'J' brachioplasty technique in massive weight loss patients.

Upper extremity body reshaping is a very frequent surgical procedure in massive weight loss patients. Many surgeons have presented different patterns of brachioplasty skin excision and a variety of adjunctive techniques, each of them claiming improvements in scar aesthetic, arm shape or overall safety of the procedure. In this pape,r we want to illustrate our personal brachioplasty technique for massive weight loss patients. Our incision design named 'J' Brachioplasty is described. Between March 2013 and March 2016, a retrospective study of patients with massive weight loss and clinical diagnosis of brachial ptosis undergoing surgical reconstruction with 'J' brachioplasty was performed. All patients were treated according to a standard surgical procedure described in detail in the paper. The presence of axillary and thoracic skin excess was also recorded for every subject, as well as clinical and surgical postoperative complications. A total number of 73 Caucasian underwent J-shaped brachioplasty. Our technique allowed us to treat both arm and thoracic skin excess with a single skin incision. Among our casuistic we had only two cases of postoperative bleeding and four cases of partial wound dehiscence due to tension. Seroma was reported only in one (female) patient. Despite the recent introduction our technique has proven to reach good results in massive weight loss patients.

Quantum molecular resonance technology in hard-to-heal extremity wounds: histological and clinical results.

Chronic wounds are commonly associated with high morbidity rates due to the patient's need of frequent dressing changes and repeated visits to the outpatient wound clinic. Furthermore, chronic wounds are often characterised by severe pain, which can cause significant disability to the patient. New technologies aim to develop an optimal device to reduce discomfort of the patient and to heal wounds. The device Rexon-age® is introduced for the first time in wound healing, and preliminary data on clinical and histological results are shown. From April 2014 to April 2015, 11 patients - 7 females and 4 males - were enrolled in the present study. The study was conducted at the Plastic and Reconstructive Institute of the Università degli Studi di Torino, Città della Salute e della Scienza of Torino, Italy. For histological characterisation, pre- and post-treatment biopsies on the wound bed were performed. Data regarding age, gender, weight, height, comorbidity, drug therapy and topical pre-treatment and dressings of the wound were collected as well. Moreover, local factors regarding the wound data were as follows: aetiology, time of the wound formation until first Rexon-age treatment, wound dimensions, wound bed, moisture, margins and anatomical region of the wound. A visual analogue scale (VAS) was used to monitor the pain before and after each treatment. Rexon-age treatment resulted in improvement in granulation tissue and wound contraction. Moreover, a significant reduction of pain was observed with the reduction of painkillers drug usage. Among these Rexon-age-treated patients, three patients displayed 60-80% reduction in pain intensity, and two patients showed complete pain relief. In outpatient follow-up appointments, we registered long-term durability of pain relief. As assessed by histological analyses, post-treatment biopsies of all nine patients revealed a decreased amount of inflammatory cells and lower expression levels of metalloproteinases (e.g. MMP9). We observed increased capillary thrombosis as well as up-regulation of vascular endothelial growth factor (VEGF) expression. The current study presents the first evidence that Rexon-age-based therapy can significantly ameliorate and accelerate the healing process of chronic wounds. Although this study analysed only a small number of patients, we could consistently observe positive effects on both the clinical aspect of the lesions, which underwent size reduction and wound reactivation, and the quality of life of our patients due to long-term pain relief.

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.

Electrical stimulation for difficult wounds: only an alternative procedure?

In the wound healing research, the exact mechanism of action of different modalities of electrical stimulation (ES) remains controversial and unresolved. In this study we discuss a particular ES, with a different type of waveform, corresponding to the principle of stochastic resonance. Between July 2008 and May 2010, 32 patients were enrolled and ES was applied to wounds using the bioelectrical signal therapy (BST) device (LifeWave, Petach Tiqwa, Israel). The outcome evaluated in group 1 (n = 21) was wound healing, while group 2 (n = 11) was evaluated for wound-related pain [Visual Number Scale (VNS) pain scale] during treatment. In group 1, 87% of the wounds closed in an average time of 97 days (range 10-150 days); three patients were lost to follow-up. In group 2, 45% of the patients experienced a complete pain disappearance after 7 days of treatment; 36% reported a reduction in VNS from 9·3 to 3·2 in 7 days; 19% stopped morphine-like painkillers after 2 weeks. The clinical application of the stochastic resonance enables the usage of easy-to-use, non-invasive, painless and pain-relief treatment. Our experience with ES has demonstrated the BST device to be a very good alternative in cases of small size defects, compared with other therapies such as surgery, dressing and negative pressure devices.

Preoperative color duplex echographical venous mapping before autologous fat graft for calf augmentation: a case report of superficial vein thrombosis and prevalence of intersaphenic anastomosis.

Autologous fat grafting for calf augmentation is considered an easy and safe technique. Only few cases of potential complications have been described in literature; among them, vein thrombosis was never reported. We report a case of superficial vein thrombosis of the intersaphenic anastomosis after fat graft for calf symmetrization in club-foot syndrome. A color duplex echographical study showed that such intersaphenic anastomoses are present in all patients, but they have an ectatic diameter in 70% of patients with great saphenous vein insufficiency and in 50% of patients without insufficiency. The plastic surgeon should be aware of the presence and topography of such anatomical variations before performing the procedure. Moreover, a preoperative color duplex echographical venous mapping may help the surgeon in avoiding the trauma on vein variants and subsequent complications.

Negative pressure wound therapy using gauze and foam: histological, immunohistochemical and ultrasonography morphological analysis of the granulation tissue and scar tissue. Preliminary report of a clinical study.

