Modified Treatment Algorithm for Pseudogynecomastia After Massive Weight Loss.

BACKGROUND: Pseudogynecomastia is the increased aggregation of fatty tissue in the area of the male breast with resultant female appearance. Two forms can appear: pseudogynecomastia after massive weight loss (pseudogynecomastia obese [PO]) and pseudogynecomastia, which is caused only by adipose tissue (pseudogynecomastia fat). For PO, only the Gusenoff classification with corresponding operative treatment options exists. However, this classification is limited by the fact that it underestimates the extensive variability of residual fat tissue and skin excess, both crucial factors for operative planning. For this reason, we propose a modification of the treatment algorithm for the Gusenoff classification based on our results to achieve more masculine results. MATERIALS AND METHODS: A total of 43 male patients with PO were included in this retrospective study (grade 1a, n = 1; grade 1b, n = 1; grade 2, n = 17; grade 3, n = 24). Forty-two mastectomies with a free nipple-areola complex (NAC) transposition (grades 2 and 3) and 1 with a subcutaneous mastectomy (grade 1a) with periareolar lifting were performed. A retrospective chart review was performed to obtain data regarding age, body mass index, body mass index loss, weight loss, reason for weight loss, comorbidities, nicotine, and additional procedures, postoperative sensitive on the NAC transplants and complications. RESULTS: None of the free-nipple grafts were lost. Forty (95%) of 42 patients with mastectomy had a resensitivity on the NAC. CONCLUSIONS: For pseudogynecomastia, the treatment algorithm of the Gusenoff classification should be modified and adapted according to our recommendations to achieve more optimal masculine results.

Updated scar management practical guidelines: non-invasive and invasive measures.

Hypertrophic scars and keloids can be aesthetically displeasing and lead to severe psychosocial impairment. Many invasive and non-invasive options are available for the plastic (and any other) surgeon both to prevent and to treat abnormal scar formation. Recently, an updated set of practical evidence-based guidelines for the management of hypertrophic scars and keloids was developed by an international group of 24 experts from a wide range of specialities. An initial set of strategies to minimize the risk of scar formation is applicable to all types of scars and is indicated before, during and immediately after surgery. In addition to optimal surgical management, this includes measures to reduce skin tension, and to provide taping, hydration and ultraviolet (UV) protection of the early scar tissue. Silicone sheeting or gel is universally considered as the first-line prophylactic and treatment option for hypertrophic scars and keloids. The efficacy and safety of this gold-standard, non-invasive therapy has been demonstrated in many clinical studies. Other (more specialized) scar treatment options are available for high-risk patients and/or scars. Pressure garments may be indicated for more widespread scarring, especially after burns. At a later stage, more invasive or surgical procedures may be necessary for the correction of permanent unaesthetic scars and can be combined with adjuvant measures to achieve optimal outcomes. The choice of scar management measures for a particular patient should be based on the newly updated evidence-based recommendations taking individual patient and wound characteristics into consideration.

Comparison of various methods and materials for treatment of skin laceration by a 3-dimensional measuring technique in a pig experiment.

BACKGROUND: The ability to obtain an objective comparison of scar formations by reproducible and quantitatively measurable results have posed a longstanding problem. This was especially troublesome when conclusions were to be drawn about the materials and methods applied. Two-dimensional methods (photography) gave no plastic impression about the spatial coherences in an examined scar. However, a quantifiable and reproducible recording of volumes and a 3-dimesional visualization of scars should provide the basis of any evaluation of methods and materials. METHODS: The OPTOCAT 3-dimensional scanning technique that was used was provided by the Breuckmann GmbH Company (Meersburg, Germany), and it permits a 3-dimensional, contact-free recording of data. The experiment animal was the Goettinger minipig. A total of 10 animals were used to examine the process of wound healing and scar development in full skin incisions. Every animal was incised 20 times with a 10-cm long and 20 times with a 2-cm long wound. In our investigation, comparable suture materials (skin adhesive, absorbing and nonabsorbing suture materials) of the companies Braun (Histaocryl, Monosyn, Safil, Premilene) and Ethicon (Dermabond, Monocryl, Vicryl, Prolene) as well as various suture techniques were used (continuous, mattress suture, and over-and-over/interrupted suture; each once with and once without an intracutaneous suture). In the course of the trial, numerous images of all wounds-a total 1200-were taken. Thanks to the 3-dimensional software, the resulting scar volumes of lacerations, which received different wound management, were quantifiably recorded, compared, and evaluated. RESULTS: In total, dehiscence occurred in 2.5% of all treated wounds. The greatest share (15%) fell to wounds treated with Histoacryl skin adhesive. In the end, skin adhesive, mattress, and interrupted suture all delivered similar results. An additional intracutaneous suture had, with an increasing wound length, a positive effect on the intention/wound healing, especially in connection with the application of skin adhesive. Except the combination of continuous absorbable suture and intracutaneous suture, the scar volume dwindled over time and adapted to the surrounding skin level. Continuous sutures were, by comparison, more inclined to an increased scarring (absorbable suture > nonabsorbable suture). It did not escape our notice that in case of small wounds, all various suturing materials and methods led to almost identical results. With respect to scarring, no significant difference regarding the suturing material was proven. CONCLUSIONS: If possible, the wound closure, treated with common suturing techniques and especially with skin adhesive, should be enhanced by an intracutaneous suture with an increasing length of the wound. Under certain circumstances, skin adhesive is an adequate substitute for common suturing materials and methods. The final decision about the method and material is as much closely related to the length and localization of the wound as to time exposure, efficiency, and the comfort of the patient. SUMMARY: For objective comparison of intention and scarring, a scanning technique was used that permits a quantifiable, contact-free, single-session recording of volume differences. For this purpose, various suture materials and methods were used. Altogether, it could be shown that, if possible, wound closure treated with common suturing techniques, and especially with skin adhesive, should be enhanced by an intracutaneous suture with an increase in wound length. At the same time and under certain circumstances, skin adhesive poses an adequate substitute for the common suturing materials and methods. In the end, however, the final decision about the choice of method and material should be made depending on the localization and expanse of the wound as well as on the comfort of the patient (eg, absorbable suture/nonabsorbable suture), the time of exposure (eg, skin adhesive vs suture), and the economic efficiency (eg, producer of suture material).

