A Proposed Classification and Treatment Algorithm for Rectus Diastasis: A Prospective Study.

BACKGROUND: This study presents a classification system and treatment method to correct Rectus diastasis (RD) during abdominoplasty. MATERIALS AND METHODS: One hundred and sixty seven patients undergoing abdominoplasty were enrolled between April 2014 and January 2018. Forty-three patients did not present with RD and were excluded from the analysis. Mean age was 40.32 years, mean BMI was 23.84, and minimum follow-up was 24 months. A four-type (A: mild 2-3cm, B: moderate 3-5cm, C: severe 5-7cm, and D: very severe 7-9cm) classification system is described. A different treatment method is performed in each category using continuous and interrupted absorbable sutures. Postoperatively patients filled up a questionnaire that involved the level of pain, the postoperative day they performed specific indoor/outdoor activities, and the evaluation of the aesthetic result. RESULTS: No statistically significant differences were observed between the four RD types regarding pain, complications, and return to specific activities. All types of RD had the same low rate complication profile. The seroma rate was 0.81%. The infection rate was 0.81%, and the thromboembolism and the pneumonic embolism rate was 0%. After 2-6 years of follow-up no clinical recurrence of rectus diastasis was observed. All reoperations (14.52%) were performed due to scar deformities. Mean pain score levels were very low (<1.5) and within a week most patients returned to specific indoor and outdoor activities. Most patients were extremely satisfied with the results. CONCLUSIONS: In this article, we present an updated classification system and treatment protocol to provide surgeons a safe and standardized method that produces high-quality aesthetic results. 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 .

Early Diagnosis and Treatment of Pyoderma Gangrenosum: Reviewing Mobile Phone Photos Saved a Patient From Unnecessary Surgeries.

Pyoderma gangrenosum of the breast following surgery is a rare aseptic inflammatory cutaneous condition that causes very rapid progressing and expanding painful ulceration of the surgical site and the adjacent skin. The greatest issue concerning pyoderma gangrenosum is its diagnosis. Almost invariably, it is misdiagnosed as a wound infection, which results in delayed identification, lengthy antibiotic regimens, and ineffective detrimental surgical debridements, causing significant patient disfigurement. We present a rare case report of pyoderma gangrenosum complicating the surgical site of the breast reduction procedure two months after simultaneous performance of operations including breast reduction, abdominoplasty, and lumbar liposuction. The diagnosis was established within four hours from the initial lesion and symptom presentation due to the accurate evaluation of photographs sent from the patient's mobile phone to the surgeon every half hour. Immediate appropriate treatment with oral corticosteroids within this time interval was initiated, resulting in favorable healing for the patient within four months.

Can a Breast Augmentation Procedure Improve the Appearance of Pectus Excavatum Deformity in Female Patients? A Prospective Study.

Background: This study evaluates a specific breast augmentation (BA) technique in patients with pectus excavatum(PE) and its results in improving this deformity, augmenting the breasts, and correcting the concurrent breast asymmetry. Methods: Twenty-eight patients with PE were treated from 2017 to 2021. All patients who visited our private practice were aiming to augment their breasts, correct their breast asymmetry, and improve their PE. The mean age of the patients was 25 years. In most cases, the submuscular dual-plane technique was chosen. Patients' quality of life regarding their chest wall deformity was assessed using the Single Step Questionnaire (SSQ). Subjects' quality of life regarding general self-esteem, psychosocial well-being, and physical function were assessed at initial screening and 24-month follow-up using the BREAST-Q V2 questionnaire. Also, patients filled out a pain-evaluating questionnaire concerning the first 5 postoperative days to determine the recovery of this specific technique. Results: No complications were observed. The SSQ revealed high satisfaction (mean score=73) and significant (P = 0.001) improvement following the operation. The improvements regarding psychosocial well-being, sexual well-being, and satisfaction with the BREAST-Q were also equally high (P = 0.001). The pain was minimal during the first five postoperative days. This is the first prospective study that evaluates the quality of life using both the SSQ, the validated BREAST-Q, and the pain score when performing BA in patients with PE and breast asymmetry using breast silicone implants. Conclusions: BA is a procedure that can give excellent results both regarding chest wall deformity and BA in PE patients.

A Safe and Effective Lip Augmentation Method: The Step-by-Step Φ (Phi) Technique.

