[Guidelines for the safe outpatient practice of aesthetic surgery]. / Linee guida per un esercizio sicuro della Chirurgia Estetica in regime ambulatoriale.

This paper presents guidelines for the safe outpatient practice of aesthetic surgery. These guidelines have been prepared by the Lombard Association of Plastic Surgery for Outpatients (ALChiPlA), an association confined to board certified plastic surgeons and holders of official authorizations issued by the Lombard ASL to perform outpatient surgery. The cornerstone of these guidelines is the health and safety of patients, who are turning to this type of surgery in ever increasing numbers. This is the first and thus far the only attempt of its kind and its value is increased by the fact that it has been prepared by specialists who have been carrying out this type of surgery in outpatient situations for years.

Posttraumatic lipomas: where do they really come from?

A series of nine patients is reported in which a subcutaneous lipoma appeared within a few months after a blunt trauma. Computerized tomography and/or nuclear magnetic resonance and/or echography were employed for the diagnosis in addition to physical examination. Surgical removal of the masses was then performed without any recurrence at the 3-year minimum follow-up. In four cases, suction-assisted lipectomy was employed to minimize the scarring. However, in these cases a biopsy was first performed to rule out malignancy. The pathogenetic mechanisms of posttraumatic lipomas are reviewed in the literature and are found to be incompatible with some of the cases presented. Instead, the hypothesis of a true adipose tissue neoformation following trauma is suggested.

Repair of a recurrent urethrovaginal fistula with an island bulbocavernous musculocutaneous flap.

This paper describes a case of recurrent postpartum urethrovaginal fistula. The extent of the vaginal tissue loss and the perilesional scarring made direct closure of the defect not practicable. After suturing of the urethra, the anterior vaginal wall was reconstructed with an island bulbocavernous musculocutaneous flap raised from the left labium majus. Seven months after surgery, the flap healed well, and cystography showed a regular voiding without periurethral suffusions. Healing of thedonor site also was aesthetically satisfactory.

Are synthetic prostheses really inert? Preliminary results of a study on the biocompatibility of Dacron vascular prostheses and Silicone skin expanders.

This study investigates the histo-pathologic reactions induced by implant of prostheses in Dacron knitted double velour and skin expanders in Silicone elastomers. Particular attention was paid to the effect of these reactions on the tissue itself. In the case of vascular prostheses it was found that fibrous connective tissue tended to accumulate in and around the prosthesis. We also observed widespread lymphohistiocytic infiltration and occasional plasmacytes. Numerous foreign body granulomas were found to be grouped around the filaments of plastic material. The prosthesis itself seemed to be composed of filaments of different calibre, fragmented into particles of varying size. Thus the structure of the prosthesis was modified and discontinued along its whole length. A similar granulomatous inflammatory reaction developed in the case of the skin expander, probably due to the leakage of particles of plastic material through the expander wall, which however did not seem to be affected by the tissue reaction. The findings indicate the need for more detailed research into the material used for prostheses, aimed at determining what modifications the tissues can produce in the synthetic material. Also, it is necessary to follow a multidisciplinary approach which takes into consideration the data available from the chemistry of polymers, fluid mechanics and cell biology.

The versatility of pectoralis major muscle and musculocutaneous flaps in the reconstruction of the oral cavity and of the anterior chest wall.

Musculocutaneous flaps, allowing one stage reconstructions and reducing the stay in hospital and rehabilitation period, have revolutionised modern plastic surgery. Muscle flaps are a good alternative to provide adequate coverage of tissue losses but with limited scarring. The authors report their 5 year clinical experience in the reconstruction of oral cavity and chest wall defects using the pectoralis major as muscle or musculocutaneous flap. The preliminary data of an angiographic study, confirming the segmentation of the pectoralis major muscle into two subunits, each provided with its own vascular supply (mainly the clavicular and the sternocostal segment), are also presented. The short and long-term results confirm the excellent viability and versatility of the pectoralis major musculocutaneous and muscle flap. In particular the complications rate is so low that this procedure can be considered safe and reliable.