Negative pressure wound therapy (NPWT) is becoming routine for the preparation of wounds prior to grafting for wound closure. We have been using both foam- and gauze-based NPWT to prepare wounds for closure prior to skin grafting and have obtained similar proportions of closed wounds; 7/7 for wounds treated with gauze-based NPWT and 11/11 for wounds treated with foam-based NPWT. In our follow-up consultations we observed that skin grafts on the foam-treated patients were less pliable than those on the gauze-treated patients. To assess what the mechanism of this effect might be, we compared the specific details of the treatments of both 11 foam and 7 gauze patients, including depth, location, patients' age and co-morbidity; biopsies of granulation and scar tissue were taken and stained with haematoxylin-eosin and by Masson's trichrome staining and conducted ultrasound analysis of the closed wounds, to see if there were features which explained those effects. All foam patients were treated at -125 mm Hg for an average of 25·9 days before skin grafts were applied. All gauze patients were treated at -80 mm Hg for an average of 24·7 days before skin grafts were applied. Biopsies of granulation tissue prior to skin grafting from five foam and four gauze-based NPWT patients did not reveal any obvious histological differences between the treatments. Ultrasound analysis of the skin-grafted wounds showed an average depth of scar tissue of 18 mm in the wound beds of the foam-treated wounds and 7 mm in the gauze-treated ones. Biopsies taken on the scar tissue after treatment with the gauze showed a minor tissue thickness and disorganisation and less sclerotic components. The findings of this preliminary analysis suggest that foam-based NPWT may induce a thicker layer of scar tissue beneath skin grafts than gauze-based NPWT which might explain a reduced pliability of the reconstructed bed. At present it is unclear which mechanism might be responsible for the difference in pressure (-125 versus -80 mm Hg), either the length of the time taken to reconstruct the wound bed or the intrinsic nature of the foam or gauze on the tissue surface. Prospective studies are necessary to investigate whether these preliminary observations are confirmed and to investigate what the mechanism might be.

Surgical debridement with VERSAJET: an analysis of bacteria load of the wound bed pre- and post-treatment and skin graft taken. A preliminary pilot study.

Surgical debridement, which is used for the removal of necrotic tissue from a wound, is becoming more and more important in the treatment of skin injuries. VERSAJET (VERSAJET™, Versajet Hydrosurgery System, Smith and Nephew, Hull, UK) is one of the techniques used for wound debridement. Medical literature does not present either analytical or comparative data correlating the bacterial load with the VERSAJET treatment. For this reason, we have decided to carry out a study to evaluate the level of bacterial contamination before and after the surgical debridement treatment with VERSAJET and, in connection with this, the correlation between the bacterial load and the successful healing of the skin graft. We took a total of 100 bacteriological swabs, 50 before and 50 from 27 selected patients after the treatment with VERSAJET, with which the wound bed was prepared to receive the skin graft or Integra graft in order to acquire data about the level of bacterial contamination. After analysing all those data we can assume that reducing the bacterial load is not the only variable which the successful healing of the skin graft depends on. In conclusion, there is still many data to analyse and study in order to better understand the qualitative and quantitative presence of bacteria and the success of this future surgical procedure. We remind that the performance of this study was not sponsored by any company.

Junior plastic surgeon's confidence in aesthetic surgery practice: a comparison of two didactic systems.

The importance of residents' training in aesthetic surgery and the need for acquiring confidence in performing cosmetic procedures is an established knowledge. A survey was done in two different training systems to evaluate the experience of junior plastic surgeons in performing four common aesthetic surgery procedures at the end of their residency. The first system guarantees a theoretical background and a certain number of aesthetic procedures to be performed by the trainee, in contrast to the second system where mainly theoretical knowledge in cosmetic surgery is warranted to residents. The residents' comfort in performing specific operations was quite varied between the two systems. The comparison showed that junior plastic surgeons reached a higher degree of self-confidence in aesthetic practice in system A when compared to system B. The similarities and differences between the two systems are analysed and discussed. The possibility of reforming residency programmes by following the structure and the philosophy of system A is proposed.

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.

Abdominoplasty after weight loss in morbidly obese patients: a 4-year clinical experience.

BACKGROUND: Morbid obesity is associated with various co-morbidities. With the significant weight loss, new dysfunctions arise, and prior body contour disorders start to severely affect the patient's quality of life. The abdominal apron is generally the greater and the first disturbance faced by the post-bariatric patient. METHODS: The authors retrospectively reviewed their clinical experience in the treatment of those disorders through abdominoplasty. The benefits in terms of relief of said disorders and drawbacks in terms of surgical complications are described. RESULTS: 117 abdominoplasties were performed from January 2002 to December 2005 on patients who had lost significant weight. The tissue removed ranged from 400 g to 10,500 g of adipose-cutaneous tissue (mean 2,276.5 g). Mean duration of the procedure was 4 hours and 25 minutes, with a maximum of 7 and a minimum of 2 and 40. Complication rate was 50.43%. CONCLUSION: Abdominoplasty in the post-obese patient is an apparently simple procedure, which in fact causes a high rate of surgical complications. The complication rate is higher than that of cosmetic abdominoplasties. Nevertheless, the improvement in quality of life following such a procedure renders it a fundamental step in the rehabilitation of the formerly obese patient.

Congenital mammary asymmetry. Classification and surgical treatment.

AIM OF THE STUDY: The Authors intend to guide the choice of surgical treatment for mammary asymmetry, according to specific form of asymmetry. MATERIAL AND METHODS: Possible types of symmetryzation surgery are listed. First Author's personal technique is described and some clinical cases are presented. DISCUSSION: Regardless to specific surgical needs for the single case, a generally valid concept is the necessity of a surgical moulding meant to obtain the same volume for both breasts before positioning of implants. This allows a longer lasting symmetry between breasts, as aging modifications bilaterally occur at equal speed if the adipo-glandular structures obtained have the same volume.

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.