The shape and fullness of the lips are essential in facial aesthetics. We describe a safe injection technique of hyaluronic acid (HA), based on the well-known golden number Φ (phi), for lip augmentation. METHODS: The name given to that procedure is "the step-by-step Φ technique." Firstly, "step-by-step" because we never inject more than 1-1.5 ml of HA in 1 session, and "phi" because we apply the golden ratio 1.618-broadly known as Φ-to identify the proper points for injection. Using a specific caliper, we identified 3-4 points in each upper half of the lip. We injected 0.01-0.05 ml of lower concentration (25 mg/g) HA in these particular areas of the upper lip, from the vermillion border into the vermillion. We took into consideration the existing lip volume to decide the proper amount of HA to be injected in every single site, as lips are often asymmetric. On the lower lip, we use the same caliper to identify again the proper injection points. If necessary, the next 2 sessions are performed at an interval of 15-30 days. RESULTS: Our technique was performed in 833 patients. Mean age was 30.2 years (range: 18-72 years), and most patients were very satisfied. With this technique, we avoid severe complications such as arterial embolism or venous occlusion and unnatural results. The most common side effects were swelling, redness, and mild pain. CONCLUSION: The step-by-step Φ technique is safe, easy to learn and perform, and can provide natural results in lip augmentation.

Three-dimensional Cryolipolysis for Submental and Lateral Neck Fat Reduction.

Median and lateral neck areas are quite challenging to improve. Three-dimensional cryolipolysis is a noninvasive technique for localized fat reduction. We investigated the efficacy and safety of the technique when applied to these areas. A prospective study of patients treated with one session of 3-dimensional (3D) cryolipolysis is performed. Clinical outcomes are assessed using caliper measurements, patient surveys, and independent, blinded plastic surgeons' photographic evaluation. The studies are conducted using a commercially available noninvasive medical device for 3D cryolipolysis. All patients received gentle massage of the treated areas for 3 minutes, and the final follow-up is after 3 months. Thirty-nine patients are enrolled in our study from June 2018 to December 2018. All 39 subjects received treatment on at least one intended area (median, right, and left lateral neck). Comparison of the pre- and posttreatment caliper measurements demonstrated a significant reduction of the treated areas at 3 months. Posttreatment, 82.05% of patients marked the results of fat reduction as exceptional or very improved, 12.82% as improved, 5.13% as no result, and 0% as worse. Improved patients and the blinded plastic surgeons noticed at these patients' groups a bonus tightening effect. No serious adverse reactions are observed; thus, 3D cryolipolysis considered as a safe and effective noninvasive localized fat reduction technique with an extra, almost regularly observed, tightening effect.

Aggressive digital papillary adenoma-adenocarcinoma.

Aggressive digital papillary adenocarcinoma and aggressive digital papillary adenoma are rare tumours of the sweat glands. They are most common in the most distal part of the fingers and are locally aggressive with a 50% local recurrence rate; 14% of tumours metastasize. We present two cases.

Radiofrequency-assisted Liposuction for Neck and Lower Face Adipodermal Remodeling and Contouring.

BACKGROUND: The purpose of this study is to report our experience using radiofrequency-assisted liposuction (RFAL) for neck and face contouring. This article details the operative technique, selection, complications, third-party surgeon appraisal, and patient satisfaction survey. METHODS: From November 2009 to November 2013, 55 patients who underwent RFAL treatment were enrolled in the study. Postoperative patient satisfaction surveys were conducted, and 2 independent plastic surgeons evaluated contour and skin quality with randomized preoperative and postoperative photographs at 6 months postoperatively. The different parameters recorded involved age, sex, weight, body mass index, operative time, amount of fat aspirated and energy delivered, complications, and aesthetic outcome in 1 and 4 weeks and 3 and 6 months. Our longest follow-up was 4 years. Patients were asked 6 months postoperatively to grade their satisfaction as poor, no change, moderate, good, and excellent. RESULTS: The mean age was 51 years (range, 35-61 years), and the mean amount of fat aspirated was 30 mL (range, 10-200 mL). Five out of 55 patients (9.1%) developed tissue hardness that resolved with massage. All patients were followed up for a minimum of 6 months. Eighty-five percent of patients were satisfied with their contouring result and degree of skin tightening (48/55 patients). Two independent plastic surgeons considered the improvement in contouring and degree of skin tightening good to excellent in 52 of 55 cases. CONCLUSIONS: In appropriately selected patients, RFAL neck and face contouring represent a safe procedure to achieve significant improvement of the skin laxity and fat deposits of the cervicomental zone and jowls.

Self-inflicted burns in Athens, Greece: a six-year retrospective study.

Self-inflicted burns represent a major social and medical problem. The aim of this study was to record the epidemiology, mortality and etiology of suicide attempts by burning, in Athens, Greece. Over a 6-year period from April 1997 to April 2003, all the medical charts of the patients who were admitted to the Burn Center of the General State Hospital of Athens, Greece, with self-inflicted burns were retrospectively studied. Of the 1435 burn patients, 53 (3.69%) had attempted suicide by self-inflicted burn. Their ages ranged from 18 to 90 years old (mean 53.5 years). Females (57%) outnumbered males (43%). The mean total body surface area (TBSA) burned was 41.6% (range: 15-100%). The overall mortality rate was very high (75.4%). A preexisting psychiatric disorder was present in 43.3% of the patients. In conclusion, the extent and the depth of the burn injuries could explain the high mortality rate seen in these patients, in correlation with their negativism to the treatment. Burn care professionals should be familiar with self-inflicted burn patients who constitute a considerable proportion of major burns and require constant psychiatric support in addition to burn care.