[New evolution of the technique in trasaxillary augmentation mammaplasty: subpectoral-subglandular implant]. / Nuova evoluzione dell tecnica di mastoplastica additiva per via ascellare: impianto in sede sottopettorale-sottoghiandolare.

Transaxillary subpectoral augmentation mammaplasty combines the advantages of an axillary located scar with those of a submuscular pocket. However, according to the classical technique, the caudal extension of the pectoral fascia prevents the prosthesis from filling completely the inferior breast pole, thus creating a double submammary fold and/or an excessive fullness of the superior quadrants. In order to overcome this limit Barnett (1990) proposed to disrupt the caudal extension of the pectoral fascia along with its insertions to the submammary fold, thus allowing the implant to lie in a submuscular plane superiorly and in a subglandular/subcutaneous one inferiorly. In this paper the authors present their clinical experience with this new surgical technique.

[Burn patients in major emergencies. The preparation of air-drop kits for emergency surgical-resuscitation use]. / Pazienti ustionati nelle grandi emergenze. Confezionamento di kit per aviolancio di pronto impiego chirurgico-rianimatorio.

The kit described is for air-dropping for immediate use in the surgical treatment and resuscitation of burn victims in major emergencies when there is no direct access to the disaster area by rescue teams or vehicles. The kit can also be used to make up for deficiencies in medicines or medical materials in remote hospitals that have admitted people with severe burns who are not immediately transferable to other hospitals.

Superior orbital fissure syndrome complicating zygomatic fractures. Pathogenesis and report of a case. Case report.

Superior orbital fissure syndrome complicates zygomatic fractures either when the nerves that cross the fissure are damaged by bone fragments, or when the increased pressure in the orbit at the time of the injury compresses the nerves against the rim of the fissure. Oedema and bleeding may also have the same effect. We present a patient who was treated conservatively, and the ophthalmological problem subsided, although not completely, within a year.

Macrocephaly with multiple soft tissue and visceral hamartomas ("Bannayan-Zonana" syndrome). Case report.

Since its first description few cases of the rare association of macrocephaly with multiple soft tissue and visceral hamartomas (Bannayan-Zonana syndrome) have been reported. In this paper we report a case of a 7 year old child in whom lipomas of the abdomen and right flank have been treated with liposuction. We could find no previous evidence that this surgical technique has been used in the treatment of this syndrome.

Bulbocavernous myocutaneous flap: a new technique in repair of recurrent urethrovaginal fistula.

This paper describes the case of a recurrent post-partum urethrovaginal fistula. The extent of the vaginal tissues loss and the perilesional scarring made the direct closure of the defect non practicable. After suturing the urethra, the anterior vaginal wall was reconstructed with an island bulbocavernous musculocutaneous flap raised from the left labium majus. Nineteen months after surgery the flap healed well without peri urethral suffusion.

Surgical anatomy in endoscopic facial rejuvenation.

Endoscopic facial rejuvenation is a new technique which allows to greatly reduce the scar morbidity especially in the forehead region. Other advantages are its safety and accuracy due to the excellent magnification provided by the endoscope which enhances the visualization of muscles, nerves and vessels and shows clear surgical planes. Anyway, a sound knowledge of the distribution of the fascial system at the temporo-zygomatic region and of the relationships between the temporal fasciae, the interposed fat pads and the frontal branch are fundamental both in the prevention of nerve injury and in the successful result of the endoscopic procedure. In this paper an accurate account of the anatomical structures and their relationships encountered during a subperiosteal endoscopic facial procedure by dissecting 20 facial halves has been provided.

Port-wine stains: long-term histologic changes induced by argon and CO2 laser treatment.

