VENTRAL ONLAY BUCCAL MUCOSA GRAFT URETHROPLASTY FOR FEMALE URETHRAL STRICTURE: MEDIUM-TERM RESULTS IN A SINGLE SURGEON EXPERIENCE.

OBJECTIVE: To describe our own approach using buccal mucosal grafting and to assess the outcome of this approach. MATERIALS AND METHODS: A total of 42 patients underwent ventral onlay BMG by a single surgeon between 2017 and 2022. A longitudinal incision along the length of the urethra was made through the anterior vaginal wall and the peri-urethral fascia was incised to create two flaps. This ventral urethrotomy ran from the meatus into the proximal health urethra above the level of the stricture. A buccal mucosal graft was harvested and sutured to the margins of the urethral mucosa itself and the flaps of peri-urethral fascia. The vaginal wall was then closed. RESULTS: The mean age of the patients was 53.6 ± 12.8 years. There were no perioperative or postoperative complications. At a mean follow-up of 38.1 months, 41 patients (98%) were stricture-free. Peak flow rate improved from a mean of 7.7 ± 3.2 ml/s preoperatively to 25.9 ± 5.9 ml/s postoperatively. No patient developed incontinence. One patient developed a recurrent urethral stricture which was treated by redo urethroplasty. CONCLUSIONS: The surgical technique applied has proved efficiency. The ventral BMG preserves the urethral sphincter and so avoids postoperative incontinence. The use of peri-urethral fascia represents a good vascular and mechanical support for the graft.

Hyaluronan Hybrid Cooperative Complexes Injection as a Biostimulation for Postobese Skin Laxity in the Arm: A Histopathologic Study.

Background: The Hybrid Cooperative Complexes of high and low molecular weight hyaluronic acids (HHCC) improve skin structure and bioactivity. Massive weight loss damages cellular composition and morphological structure of skin. An injective treatment of postobese skin consisting of HHCC may have a role in counteracting these histopathological alterations. Objectives: To analyze the histological effects of HHCC injection in the cutaneous tissues of massive weight loss patients suffering from arm laxity. Methods: Nine ex-obese patients with postweight-loss-related arm laxity and ptosis requiring brachioplasty were prospectively recruited at the first author's department. HHCC injection was performed on only 1 arm, which included 2 injective sessions separated by 30 days. One month posttreatment, patients underwent a bilateral brachioplasty, and the surgical specimens were histologically examined, searching for any variation in the cutaneous connective tissue following injections. Histology on treated specimens showed a statistically significant increased density of elastic fibers along with a lower fragmentation of the same fibers compared to the untreated tissue. Fibroblasts demonstrated a swollen appearance as if involved in a bioactivation process. Results: Treatment with HHCC increases the number of elastin fibers and determines a more regular elastin deposition and architecture, as well as the bioactivation of fibroblasts. The contralateral untreated area showed an irregular structure with elastosis and elastolysis. Conclusions: More studies are necessary, but histologically proven benefits are demonstrated in the HHCC-treated skins when compared with basal controlateral skin. These data support the use of HHCC formulations for the treatment of postobese skin laxity.

The ethical foundations of patient-centered care in aesthetic medicine.

This article addresses some critical aspects of the relationship between aesthetic medicine (AM) and ethics and proposes a possible deontological ethical line to pursue based on current practices. The role of AM has always been controversial and suffers from unclear practical and moral boundaries, even within academic settings, since it aims to improve the appearance of individuals, not to cure a disease. Today, it is essential and pertinent to discuss these issues, as AM specialists are dealing with a growing and increasingly demanding patient population that has undergone profound evolution in recent years. Current challenges within the field of AM include a lack of global uniformity concerning the education of AM specialists, an increasing number of physicians practicing AM with diverse training backgrounds, the spread of AM being practiced outside of medical practice or hospital settings, and the influence of social media where the success is modelled and dictated by the identification of a youthful appearance). By the field of action enriched by technologies that aim not only at enhancement per se but also at the preservation and regeneration of tissues, it is necessary to establish an active multidisciplinary discussion on the definition of shared ethical limits. This discussion would allow AM to fully reclaim its identity as a specialty that aims to improve patient well-being whilst maintaining respect for patient aesthetic harmony, the expertise of specialists who practice AM, the essential role of safety, and awareness of the importance of a confidential doctor-patient relationship.

