fat merged across the midline, that generates the disappearance of the intermammary sulcus. Apart from the rare congenital cases, this condition is usually a result of technical complications during breast augmentation surgery.This article describes a simple and reliable method for correcting symmastia. METHODS: From November 2006 to June 2015, we treated 10 patients with acquired symmastia who had previously undergone an implant-based reconstruction. We performed a crescent-shape medial capsulectomy and we then performed an adequate and resistant closure with a substitute device, consisting of a Tuohy epidural needle and polydioxanone sutures, which are easily accessible and inexpensive. The process outcome was successful and resulted in a normal cleavage between the breasts. RESULTS: Mean follow-up was 24 months. We haven't observed any recurrence of symmastia to date in this study. One postoperative hematoma and one seroma occurred. All ten patients achieved acceptable results through the procedure. CONCLUSION: Our pericapsular Tuohy technique for medial closure of the pocket is a practical and efficient substitute to traditional capsulorraphy and provides reliable and reproducible results.

A case of gestational gigantomastia in a 37-years-old woman associated with elevated ANA: a casual linkage?

Hypertrophy of the breast (macromastia and gigantomastia) is a rare medical condition of the breast connective tissues. The etiology of this condition is still not clear; rarely, gigantomastia has been reported to develop in the setting of an autoimmune illness. We reported a case of a 37-years-old woman with undifferentiated connective tissue disease of 2-years duration presented with enlargement of breasts. The breast enlargment started at 5 months of gestation. She successfully underwent reduction mammoplasty with free nipple graft. In the succeeding months the level of antinuclear ANA remained stable. It is uncertain whether a positive antinuclear antibodies in gigantomastia is a casuative agent or an effect.

Soft tissue and tendon reconstruction after achilles tendon rupture: adipofascial sural turnover flap associated with cryopreserved gracilis tendon allograft for complicated soft tissue and achilles tendon losses. A case report and literature review.

Soft tissue and tendon reconstruction after Achilles tendon rupture:Adipofascial sural turnover flap associated with cryopreserved gracilis tendon allograft for complicated soft-tissue tendon losses.A case report and literature review Achilles tendon rupture is often complicated by skin substance loss around the tendon, which is a poorly-vascularized site. Treatment may be conservative or surgical, but the former is not generally accepted by the orthopedic community and is reserved for selected cases, while surgery remains the most widely-used approach. Soft tissue repair at this site is a crucial reconstruction problem, and becomes very complex if skin reconstruction has to be associated with a complex tendon repair. The Authors describe a new approach to the repair of Achilles tendon substance loss compounded by a soft tissue defect, using a cryopreserved gracilis tendon allograft in combination with a distally-based adipofascial sural flap.

The distally-based radial fasciosubcutaneous flap for soft tissue cover of the flexor aspect of the wrist.

The distally-based radial forearm fasciosubcutaneous flap is based on the distal perforators of the radial artery. We used it in a particularly difficult case involving loss of soft tissue at the wrist with exposure of tendons and nerves after an operation to section the transverse carpal ligament for carpal tunnel syndrome complicated by a chronic fistula.

Lower lid reconstruction utilizing auricular conchal chondral-perichondral tissue in patients with neoplastic lesions.

PURPOSE: To assess surgical outcomes of lower lid reconstruction surgery using auricular conchal tissue. METHODS: This prospective study included 20 patients that underwent reconstructive lower lid surgery using autologous auricle chondral-perichondral graft tissue. Auricle tissue was used to provide adequate support and protection with similar conjunctiva tarsal structures on overlying soft tissues in patients with pathologic inferior lid tissue loss requiring reconstructive surgery. Biopsies with histopathology and cytology analysis were taken after 1 year. Cytology analysis using CK19 was used to confirm newly formed conjunctiva overlying the graft. RESULTS: All patients showed no graft rejection. Surgical outcomes were generally good, with minimal or no ocular complications. 16 of 20 patients had excellent results, showing good lid symmetry and esthetics, minimal auricular discomfort, patient satisfaction and proper lid function. Surgical outcomes were highly dependent on proper post-op conjunctiva formation. All patients were positive for CK19, thus indicating proper conjunctiva tissue formation. CONCLUSIONS: Lower lid reconstruction surgery using auricular chondral-perichondral conchal tissue is a good alternative in patients with neoplastic lesions. Autologous chondral-perichondral tissue provides good functional and mechanical support in the reconstructed lid, thus reducing the risks of ectropion and corneal exposure and ensuring a protected ocular surface.