Extensive metastasis to the hand from undiagnosed adenocarcinoma of the lung.

Metastatic tumours of the hand are uncommon; we present a case of undiagnosed adenocarcinoma of the lung with extensive metastases to the carpal, and to the third, fourth, and fifth metacarpal, bones. Biopsy confirmed the diagnosis and the patient died three months later, no surgical treatment being offered.

Striae distensae after subfascial breast augmentation.

Striae distensae or stretch marks after breast augmentation are a rare complication. To date, 10 cases have been published. In seven of these cases, the implant was placed in a subglandular position and in the other three cases, placement was submuscular. Two cases of stretch marks in two young nulliparous women who underwent subfacial breast augmentation are presented. To the best of the authors' knowledge, this is the first report of striae distensae after subfascial breast augmentation.

Ropivacaine versus lidocaine in digital nerve blocks: a prospective study.

BACKGROUND: Ropivacaine is a relatively new long-acting amide local anesthetic. Since its introduction in 1996, it has been used for subcutaneous infiltration; epidural, intrathecal, and peripheral nerve block surgery; and postoperative analgesia. However, it has never been used for digital blocks. This prospective, randomized, double-blind study compares the digital block results following the administration of 2.5 ml of 0.75% ropivacaine solution and 2.5 ml of 2% lidocaine solution. METHODS: From March of 1999 to March of 2001, 70 adult patients who underwent immediate reconstruction for traumatic injuries of the digits were prospectively randomized into two groups. Group A (n = 35) received 2.5 ml 0.75% ropivacaine and group B (n = 35) received 2.5 ml of 2% lidocaine for digital anesthesia. Onset time of anesthetic action, duration of anesthesia, time until first postoperative requirement for pain medication, and digital-brachial artery systolic blood pressure index were recorded and evaluated. Local vascular effects were observed visually. RESULTS: No side effects were observed. Lidocaine had the quickest onset of anesthesia, with a mean time of 1.3 minutes (range, 1 to 2.7 minutes). Ropivacaine had a mean onset time of 4.5 minutes (range, 3.5 to 5.5 minutes). The mean duration of postoperative anesthesia for lidocaine was 2.4 hours (range, 1.4 to 4 hours), compared with 21.5 hours for ropivacaine and less requirement for analgesics during the first 24 postoperative hours (p < 0.05) (range, 19 to 23 hours). No significant difference was found between the digital-brachial artery systolic blood pressure index of group A compared with group B. CONCLUSIONS: Ropivacaine can be used effectively as a local anesthetic for digital nerve blocks. It can be used for prolonged operations (>1.5 hours) without additional injections and can provide long-lasting postoperative analgesia.

The Suzuki frame for complex intra-articular fractures of the proximal interphalangeal joint of the fingers.

In 1994, Suzuki et al proposed the pins-and-rubbers traction system, a new dynamic distraction technique for difficult complex intra-articular fractures of the digits of the hand. From February 1999 to April 2003, we used the Suzuki frame for 15 complex fractures of the proximal interphalangeal joint of the fingers. The mean follow-up period was 18 months. Four patients missed their follow-up. In the remaining 11 patients, the mean active range of motion achieved following treatment was 84 degrees in the proximal interphalangeal joint finger injuries.

Adult hand injuries on artificial ski slopes.

Artificial ski slope skiing is a popular sport in Great Britain with significant risk of injury. We reviewed 36 patients who had been treated for hand injuries excluding the wrist in our plastic surgery department over a 14-month period after skiing on an artificial ski slope. Specifically, they were 15 fractures of the digits, 3 dislocations of the finger joints, 7 ulnar collateral ligament injuries of the metacarpophalangeal joint of the thumb, and 11 bruises and abrasions. The mean age of the patients was 28 years, and there were 20 men and 16 women. It is concluded that the hardness of the surface of the artificial ski slopes could be responsible for the types of injuries.

The Suzuki frame for complex intraarticular fractures of the thumb.