Labia Majora Hypertrophy in a Patient Affected by Familial Partial Lipodystrophy Type 5: A Case Report on Diagnosis, Presentation, and Surgical Correction.

BACKGROUND: Familial partial lipodystrophy (FPLD) is a rare disease, presenting as localized areas of lipodystrophy in the body and associated with defined genes mutations. Labia majora hypertrophy is rarely reported in the literature, and it has been described only once associated with the FLPD syndrome. We present a rare case of labia majora lipodystrophy successfully corrected with a pubo-pexy and a labial reduction plasty. METHODS: A 26-year-old girl presents with massive labia majora hypertrophy, not associated with any type of systemic comorbidity or infection. The hypertrophy was pure adipose and subcutaneous tissue. After exclusion of lymphedema, a lateral reduction labioplasty with pubo-pexy was performed in general anesthesia. RESULTS: The patient presented also a c.623G>A p. (Arg208Lys) missense mutation in AKT2 gene, usually associated with insulin resistance and lipodystrophy. After genetic counseling, the patient was diagnosed with FPLD type 5. The wounds healed perfectly, and the patient returned to normal life after 4 weeks from the operation. CONCLUSIONS: We report the first case in the literature of FPLD type 5 associated with labia majora lipodystrophy and successfully corrected with reduction labioplasty. LEVEL OF EVIDENCE V: 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 .

Brachioplasty with Extended Incision at the Elbow: A Comparison with the Traditional Short Technique.

BACKGROUND: The elbow area is frequently affected by excessive sagging skin post-massive weight loss. The aim of this study is to present a brachioplasty with distal extension of incision to the anticubital surface, in order to make the transition from middle arm to distal arm/elbow more nuanced and aesthetically pleasing. MATERIAL AND METHODS: An observational retrospective comparative study was performed confronting two groups of female patients. All patients treated with brachioplasty between January 2015 and December 2020 due to brachial laxity following massive weight loss were included in the study. Group A consisted of patients who underwent the novel procedure and Group B comprised subjects with the standard brachioplasty technique. Demographics, including age, BMI and comorbidities were taken into account. The mean outcome measure was the Body-QTM-satisfaction with upper arms score, which was administered preoperatively and one year postoperatively. RESULTS: In the period considered, Group A consisted of 92 patients and Group B of 78. No difference was found between groups concerning BMI and age. The groups were comparable also based on the Body-Q pre-surgery levels. The Body-Q scores at one year postoperatively were 22.80 ± 2.28 in group A and 19.50 ± 2.42 in group B. The postoperative Body-Q scores across the two groups were a higher in group A, and the result is statistically significant (p < 0.05). CONCLUSION: The utilization of the proposed elbow-extended technique allows an improvement of the upper limb profile, with far higher satisfaction of patients, at the price of minimal sequelae in terms of scar. The elbow area is a critical part in post-obese deformities of the brachium, and is frequently neglected. In case of skin laxity and redundancy an elbow extension of the brachioplasty incision is indicated. Results of elbow-extended brachioplasty are p valid and the additional scar well concealed and accepted by patients. LEVEL OF EVIDENCE III: 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 .

Minimally Invasive Buccal Mucosa Dorsal Graft for Female Distal Urethroplasty.

BACKGROUND: Female urethral stricture (FUS) represents a sporadic condition. There is a lack of data and standardized guidelines on diagnostics and therapeutics. Several surgical techniques have been described for FUS urethroplasty, among which the flap-based or graft-based ones are most reported. Buccal mucosa graft (BMG) represents the gold standard for male urethroplasty, and this can theoretically be applied also to FUS treatment. OBJECTIVE: To describe and present preliminary results of a novel minimally invasive technique for buccal mucosa dorsal graft (mini-dorsal BMG) urethroplasty for the treatment of FUS. DESIGN SETTING AND PARTICIPANTS: This is a retrospective study on buccal mucosa dorsal graft urethroplasty for the treatment of FUS. SURGICAL PROCEDURE: Every patient was placed in lithotomic position. Two stiches were placed at 10 and 2 o'clock positions to facilitate the dorsal median urethrotomy. The margins of the incised dorsal urethra at the 12 o'clock position are then dissected from the periurethral tissue. This dissection results in an elliptical raw area between the edges of the urethra over the periurethral tissue. The harvested BMG was fixed with several quilting sutures, using 5-0 and 4-0 absorbable sutures, to cover the raw area. The margins of the graft were sutured to the edges of the incised urethra. MEASUREMENTS: A chart review was performed. RESULTS AND LIMITATIONS: Thirteen patients underwent the mini-dorsal-BMG technique. The median preoperative uroflow was 5.6 (3-13) ml/s, and the median postoperative value was 23.4 (14-58) ml/s. CONCLUSIONS: The mini-dorsal-BMG technique for the treatment of FUS gives good results with low complication rates. Other series and long-term follow-up are necessary to confirm the reproducibility of this technique. PATIENT SUMMARY: We present the technical aspects and the promising preliminary results of a novel surgical technique for the treatment of female urethral stricture by using the buccal mucosa to correct this invalidating disease.

