Superficial Enhanced Fluid Fat Injection (SEFFI) to Correct Volume Defects and Skin Aging of the Face and Periocular Region.

BACKGROUND: Although recent research on micro fat has shown the potential advantages of superficial implantation and high stem cell content, clinical applications thus far have been limited. OBJECTIVES: The authors report their experience with superficial enhanced fluid fat injection (SEFFI) for the correction of volume loss and skin aging of the face in general and in the periocular region. METHODS: The finer SEFFI preparation (0.5 mL) was injected into the orbicularis in the periorbital and perioral areas, and the 0.8-mL preparation was injected subdermally elsewhere in the face. RESULTS: The records of 98 consecutive patients were reviewed. Average follow-up time was 6 months, and average volume of implanted fat was 20 mL and 51.4 mL for the 0.5-mL and 0.8-mL preparations, respectively. Good or excellent results were achieved for volume restoration and skin improvement in all patients. Complications were minor and included an oil cyst in 3 patients. The smaller SEFFI quantity (0.5 mL) was well suited to correct volume loss in the eyelids, especially the deep upper sulcus and tear trough, whereas the larger SEFFI content was effective for larger volume deficits in other areas of the face, including the brow, temporal fossa, zygomatic-malar region, nasolabial folds, marionette lines, chin, and lips. CONCLUSIONS: The fat administered by SEFFI is easily harvested via small side-port cannulae, yielding micro fat that is rich in viable adipocytes and stem cells. Both volumes of fat (0.5 mL and 0.8 mL) were effective for treating age-related lipoatrophy, reducing facial rhytids, and improving skin quality. LEVEL OF EVIDENCE: 4 Therapeutic.

Lymphatic microsurgery to treat lymphedema: techniques and indications for better results.

This study aimed to report new clinical approaches to the treatment of lymphatic disorders by microsurgical techniques based on histological and immunohistochemical findings. The authors' wide clinical experience in the treatment of patients with peripheral lymphedema by microsurgical techniques is reported. Microsurgical methods included derivative lymphatic-venous anastomoses and lymphatic reconstruction by interpositioned vein grafted shunts. In all patients, lymphatic and lymph nodal tissues were sent for histological assessment, together with specimen of the interstitial matrix. Diagnostic investigations consisted in venous duplex scan and lymphoscintigraphy. Results were assessed clinically by volumetry performed preoperatively and postoperatively at 3 to 6 months and at 1, 3, and 5 years. The outcome obtained in treating lymphedemas at different stages was analyzed for volume reduction, stability of results with time, reduction of dermatolymphangioadenitis attacks, necessity of wearing elastic supports, and use of conservative measures postoperatively. Microsurgical lymphatic derivative and reconstructive techniques allow bringing about positive results in the treatment of peripheral lymphedema, above all in early stages when tissular changes are slight and allow almost a complete restore of lymphatic drainage.

Lymphatic complications in surgery: possibility of prevention and therapeutic options.

The problem of prevention of lymphatic complications in surgery is extremely important if we think about the frequency of both early complications such as lymphorrhea, lymphocele, wound dehiscence and infections and late complications such as lymphangitis and lymphedema. Nowadays, it is possible to identify risk patients and prevent these lesions or treat them at an early stage. This report helps to demonstrate how it is important to integrate diagnostic and clinical findings to better understand how to properly identify risk patients for lymphatic injuries and, therefore, when it is useful and proper to do prevention. Authors report their experiences in the prevention and treatment of lymphatic injuries after surgical operations and trauma. After an accurate diagnostic approach, prevention is based on different technical procedures among which microsurgical procedures. It is very important to follow-up the patient not only clinically but also by lymphoscintigraphy. A protocol of prevention of secondary limb lymphedema was proposed and it includes, from the diagnostic point of view, lymphoscintigraphy and, as concerns therapy, it recognizes also a role to early microsurgery. It is necessary to accurately follow-up the patient who has undergone an operation at risk for the appearance of lymphatic complications and, even better, to assess clinically and by lymphoscintigraphy the patient before surgical operation.

Factors affecting symmetrization of the contralateral breast: a 7-year unilateral postmastectomy breast reconstruction experience.

Although a number of studies compare different techniques of breast reconstruction, information documenting the factors that affect breast symmetry after unilateral mastectomy and reconstruction seems to be scarce. A statistical analysis of 606 patients undergoing unilateral mastectomy and breast reconstruction performed during a 7 year period was undertaken in an endeavor to identify these factors. Patients were classified according to time of reconstruction, method of reconstruction, type of implant, and mastectomy type. Contralateral procedures included mastopexy, augmentation, and reduction mammaplasty. Delayed reconstruction more frequently required a symmetrization than an immediate reconstruction. The percentage of contralateral procedures was higher for implant reconstructions than for autologous reconstructions, and the type of mastectomy was significantly associated with the symmetrization procedure. The findings showed that non-skin-sparing mastectomy (non-SSM) needed symmetrization surgery more frequently than did SSM procedures. The data suggest a preoperative collaboration and case study between oncologic and plastic surgeons to apply, when possible, SSM with immediate implant breast reconstruction, resulting in fewer symmetrization procedures and the best aesthetic follow-up result. These factors need to be considered when mastectomy and reconstruction are planned in order to optimize the aesthetic result together with the development of breast surgery specialty units.

The nuss procedure after breast augmentation for female pectus excavatum.