A good success rate has been achieved using argon and CO2 laser in the treatment of port-wine stains. So far however only a few studies have been published concerning the long term histologic changes in the irradiated skin. In the present study we report our findings from skin biopsies in patients treated for port-wine stains with argon and CO2 lasers. The results show that in spite of the high level of selectivity of optical absorption of argon emission by hemoglobin, after 3-9 months there is histologic evidence of connective proliferation and reactive fibrosis of the necrotic dermis comparable with that resulting from CO2 emission.

Bone lengthening in malformed upper limbs: a four year experience.

Bone lengthening by corticotomy, gradual distraction and stabilization with an external frame has proved to be effective in the repair of osseous defects in lower extremities. More recently this technique has been introduced also in the treatment of post-traumatic deformities and malformations of the upper limbs. From 1989 to 1992 we treated 38 patients (46 upper limbs) with bone lengthening of which 12 (16 upper limbs) affected by post-traumatic deformities and 26 (30 upper limbs) by malformations. We present herein our four year experience with malformed cases only. The results suggest that bone lengthening is a simple and reliable procedure to obtain good function, to correct angular deviations and, also, to give a better esthetic appearance. Satisfying results, low complication rates and simple execution recommend its use in the treatment of many congenital malformations of the upper limbs, usually in association with traditional techniques. However, we are now strongly selecting the indications in order to improve our future results. We stress in particular that the treatment of some malformations, as ulnar or radial club hands, could be radically modified by introduction of bone lengthening.

Anatomical study of the temporal fasciae and fat pads.

BACKGROUND AND AIM: Although a great number of studies have been published on the anatomy of the various fascial layers in the temporal region and the interposed fat pads, there is still uncertainty regarding the organization of the temporal fasciae, above all at the level of the zygomatic arch, and the relationships between the latter and the frontal branch of the facial nerve. This study aimed to describe the anatomy of the temporal fasciae and their relationships both with the interposed fat pads and with the frontal branch of the facial nerve. METHODS: The study was carried out in 10 heads from fresh cadavers which were used to dissect the different tissue layers at the level of the temporo-zygomatic arch. RESULTS: The results of the dissections made in this study confirm the existence of three over-lying fascial layers (superficial temporal fascia, intermediate temporal fascia and deep temporal fascia), interposed by the same number of fat pads (superficial, intermediate and deep). The frontal branch runs below the superficial fat pad in close contact with the periosteum of the zygomatic arch. CONCLUSIONS: The authors suggest adopting a single nomenclature to describe the fasciae and the fat pads in the temporal region.

Anatomical study on the temporal fascial layers and their relationships with the facial nerve.

The recent application of endoscopic techniques in facial rejuvenation has stimulated a new interest in the anatomy of this region. In endoscopic face lift, as in open techniques, one of the main steps is the conjunction of dissections of the upper and midface without damage to the frontal branch of the facial nerve. This article provides an accurate account of the organization of the temporal fascial layers and their relationship with the facial nerve. The authors' dissections confirm that the frontal branch, despite the variations in branching patterns, has an anatomical relationship with the surrounding fasciae that can be deemed constant and predictable: The frontal branch lies in the deep layer of the fatty tissue interposed between the suprazygomatic extension of the superficial musculoaponeurotic system (SMAS) and the superficial leaflet of the temporal aponeurosis. The arrangement of the temporal fasciae on the zygomatic arch is also discussed.

Augmentation mammoplasty: personal evolution of the concepts looking for an ideal technique.

The purpose of this paper is to report our personal experience in the field of augmentation mammoplasty. This experience is based on over 15 years in practice and working with more than 400 cases using different types of prostheses (single-lumen gel-filled, single-lumen saline-filled, double-lumen, smooth or texturized surfaces), different routes (submammary, periareolar, transaxillary), and different locations of the implant (complete submuscular, subglandular, subpectoral). Our present preference is for a partial submuscular (subpectoral) augmentation mammoplasty through an inferior periareolar route. The results of 91 consecutive patients operated on with this technique from January, 1990 to December, 1994, during the blow-up of the controversy on silicone, are reported.