Negative pressure treatment for improvement of surgical wounds after circumferential thigh lift.

BACKGROUND: The circumferential thigh lift (CTL) with vertical scar is a more extensive and effective procedure compared to the traditional lift, but the scar is not aequally concealed. Negative pressure treatment (NPT) is considered to have a beneficial effect on the physiological process of wound healing and early scar formation. A comparison study was therefore carried out in order to evaluate the effect of NPT on scar quality. METHODS: All postobese patients consecutively treated for thigh laxity in the period January 2012 to April 2013 were recruited in a prospective cohort study. All patients underwent CTL. In group A, NPT was applied on the sutured wound in the immediate postoperative phase for a period of one week. In Group B traditional dressings were used. The quality of scars was evaluated by means of the Stony Brook Scar Evaluation Scale (SBSES) at 7, 15, 30 and 365 days postoperatively. RESULTS: 91 patients were included in the period defined, of whom 48 in group A and 43 in group B. In group A, the mean SBSES score was 4.4 at 7 days, 4 at 15 days, 4.6 at 30 days and 4.8 at 365 days. In group B the SBSES score was 3.2 at 7 days, 3 at 15 days, 3 at 30 and 365 days. At all postoperative stages the quality of the scar showed to be significantly improved by the use of NPT (p<0.05). CONCLUSIONS: NPT is a useful adjunct to the postoperative wound healing after circumferential thigh lift, when compared to a hostile cohort of patients whose wounds are not treated with NPT. KEY WORDS: Thigh lift, Negative Pressure Therapy.

Impending Facial Skin Necrosis and Ocular Involvement After Dermal Filler Injection: A Case Report.

Demand for non-surgical rejuvenating procedure is constantly increasing due to the aging population, increasing expense of aesthetics and beauty procedures, introduction of new applications and rising demand for noninvasive aesthetic procedures over surgical procedures. Skin necrosis is a rare but severe potential complication. It is caused by impediment of the blood supply to the skin area by compression and/or obstruction of the vessel with filler material, and/or direct injury to the vessel. We report the case of a young patient who presented an acute and severe complication after a dermal filler injection by an unlicensed therapist. High-dose corticosteroids i.v. therapy among others helped in the process of healing. Skin necrosis left the patient with a full thickness scar on the forehead region. Dermal fillers are to be considered safe only when handled by trained doctors. Level of Evidence V 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 .

Is the high superior tension technique an equivalent substitute for progressive tension sutures in postbariatric abdominoplasty? A comparison prospective study.

BACKGROUND: The addition of progressive tension sutures to the abdominoplasty technique is advocated to reduce the risk of several complications. High superior tension abdominoplasty is another technique aimed at reducing tension at the prepubic suture line and improving cosmesis of the umbilical area. METHODS: A cohort of massive weight loss patients undergoing abdominoplasty, treated with the progressive tension suture technique in association with the high superior tension technique (group A), was followed up and compared to a cohort of patients who underwent high superior tension abdominoplasty (group B). Several variables including rate of complications and patient satisfaction were explored to determine any possible benefit deriving from the combination of progressive tension suture and high superior tension techniques in the abdominoplasty. RESULTS: A total of 90 patients were included in the study, of whom 34 were in group A and 56 were in group B. No statistically significant difference was found between the two groups in terms of duration of the procedure, hospitalization time, rate of complications, drained volume, and patient or physician satisfaction. CONCLUSION: No beneficial effect appears to derive from the progressive tension suture technique in massive weight loss patients undergoing abdominoplasty, provided that the high superior tension technique is performed as an adjunct to the traditional method.

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.