Pectus excavatum, the most common congenital chest wall malformation, has a higher incidence among men. Since 1987, when Donald Nuss performed his technique for the first time, the minimally invasive approach has become the most widely used technique for treating pectus excavatum. Few reported studies have focused on the repair of female pectus excavatum. Women with pectus excavatum often present with breast asymmetry that may require breast augmentation, either before or after pectus excavatum repair. To the authors' knowledge, no reports on the Nuss procedure after breast implant surgery have been published. This report describes the case of a 26-year-old woman who underwent minimally invasive repair after breast implant surgery. The authors believe that for women with severe pectus excavatum, the Nuss procedure should be the first choice for surgical correction. Moreover, for breast implant patients, this technique is absolutely feasible without major complications.

One-stage breast reconstruction using McGhan Style 150 biodimensional expanders: a review of 107 implants with six years experience.

Permanent expanders have revolutionised breast reconstructive surgery, allowing one-stage procedures and the development of increasingly sophisticated implants (textured, anatomically shaped) has played an important role in enhancing the aesthetic outcomes. It is important to evaluate the tolerability of the implant. The aim of this present study was to evaluate the survival curves for McGhan Style 150 permanent expanders, in a consecutive series of breast reconstructions. Complications rates were also examined. Between April 1997 and May 2003, 107 McGhan Style 150 expanders (either full height or short height depending on patients' requirements) were used in 97 consecutive patients for a variety of breast reconstructive procedures. Overall, 46 devices were used for immediate reconstruction, 15 for delayed reconstruction and 46 for implant exchange, respectively. The mean age at implantation was 48 years (min: 26; max: 71). The mean follow-up was 60 months (min: 12; max: 72). Explantation was considered the most objective outcome variable, therefore this parameter was carefully monitored and then analysed using the Kaplan-Meier method of survival analysis. Different curves were compared using the log-rank test. Long term complications were also recorded. Among complications the most frequent finding was Baker 3-4 capsular contracture, occurring in 26% of immediate reconstructions at six years. Explantations increased in an almost linear fashion, with an overall rate of 25%, with a statistically significant difference among immediate reconstruction group and the implant exchange group. The rate of explantations was high, if compared with other series, because the sample included patients undergoing strong adjuvant therapies, particularly in the immediate group (locally advanced disease). The overall rate of explantations and of capsular contracture was found to be significantly lower in the delayed and substitution groups, than the immediate group (p<0.05). In our hands, the McGhan Style 150 anatomically shaped permanent expanders were associated with acceptable results, especially when used as 'permanent prostheses' for second stage procedures.

Trilucent breast implants: five years' experience from an Italian perspective.

In June 2000 the Medical Devices Agency (MDA) issued a Hazard Notice recommending the explantation of Trilucent breast implants (TBP) as a precautionary measure. Following that recommendation, we reviewed our series of 52 patients (71 implants) operated on from 1994 to 1998 to recall and advise those still harboring TBP. We have analyzed all the recorded adverse events in our setting before June 2000 to estimate the adverse reaction frequency and their time relation (review series). We have also recorded the rate of preoperative symptoms and postoperative findings in 23 patients (29 implants) who underwent explantation after the MDA recommendation (explantation series). In addition, some histologic observations have been made. The rates of significant capsular contracture (Baker 3-4) and explantations were estimated using the Kaplan-Meier method of survival analysis, and the rates of wrinkling and palpability were compared at 1 and 5 years of follow-up. Overall, the rate of grade 3-4 capsular contracture was approximately 45% at 6 years of follow-up with no statistically significant difference among the reconstruction and augmentation groups. The analysis of survival curves showed an overall rate of approximately 55% of explantations at 6 years. Preoperatively, capsular contracture and volume modifications were the most frequent findings in the explantation series. Postoperatively, most implants opposed inadequate resistance to the operative stress and ruptured, showing a creamy content. Free oil has never been found in tissue surrounding the periprosthetic capsule. In conclusion, it appears that the TBP-claimed advantages over other available implants seem to be inconsistent and the MDA advice appropriate. The problems related to these implants have had a great impact on public opinion in Europe and have contributed to the implementation of the conformity assessment procedures to be followed for medical devices: on the 4th February 2003 breast implants were in fact reclassified as class 3 products, in order to provide the best guarantee for health protection. The publication of a communication by the European Parliament in November 2001 gives us hope for the future.

High prevalence of the G101W germline mutation in the CDKN2A (P16(ink4a)) gene in 62 Italian malignant melanoma families.

CDKN2A germline mutation frequency estimates are commonly based on families with several melanoma cases. When we started counseling in a research setting on gene susceptibility analysis in northern and central Italy, however, we mostly found small families with few cases. Here we briefly characterize those kindred, estimate CDKN2A/CDK4 mutation test yields, and provide indications on the possibility of implementing formal DNA testing for melanoma-prone families in Italy. In September 1995 we started genetic counseling in a research setting at our Medical Genetics Center. Screening for CDKN2A/CDK4 mutations was performed on families with two melanoma patients, one of whom was younger than 50 years at onset, the other complying with one of the following: 1) being a first-degree relative, 2) having an additional relative with pancreatic cancer, or 3) having multiple primary melanomas. Sixty-two of 67 (80%) melanoma cases met our criteria. Four previously described CDKN2A mutations (G101W, R24P, V126D, and N71S) were found in 21 of the 62 families (34%) with a high prevalence of G101W (18/21). The percentage of families with two melanoma cases/family harboring a mutation was low (7%, 2/27), but rose to 45% (9/20) if one of the melanoma patients carried multiple melanomas or if pancreatic cancer was present in that family. In the 15 families with three melanoma cases the presence of a mutation was higher (67%, 10/15) and reached 100% in the 4 families with four or more melanoma cases. Our results suggest that CDKN2A/CDK4 counseling-based mutational analysis may be reasonably efficient also for families with two melanoma cases, if one patient carries multiple melanomas or if pancreatic cancer is present in the family.