Aesthetic rhinoplasty as the final step of nasal reconstruction with a forehead flap

Background

The reconstruction of nasal defects represents a difficult challenge for a plastic surgeon as it can be actually difficult to obtain good aesthetic and functional results. Reconstruction needs the use of several complex flaps, including the forehead flap. However, the use of the forehead flap does not give always the optimal aesthetic result. In our opinion, rhinoplasty can optimize the aesthetic outcome and can be used as the last step in nasal reconstruction.

Methods

From the patients admitted to our department, resulting in full thickness nasal defects and reconstructed using the forehead flap, ten were selected to perform rhinoplasty after passing the inclusion criteria.

Results

In the patients where rhinoplasty was performed we obtained aesthetic and functional improvement. The patients referred better acceptance of the residual surgical stigmata and improvement of social acceptance.

Conclusions

Optimizing the aesthetic appearance of the nose, making it look better than before surgery, is fundamental to improve patient’s life quality and better acceptance of the demolition or trauma.Level of Evidence: Level V, therapeutic study.

     

Launois-Bensaude Syndrome: An Unusual Localization of Obesity Disease

Background  Launois-Bensaude syndrome is a rare pathology consisting of adipose masses symmetrically distributed mainly in the superior part of the body. Men are especially affected between age of 30 and 60 as well as chronic alcohol abusers. Etiopathogenesis is attributable to mutations or deletions of mitochondrial DNA, and alcohol is a possible cofactor. Methods  The current treatment of the disease is described based on the authors’ experience. Four cases treated in our department are retrospectively reviewed regarding comorbidities and type of surgery performed. Results  A relevant and long-lasting reduction of fat bulges has been obtained in all cases with no major complications except for a mild anemia. Conclusion  Launois-Bensaude syndrome causes a functional rather than esthetic concern due to the peculiar localization of fat bulges. Currently, the only effective therapy is surgery, through lipectomy or liposuction of adipose bulges.     

A single-center retrospective study on 3,957 consecutive excisions of basal cell carcinomas. BCC behavior patterns: retrospective statistical analysis

Basal cell carcinoma (BCC) is the most common skin malignancy. BCC generally has a clinical course characterized by slow growth, minimal local invasiveness, and a high cure rate. Occasionally, however, BCC behaves aggressively with deep tissue invasion, clinical recurrence, and regional/distant metastases. Surgical excision is uniformly indicated as a primary treatment. We carried out a retrospective study by selecting all patients operated for BCC in our Plastic Surgery Department between 1 January 1992 and 1 September 2007. The data collected were about 3,957 excisions performed on 2,358 individuals which is, to our knowledge, the largest population sample ever studied internationally. For this reason, we analyzed the most common BCC features generally reported in published papers so as to identify any difference compared to the data that we gathered in our series. From all of the collected data of the 2,358 patients and 3,957 excisions, 16 variables were drawn, which provided detailed information about patients’ status, biopsy when performed, surgery, and follow-up. All results concerning such variables are discussed. The results of our retrospective statistical analysis on a very large, single-center patient population sample are fully in line with what were previously published in the international literature.     

Fat grafting used for the prevention of cardiac implantable electronic devices (CIED) exposure. Preliminary report of a clinical study

Background

Subcutaneous cardiac devices can sometimes undergo exposure, and often, the removal and contralateral repositioning of a new device is necessary. Pressure sores of the device cause a gradual thinning of the cutaneous and subcutaneous layers resulting in implant exposure. Our department has developed a closed collaboration with the Department of Cardiology in order to prevent the exposure of subcutaneous devices and to avoid the more risky and invasive surgery necessary for implant removal and reposition.

Methods

Thirty selected cardiopathic patients presenting pressure sores of the device, without exposure, were selected for lipofilling. The selection of patients is a key moment to ensure the success of the procedure. The surgery was performed under local anaesthetic without epinephrine.

Results

There was an improvement of local conditions, and none of the patients, after a year, were subjected to a removal operation of the implant. No cases of infection were observed.

Conclusions

Adipose tissue graft improved cutaneous trophism and increased the thickness of the subcutaneous tissue, reducing the risk of implant exposure. Level of Evidence: Level IV, risk/prognostic study.     

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.     

The Plastic Surgeon in the Treatment of Obesity

Obesity is an increasingly common disease, whose complex treatment often terminates with the patient's discontinuation of therapies. The authors suggest how to improve a multidisciplinary approach to the obese, to increase compliance with therapy. A characterization of obesity is a helpful initial step. It consists of an accurate anatomic definition of fat distribution, which can more accurately be performed by imaging (U/S, CT, MRI). The patient's obesity should also be identified based on the physical characteristics that we propose. The plastic surgeon's intervention is often required and beneficial in every type of obesity. Many body areas are appropriate for contouring. Apart from providing a gain in esthetic appearance, plastic surgery also results in several benefits for the patient's general health.     

The use of a topical antibacterial agent (silver sulfadiazine) on soft-tissue wounds

Reducing the quantitative level of bacterial contamination in an open, acute or chronic, soft tissue wound below the critical level of 10(5) bacteria per gram of viable tissue is essential to delayed primary closure. First step in the management of the contaminated or infected wound is accurate local debridement, preferably with pulsating jet irrigation. Topical antibacterial agents, specifically silver sulfadiazine cream, are then usefully employed to reduce the bacterial count. Contrary to systemic antibiotics, these agents penetrate adequately into the open, granulating wound with a direct bacteriostatic or bactericidal action on a wide spectrum of gram positive and negative organisms, without the effect of local tissue injury typical of topical antiseptics. The use of topical antibacterials, traditionally confined to the treatment of the burn wound, the open "difficult" wound for excellence where control of local infection is first priority, provides a rapid local reduction of the bacterial level and paves the way to the final goal of primary delayed closure of the wound, either direct or with the use of grafts or local, distant, or free flaps.     

Limb Contouring after Massive Weight Loss: Functional Rather than Aesthetic Improvement

Background  After massive weight loss, both upper and lower limbs show a similar deformity which consists of redundancy and ptosis of the cutaneous mantle. Many disturbances are associated with this abnormality, which can be treated surgically. A retrospective review of limb-contouring procedures after massive weight loss is presented. Methods  Thigh lift and arm lift procedures are described. All surgeries of upper and lower limbs contouring performed between 2003 and 2006 are reviewed with regard to quantity of tissue removed, comorbidities, complications and patients’ satisfaction, which was surveyed through a questionnaire exploring functional and esthetic results (maximum score 3). Results  Among 48 bilateral limb-contouring procedures, medial thigh lifts were 35 (73%) and brachioplasties were 13 (27%). Mean age was 46 and average body mass index variation was 20 kg/m². The most frequent comorbidity was gallstones (28%). In 46% of the whole group of patients, there was no complication to mention. The most frequent complication was acute anaemia in both procedures (43% in thigh lift and 54% in arm lift). Mean quantity of adipose–dermoid tissue removed was 766 g in thigh lift and 463 g in arm lift. In case of surgery combined with liposuction, the average aspirated volume was 1,933 ml (thighs) and 1,117 ml (arms). Patients’ satisfaction was 2.7 for thighs and 2.6 for arms, as average. Conclusion  The rate of complications in limb contouring after weight loss is higher than the analogue esthetic procedures. Nevertheless, due to the rehabilitative significance of limb surgery after weight loss, this step is to be included as fundamental in obese patients’ surgical therapy. Data partially presented at the XVI Conference of the Italian Society of Obesity Surgery (Capri, May 14–16, 2008).