BACKGROUND: Suzuki et al. in 1994 described the pins and rubber traction system for comminuted intraarticular fractures and fracture-dislocations of the proximal interphalangeal joint of the hand. The authors used the pins and rubber traction system to treat five complex fractures of the thumb. METHODS: From February of 1999 to April of 2003, five patients, four men and one woman, had a pins and rubber traction system applied for complex fractures of the interphalangeal joint (two patients) and metacarpophalangeal joint (three patients) of the thumb. The mean age of the patients was 35.4 years (range, 28 to 50 years). The system was applied for 4 weeks in all cases. RESULTS: The mean follow-up period was 23.6 months. The mean range of total movement for the metacarpophalangeal joint was 55 degrees (45 degrees of flexion and 10 degrees of extension). The two patients with the interphalangeal joint fractures achieved flexion of 0 to 65 degrees and 0 to 55 degrees, respectively. Joint space narrowing was observed in three cases. One patient had persistent swelling of the metacarpophalangeal joint 14 months after the initial treatment but had no functional deficit or pain. No pin track infection was observed in this series. CONCLUSIONS: Previous reports regarding the application of the pins and rubber traction system have focused on pilon fractures and dorsal fracture-dislocation of the proximal interphalangeal joint. In the present study, the authors described their experience with application of the Suzuki frame for complex intraarticular fractures of the thumb. The authors believe that the pins and rubber traction system can be used to treat difficult intraarticular fractures of the thumb, with very good functional results.

Comparison of transthecal digital block and traditional digital block for anesthesia of the finger.

A randomized, double-blind study was performed in 50 patients to compare the transthecal and traditional subcutaneous infiltration techniques of digital block anesthesia regarding the onset of time to achieve anesthesia and pain during the infiltration. All the patients had sustained injury involving two or four fingers of the hand. Each patient served as his or her own control, having one finger infiltrated with the transthecal technique and the other with the subcutaneous infiltration technique. Time to loss of pinprick sensation and pain (at the time of the infiltration and 24 hours postoperatively) were assessed using a visual analogue scale and verbal response score. A total of 104 blocks (52 transthecal and 52 subcutaneous infiltration) were performed. All of these blocks were successful. Mean time to achieve anesthesia with the transthecal block was 165 seconds, compared with 100 seconds for the subcutaneous infiltration block. The mean analogue pain score was higher for transthecal blocks than for subcutaneous infiltration blocks (3.2 +/- 0.19 versus 1.6 +/- 0.14). Twenty-four hours postoperatively, 24 patients who had the transthecal block experienced pain at the injection site of the digit. However, none of the patients who received the subcutaneous infiltration block complained of pain at the digit. The technique of anesthesia preferred by patients for their finger was the subcutaneous infiltration block, because it causes less pain. Our results confirm the efficacy of the transthecal block for achieving anesthesia of the finger; however, because it is a more painful procedure, it is not recommended.

Early escharotomy as a measure to reduce intraabdominal hypertension in full-thickness burns of the thoracic and abdominal area.

Intraabdominal hypertension (IAH) can occur in critically ill patients who have undergone surgery, who have required fluid resuscitation after intraabdominal operations, or whose abdominal surgical wound closure was under tension. If IAH remains unrelieved, it can lead to development of the abdominal compartment syndrome (ACS). The latter presents with severe cardiorespiratory and urinary symptoms such as hypotension, hypoventilation, and oliguria, and it can become fatal if it is not diagnosed early and treated properly. Moreover, IAH has been documented in the context of major burns, complicating the initial resuscitation of these patients. This study was set up to investigate the role of full-thickness burns of the thoracic and abdominal areas in IAH during the early resuscitation period, to determine whether escharotomy could influence its levels. During the past 2 years 10 burn patients were enrolled in this study, as they fulfilled the necessary criteria: >35% total body surface area (TBSA) full-thickness burn affecting the anterior, lateral, and most of the posterior surface of the thorax and abdomen (torso), no respiratory mechanical support at admission, and initial evaluation at another facility and transfer to our burn center 2-6 h postburn. Upon admission, the following parameters (indicative of intraabdominal hypertension, IAH) were measured: bladder pressure and gastric pressure. Also, we monitored inferior vena cava pressure, and as a routine, central venous pressure, systolic blood pressure, and arterial blood gases. Elevated intraabdominal pressure to hazardous levels was documented in all patients included in our study. The same escharotomy pattern was performed in every case, and 5-10 min after the procedure all measurements were repeated. Immediate improvement of all the parameters measured was recorded, and the alterations were found statistically significant. These results were indicative of significant relief of the elevated intraabdominal pressure in all patients after escharotomy, as well as the efficacy of the procedure. It is thus demonstrated that full-thickness burns of the thoracic and abdominal areas can cause a significant early increase in intraabdominal pressure that, if left untreated, can lead to the development of ACS. However, the application of simple decompression techniques can offer remarkable, immediate, and often lifesaving results and is absolutely indicated for this reason, as well as for its well-known beneficial effects on respiratory function.