Capillary activity of surgical sutures and suture-dependent bacterial transport: a qualitative study.

OBJECTIVE: To evaluate the multitude of new synthetic absorbable sutures (both monofilament and multifilament) in comparison with older materials with regard to capillarity and bacterial transport. METHODS: Sutures of United States Pharmacopoeia (USP) 4-0 thickness were arranged in a three-chamber system under sterile conditions. Either a colorant (liquid transport evaluation) or bacteria (bacterial transport evaluation) were added to the contamination chamber, and movement of colorant or bacteria was evaluated for as long as 30 days. RESULTS: None of the monofilament sutures transported colorant or bacteria. Colorant transport was found on the pseudomonofilament and multifilament sutures between the first and the fifth day. Escherichia coli were transported on the majority of the multifilament sutures, although no transport was found on silk or polyester sutures. Bacterial transport was most often evident in tests using the motile Proteus mirabilis. CONCLUSIONS: All multifilament and pseudomonofilament suture designs allowed transport of colorants and bacteria to some degree. The movement of fluids and bacteria did not depend on the absorptive capacity of the sutures, coating, or the presence of an open suture end.

Clinical correlation between the consumption of nicotine and cotinine concentrations in urine and serum by competitive enzyme-linked immunosorbent assay.

Different negative effects of smoking are known (e.g. postoperative complications), which lead, especially in plastic surgery, to unsatisfactory results. The aim of this study was to examine the appropriateness of a cotinine enzyme-linked immunosorbent assay (ELISA) for routine usage in operative disciplines. By correlation of smoking habits and concentration of cotinine in serum and urine, we tried to ascertain reference values for smokers, passive smokers and non-smokers. The reliability and sensitivity of the cotinine ELISA concerning nicotine exposure need to be proven. 165 (108 men, 57 women) test persons were examined by detecting cotinine in serum and urine by ELISA. The study shows a very good sensitivity, precision and reproducibility of the cotinine ELISA according to the laboratory criteria. The test shows significance of a good differentiation between smokers, passive smokers and non-smokers in urine. In serum, cotinines are excellent to differentiate between smokers and non-smokers/passive smokers. Urine and serum tests demonstrate valid and comparable results.

International clinical recommendations on scar management.

Many techniques for management of hypertrophic scars and keloids have been proven through extensive use, but few have been supported by prospective studies with adequate control groups. Several new therapies showed good results in small-scale trials, but these have not been repeated in larger trials with long-term follow-up. This article reports a qualitative overview of the available clinical literature by an international panel of experts using standard methods of appraisal. The article provides evidence-based recommendations on prevention and treatment of abnormal scarring and, where studies are insufficient, consensus on best practice. The recommendations focus on the management of hypertrophic scars and keloids, and are internationally applicable in a range of clinical situations. These recommendations support a move to a more evidence-based approach in scar management. This approach highlights a primary role for silicone gel sheeting and intralesional corticosteroids in the management of a wide variety of abnormal scars. The authors concluded that these are the only treatments for which sufficient evidence exists to make evidence-based recommendations. A number of other therapies that are in common use have achieved acceptance by the authors as standard practice. However, it is highly desirable that many standard practices and new emerging therapies undergo large-scale studies with long-term follow-up before being recommended conclusively as alternative therapies for scar management.